The International Journal of Psychosocial Rehabilitation

Supported Education Strategies for People with
 Severe Mental Illness: A Review of Evidence Based Practice

 
 
Eldon J. Leonard, RN, BSc Psych
Mental Health Centre Penetanguishene,
Penetanguishene ON (Canada)
Wifrid Laurier University
Waterloo, ON
 
 
Robert A. Bruer, ARCT MPE MTA
Mental Health Centre Penetanguishene,
Penetanguishene ON (Canada)
Department of Psychiatry, Washington University School of Medicine,
St. Louis MO 
 

  Citation:
Leonard E.J. & Bruer R.A. (2007) Supported Education Strategies for People with  Severe Mental Illness:
A Review of Evidence Based Practice. 
International Journal of Psychosocial Rehabilitation. 11 (1) 97-109



Abstract
The article reviews extant literature related to the study of evidence based practice of the provision of supported education to the mentally ill and provides a chronological history of efforts from various institutions and mental health and educational facilities in North America.  Priority is given to the studies that operated under controlled situations and randomly assigned their subjects.  Comments are included with each review discussing the limitations of the program or study.  The discussion includes an overall impression of the limitations of all of the studies such as the tendency toward variance in the description of outcomes used to measure success in education and the cloudiness of definitions of prevocational training. Recommendations are offered in an effort to guide future endeavours to provide education to the mentally ill and some direction is given regarding the development of standards for future research such as the inclusion of sample groups that more realistically represent the functional levels of clients from publicly funded state and provincial hospitals.
 
Keywords: supported education, academic education, severe mental illness, psychiatric illness, supported employment, prevocational training


Introduction
Mental Health facilities and prisons in the US and Canada have for some time offered on-site training and academic educational opportunities (Zwicker, N. & Myers, M. A., (1991).  As well as increasing proficiencies among inmates, “there is evidence that token economy programs that emphasize vocational and educational training in prison settings reduce post release recidivism” (Quinsey et al 1998; p.205).  Recently, such interventions have moved beyond institutional walls to include academic education programs for clients living in the community.  These programs provide one-on-one or small-group education, comprised of Literacy Basic Skills, Secondary School Courses, General Interest Education,Diploma Courses and Computer Skills Training.  Programs often fall under the supervision of local school boards or colleges, resulting in mental health consumers, occasionally attending programs within normal campus settings.

 Cursory database searches reveal little published information about such programs, making program evaluations elusive and results uncertain. Evaluations are further challenged by the wide range of treatment protocols and outcome measures found within literature searches.  For example, some searches for supported education (SEd) identified meta-analyses of studies comparing supported employment (SEm), prevocational training (PVT; a form of education specific to job preparation), and more traditional forms of workplace preparation such as sheltered workshops and transitional employment.  Only a few studies clearly looked at the efficacy of supported academic education.

Objectives
The primary objective of this review was to systematically search available literature databases for relevant information that would guide mental health facilities in more effective provision of academic education for clients both in the hospital and in the community.

The length of sustained employment at a mainstream job was the primary outcome measure consistently appearing for employment success.
However, outcome measures deemed relevant to successful provision of academic education include course or diploma completion, along with the measurement of length of sustained studies thought to contribute to vocation or career choice. 

A search for evidence-based practice in the provision of academic education to people with a severe mental illness would be helpful to reassure funding sources that:
1)      SEd is indeed a necessary part of the client’s overall rehabilitation and contributes to the client’s successful recovery.
2)     Current SEd is being provided in the best possible venue.
3)     Methods employed for SEd are drawn from empirically supported approaches.

Initial Search Strategy
Initial literature searches were as follows:
1. A Pub Med search using the general terms “Academic Education” and “Mental Illness”.

2.  A Pub Med search using the MeSH terms “Education, Special” and “Psychiatry” or “Diagnosis, Dual (Psychiatry)” or “Community Psychiatry” or “Biological Psychiatry” or “Forensic Psychiatry”.

3. A Cochrane Collaboration search using the terms “Academic Education” and “Mental Illness”, “Supported Education” and “Mental Illness”.

4. A Psych Lit search using the terms “Academic Education” and “Mental Illness”, “Academic Education” and “Psychiatric Illness”, and “Supported Education”.

5. A Cumulative Index of Nursing and Allied Health Literature search using the terms “Academic Education” and “Mental Illness”, “Academic Education” and “Psychiatric Illness”, and “Supported Education”.
6. A Google search using the terms “Academic Education” and “Mental Illness”, “Academic Education” and “Psychiatric Illness”, and “Supported Education”.

7. A second Google search using the term, “Participatory Action Research”.
As a result of the final “Participatory Action Research” search, the Canadian “Review of Best Practices in Mental Health Reform” (Goering et al., 1997) was identified, and subsequently used to locate a number of additional articles.

 Follow-up Strategies
The literature review began with an examination of the groundwork paper “Review of Best Practices in Mental Health Reform”, that was commissioned by the Minister of Public Works and Government Services Canada and carried out by the Health Systems Research Unit of the Clark Institute of Psychiatry (Goering et al., 1997).
Guided by the finding of the “Review of Best Practices in Mental Health Reform” report, post hoc efforts were made to find recent outcome studies (i.e., within the last fifteen years). Searches for randomised controlled trials of approaches to providing academic education to the mentally ill were given highest priority.  However, only one such study was found (i.e.,Hoffmann & Mastrianni, 1993) where a comparison was made between two different inpatient settings in New York State, one with an SEd program and one without. This study, first identified within the above-described “Review of Best Practices” document, will be described briefly, below.

Post hoc efforts continued on to a comprehensive review of “The Handbook on Supported Education” by Karen Unger (1998), a book which not only provided guidelines for supported education but also described five different models of supported education: first, within a college, second, a consumer alliance, third, within a clubhouse setting, fourth, within a community services agency, and fifth, a supported education program within a hospital setting.  The models set within a clubhouse setting, community services agency and hospital setting will be briefly reviewed below.
Next, additional attention was given to another study by Dr. Unger entitled, “Program of Supported Education for Young Adults With Long-Term Mental Illness” (1991) at Boston University; again, described below. 

Also considered was a very unique Supported Education model for students with psychiatric disabilities run within a community college in Houston (Housel & Hickey, 1993).  However, it is noted from the outset that this program was difficult to assess, given the lack of a controlled comparison.

In 2004, an article appeared in the American Journal of Psychiatric Rehabilitation entitled “Redirection Through Education (RTE): Meeting the Challenges” (Gilbert et al., 2004).  This article described a historical RTE program established in 1973 at Lakeshore Psychiatric Hospital in Toronto, Ontario.  This program would appear to be one of the earliest supported education programs in North America, begun when Lakeshore Hospital negotiated with George Brown College to provide educational support for discharged clients.

Search criteria for ‘academic education for mentally ill’ commonly identified studies of vocational rehabilitation and found insightful results for related topics such as a Review of Vocational Rehabilitation for People with Severe Mental Illness, a comparison of Supported Employment and prevocational training (Crowther et al., 2001).  This meta-analysis will be examined below, with the intent that the protocol used by the reviewers could appropriately guide future studies of Supported Education.

Also considered was a recent Archives of General Psychiatry article detailing the “Results of a Multisite Randomized Trial of Supported Employment Interventions for Individuals With Severe Mental Illness (Cook et al., 2005), in which supported employment was compared to services as usual.  This study will also be examined briefly.

 Various online information was gleaned from the vast web site of the New York State Office of Mental Health, including the values and quality standards underlying all evidence-based practices for the provision of mental health services in the State of New York ("Creating An Environment of Quality Through Evidence-Based Practices", 2006).

Results
The Role of Supported Education in the Inpatient Treatment of Young Adults: A Two-Site Comparison, (Hoffmann & Mastrianni, 1993):
This study compared a convenience sample of inpatients receiving SEd with a matched group of patients not receiving SEd.
The study was carried out at two sister facilities in New York state.  Both facilities were private inpatient psychiatric hospitals providing treatment for patients.  Only the Four Winds – Saratoga patients (n = 68) were in close enough proximity to a college setting for educational experiences and opportunities to be integrated into the treatment milieu.  The control group selected from the Four Winds-Winchester Hospital were matched by age, prior education, and were hospitalized during the same period (September 1986 to June 1986) as the experimental group.  Patients treated in the Four Winds-Saratoga College Service were significantly more likely to return to college than those treated at the Four Winds-Westchester (69% versus 47%).  Likewise, 88% of College Service patients who had returned to college were full-time at the time of follow-up compared with 58% of Westchester patients, and 55% of Saratoga patients planned to obtain graduate degrees compared with 37% of Westchester clients.

This study has several limitations.  First, patients were not randomized to the treatment conditions.  Second, the SEd treatment was rather elitist in that it necessitated patients residing in close proximity to a college campus.   Finally, the study involved subjects with abnormally high levels of baseline education.  Both groups had completed between 12 and 15.5 years of schooling with a mean of 13 years.  In comparison, the average education of a group of 29 subjects from a recent study done on the Geriatric Services Program at the Provincial Mental Health Centre in Penetanguishene was 10.7 years (Bruer et al, 2006) (Bruer et al., 2006). 

“Program of Supported Education for Young Adults With Long-Term Mental Illness” (Unger et al., 1991):
In this program, applicants were recruited from a population of medically stable young adults (ages 18-35) who had experienced a severe disability due to a mental illness.  Inclusion required average or above average intelligence and an ability to use a classroom based approach program for career planning.  Of the applicants, 52 were accepted into the program and were compared demographically at baseline with 76 applicants who had applied but not been interviewed or accepted.  No significant differences were found in age, gender, marital status, employment status or educational level attained.  Classes ran for 16 months, three days weekly, for two and one half hours per class and no fee was charged.  The program curriculum was comprised of four instructional components related to career exploration and development: profiling vocational potential, researching occupational alternatives, career planning and mobilizing personal skills and resources.  Program teachers were master’s-level counsellors who had experience in mental health settings and training in classroom-based interventions.  Of the 52 participants enrolled, 2 had less than high school education, 15 had a high school diploma and 83 had post high school education.  Again, the high mean education is a factor for further discussion.  Of the 52 subjects in the program, 35 completed all four semesters, 15 completed less than three semesters and 7 did not complete one semester.  Two subjects committed suicide and were not included in the analyses of study outcomes.  Before the program 19% were competitively employed or enrolled in educational programs compared with 42% of the students after the intervention.  Between the first and last assessments, significant increases were found for employment (p< .001, N=44), for educational status (p < .0001, N=43), for self esteem using the Rosenberg self esteem scale, (p < .05) and significant decreases were found in hospitalization rates during the first year (p < .05).  The authors concluded that community integration on a university campus provided an accepting environment for students with psychiatric disabilities to enter into the rehabilitation process and begin to define themselves as students rather than patients.

This study also has several limitations.  Again, participants had abnormally high levels of baseline education.  Also, unrealistic elitism was suggested by the fact that all instructors had masters’ level education.  Finally, while this study did compare baseline demographics between subjects and other general inpatient populations, the study did not compare pre and post outcome measures.   Therefore, while the study’s subjects admittedly improved, it cannot be stated whether they improved more or less than, or possibly stayed relatively even with, inpatients not in the program. 
Supported Education in a Community College for Students with Psychiatric Disabilities: The Houston Community College Model, (Housel & Hickey, 1993):   
Through a revolutionary partnership, the Mental Health and Mental Retardation Authority (MHMRA) of Harris County Texas, has entered into a liaison with the Houston Community College System (HCCS) to remove the barriers for admission to a postsecondary environment faced by people with a serious mental illness.

In January of 1992 the Office of Supported Education was established at the Central College in response to a needs survey of 1000 local consumers that had indicated an interest in training for a wide range of professions.  Initial goals of the Office were to train counsellors, administration and faculty to work with students with psychiatric disabilities, to identify support services to be provided to program participants, market services to the population to be served and establish referral procedures.  The development of an active advisory board, representative of the community being served, was paramount to the continued success of the program.  The Supported Education Advisory Board included representatives of the College, MHMRA, the Mental Health Association, the Alliance for the Mentally Ill, and students with and without a psychiatric disability.  On site support through the Office of Supported Education, that coordinated mobile support in the form of specialized case managers, was viewed as a psychological reassurance to students enrolled in the segregated programs as well as to those consumers engaged in mainstream programs. 

In July of 1992 “The Entry/Re-entry Program for Students in Transition was implemented.  This program, established in a segregated classroom at the college, accentuated: 1) management of one’s psychiatric disability 2) study skills training 3) Basic English and math 4) vocational exploration 5) building a support network amongst the students 6) assistance in navigating and re-entering the mainstream educational system.  Of the 34 consumers enrolled in this program, 28 went on to enrol in regular classes.

At the same time and with the support of the MHMRA, the College also developed a Program to train psychiatric consumers as case management aides.  This program called the Community Service Aide Training Program is a one-year program that involved 27 credits, some achieved through in class education, and the balance as part of a 256-hour paid internship.  The MHMRA was responsible for screening and selecting students from a large group of applicants (for each person accepted into training, two were turned away), providing psychiatric support to students, and providing employment opportunities to successful graduates.  Funding for books, tuition and clothing came from various sources (pg43) and HCCS developed the curriculum, provided instruction and accreditation.  Thirteen of the fifteen students (87%) enrolled in the first class completed the internship and were hired as case manager aides.  This rate of success was replicated in two subsequent classes.

The three facets of the entire program have assisted over 200 students with psychiatric disabilities to access educational services that had previously been out of reach.  These kinds of programs insist on a close working relationship between mental health agencies and community colleges, and demand that the college maintain an open door policy regarding enrolment (Housel & Hickey, 1993, p. 47).

Besides limitations relating to the lack of randomized controlled studies of the above, it should be noted by facilities responsible for whole populations of mental-health consumers that two thirds of applicants were turned away from one component of the above program.  Suitable, yet meaningful alternative opportunities would logically be required for the excluded by any facility mandated to service all consumers comparably. The Handbook on Supported Education (Unger, 1998):

A Supported Education Program in a Clubhouse
Laurel House in Stamford, Connecticut developed a program in the 1980’s to assist students with admissions, enrolment and obtaining financial aid to students planning to attend a post secondary institution (Doughterty, 1997).  The program also provides emotional, psychological and administrative support to the members of the clubhouse enrolled in school programs.  One full-time staff at Laurel House is employed to discuss students’ plans to return to school, assist with registration and financial aid, offer or arrange tutoring, help with schoolwork, lead an educational support group and travel to the campus if the student requires any on-campus assistance.  One interesting development of the program is the culture of support for education that has evolved at Laurel House.  Staff and fellow members have come to value education and support the educational goals of those enrolled.  A review of the program in 1998 found that 70 members of Laurel House had returned to school enrolling in a total of 300 courses.  Of these 70 members, several had graduated.

A Supported Education Program in a Community Services Agency
The Kennedy Service Centre, a supported employment program was established in Trumbull, Connecticut in 1989 with the assistance of the State Department of Mental Health.  Through this program, students with psychiatric disabilities can pursue their vocational goals by accessing and completing postsecondary educational opportunities (Petella, Tarnoczy, & Geller, 1996).  Services offered by the Program include; testing for career interests, skills and abilities; help in formulating a long-term vocational goal and associating it with their educational plan; financial aid planning; education support/discussion groups and summer workshops promoting education; individualized tutoring and the fostering of student support skills such as time management, organizational skills, study skills and stress management with an emphasis on making use of existing supports available on the college campus.  A consulting psychologist is also available to help staff contend with situational problems. 

A Supported Education Program in a Hospital Setting
The Western State Hospital Patient and Family Education Program, in Tacoma Washington is a program contracted through Pierce Community College, thus providing comprehensive educational services to consumers and their families since the mid 1970’s.  Client’s who had not previously been considered appropriate for the classroom have been observed to be “cogent, focussed and student-like in the classroom” (Gilmur, 1997, pg 29).  What is astounding, about this program, is the universality of the services offered and the provision of services to all groups within the hospital including forensic patients, older adults, and all psychiatric diagnoses.  The services offered consist of Adult Basic Education, and high school completion/general equivalency diploma; psycho-educational classes; health and wellness; women’s health issues; medication education; HIV education; substance abuse; empowerment; symptom management and recovery and family /consumer illness education.  The program’s staff members include six instructors, a director, and an office assistant.  Remarkably, 500 clients are enrolled in education classes each semester, a whopping 62% of the individuals in the hospital.  Teaching methods draw from methods used with students with learning disabilities and embrace multimodality teaching, repetition, stimulus reduction, experiential learning, and individualized instruction.  A support program has also been developed for students who plan to continue their college education when they leave the hospital.

The book did not indicate that any of the three models reviewed had been studied using an experimental design.  However, the programs, each in their own way, suggest relevant and important protocols for effective supported education, and in light of the high level of patient participation, most particularly in the Western State Hospital Patient and Family Education Program (62%).

Redirection Through Education: Meeting the Challenges (Gilbert et al., 2004):
In the fall of 1973 the Rehabilitation ‘Through Education Program’ was established in a trailer, on the grounds of Lakeshore Hospital in Toronto. Initially the program began with two George Brown College faculty members teaching life skills, refresher English and math every morning.  Eventually, a full time program for 20 students was placed on the main college campus, in response to demands to prepare consumers seeking to return to the community and to work.  The program was subsequently expanded to help with community support for finances, housing, health care as well as establishing programs to meet social, vocational, academic and recreational needs.  The Ministry of Health provided Vocational Rehabilitation Funding for two more full time staff in 1977 and in 1979 George Brown College funded another full time faculty position.  By 1979 enrolment had had climbed to 65 consumer/survivor/students and the program continued to undergo changes to respond to social and economic trends.  The 1980’s saw the organization delineated in three major directions, the first focussing on self-assessment, self-esteem, and confidence building, the second on vocations and offering supportive work placements through the creation of downtown cafes, and the third concentrating on enhancement of vocational skills so as to increase employment outcomes.  More recently, the program has experienced curriculum changes and because of an increasingly competitive job market and the RTE faculty have begun providing post secondary school credit courses that students can complete without charge.  These courses include 1) Strategies for Student Success; 2) Society Challenges and Change; 3) English; and 4) The E-course, a mandatory Ontario wide computer course.

In 2002 the RTE program joined the Access Centre of Excellence, a division of the College formed to serve under-prepared students.  Because it was grouped with other college programs such as, English as a Second Language, the Academic Bridging Program, pre-programs in Health Sciences, Hospitality, Community Services, and Business, it is hoped that students from the RTE program will readily access some of these courses as well.


RTE Outcomes (2000-2001)
Phase Number of Students To next phase Extended phase To work or further education Withdrew
1 92 61 (66%) 7 (8%) 6 (7%) 18 (20%)
2 89 26 (29%) 40 (45%) 12(13%) 11(12%)
3 26 n/a  n/a 24(92%) 2(8%)
 
It is interesting to note that after 30 years, RTE is moving to the main campus of George Brown College, thereby offering students access to all of the main campus facilities and providing them with a greater access to other mainstream college courses, a definite step toward further integration into mainstream education.

The article reports that most of the students enrolled in the program had completed high school, some had a college diploma or university degree, and a few had completed graduate work.  Therefore, generalization of the above programs is limited by participation criteria, which appear specific to more highly educated students (i.e., mean educational level of 12 years or more).

Review of Vocational Rehabilitation for People with Severe Mental Illness, a Comparison of Supported Employment (SE) and
Prevocational Training
(Crowther et al., 2001):
This Cochrane meta-analysis of 18 randomized controlled trials (N=2539) comparing prevocational training, supported employment and standard community care, found that people who received Supported Employment were significantly more likely to be in competitive employment at 12 months (34%) than those who received Pre-vocational Training (12%).  For the purposes of this review, pre-vocational training was described as “any approach to vocational rehabilitation in which participants were expected to undergo a period of preparation, before being encouraged to seek competitive employment.  This preparation could involve either work in a sheltered environment (clubhouse approaches and sheltered workshops) or some form of pre-employment training or transitional employment”.  Supported employment was defined as, “any approach to vocational rehabilitation that attempted to place clients immediately in competitive, integrated employment with a period of workplace preparation no longer than one month and indefinite follow up or support”.  Standard community care was defined as, “usual psychiatric (outpatient) care for patients in the trial, without any specific vocational component”.  Outcome measures included: engagement in competitive employment; amount earned in dollars per month; length of employment measured at follow up intervals and health care costs per client.  Clinical outcomes were also measured using a variety of scales, listed as: the Global Assessment Scale (Endicott et al., 1976), the Positive and Negative Symptom Scale (Kay et al., 1987), the Brief Psychiatric Rating Scale (Overall & Gorham, 1988), the Self Esteem Scale (Rosenberg, 1965) and the Quality of Life Scale (Heinrichs et al., 1984).  A total of 31 studies were excluded from the review because they did not meet the requirements for the review. (i.e.; not randomised, no vocational component offered, diagnosis unclear)  The results of this meta-analysis emphatically pointed out that pre-vocational training was no better at increasing length of employment than standard community care (Crowther et al., 2001), and echoed the findings of Bond et al. (1997) that pre-vocational training promoted dependency and deterred clients from finding competitive employment.

One obvious limitation to this otherwise thorough review of the extent literature is the fact that the extent literature (i.e., all rigorous studies to date and therefore included in the meta-analysis) is restricted to the United States.  The replication of results in Non-American studies is needed to generalize the conclusions and promote understanding in this area.
Results of a Multisite Randomized Trial of Supported Employment Interventions for Individuals With Severe Mental Illness (Cook et al., 2005):

This trial randomly assigned 1273 outpatients with severe mental illness either to an experimental Supported Employment program, a comparable program, or a services-as-usual condition”.  The outcome analysis considered three measurable vocational outcomes; competitive employment (mainstream, minimum wage job); working for 40 or more hours in a single month; and monthly earnings.  Follow up was conducted after 24 months.  Experimental group participants in this study were more likely than those in comparison programs to achieve competitive employment, more likely to work 40 or more hours in a given month and had significantly higher monthly earnings than those in comparison programs.

This study provides admirable standards for future SEd research.  Specifically, the study included the use of a large sample, randomization, practical outcome measures, and the comparison of treatment with both a comparable program and “service-as-usual”. 

Regrettably, while the study goes so far as to include multiple sites and a large study sample, it again is restricted to the continental United States.

Discussion
The determination of the effectiveness of studies of educational programs is made more difficult by variance in the method of selection of subjects or participants, the differences in site selection or location of the program, and the variety of educational programs offered to psychiatric clients, (hereby referred to as students in this discussion).  At first glance studies that showed significant improvement in continued enrolment in post secondary courses and longer terms of competitive employment inspired optimism.  However the first three studies, examined above, all include, as part of their selection criteria, students with above average intelligence and students who have a mean education at least 13 years.  This is not a random cross section of the population of adults with a psychiatric disability and it would seem that more favourable study results could be expected from a more highly educated and intelligent experimental group.  Having said this, the studies are important because they demonstrate that for higher functioning students, an educational approach to rehabilitation both increases the desire to stay in school and results in longer terms of competitive employment.

On the other hand, the meta-analyses of randomised controlled studies, such as the Cochrane Review (Crowther et al., 2001) of Vocational Rehabilitation for People with Severe Mental Illness and the Multisite Randomized Trial of Supported Employment Interventions for Individuals With Severe Mental Illness (Cook et al., 2005), have a more inclusive selection criteria for experimental subjects and are more representative of the entire population rather than dealing with an elite group.  One confusing aspect of the Cochrane meta-analysis begins with the definition of Pre-vocational Training. The definition offered for the purposes of this collection of studies perhaps muddies the waters by including transitional employment, sheltered workshops and Clubhouse Approaches along with an “in-class” pre-vocational training model.  (The in-class pre-vocational training model has been described by Unger and Anthony, in the Boston University study in 1991, as having significant effect on high functioning students with psychiatric disabilities.)  These meta-analyses both claimed that supported employment was clearly more effective than pre-vocational training and other approaches to vocational rehabilitation or standard community care (that offered by an outpatient service or assertive community treatment model).

 The Houston Community College was unique in the creation of new approaches to SEd including the creation of a Consumer Case Management Aide Program, an Entry/Re-entry Program for Students in Transition and an Office of Supported Education designed to provide psychological support, counselling and educational accommodations to students enrolled in the college.  These programs, (although still limited to higher functioning psychiatrically disabled students), should be viewed jealously by universities and colleges, both for the creation of new academic programs and for the removal of barriers to enrolment in the college system.

The alliance formed between Western State Hospital and Pierce Community College in Tacoma Washington is another model that waves the gold standard for approaches to supported education within a hospital setting.  The sheer numbers of students enrolled in educational events during a quarterly period in this hospital comprised a staggering 62% of the hospital population.  The wide variety of educational services offered in the Tacoma program would rival even the in-service staff training for many hospitals.  The Tacoma model establishes education as a right, not a privilege, and echoes the writings of more liberal adult educators such as Paulo Freire (1972) who felt that education should be freely provided, regardless of social class, level of intelligence, or current geopolitical location.  Underlying Freire’s vision of popular education are the following precepts:

* Identifying the problems, expectations and expressed needs of a community;
* Identifying areas of change relevant to the groups' needs;
* Considering the community's history, its local power base and economic distribution;
*Understanding why there are those who are disadvantaged, or oppressed.

Certainly the mentally ill inside and outside of a hospital are members of a community who are disadvantaged and (some might argue) oppressed by mainstream educational values that uphold the rivalry for marks and vicious financial and academic competition for entry into learning.

Recommendations
Provision of an Extensive Variety of Services:
One key to the provision of academic opportunities to the seriously mentally ill lies in the offering of a wide variety of services, so as to challenge and reward each and every individual regardless of mental illness, age, sex, social status or intellectual level.  There should therefore exist, an educative and rehabilitative opportunity appropriate for every individual with a psychiatric disability, regardless of functional level.  The mainstream community of people are a diverse and heterogeneous lot whose intellects vary greatly.  We should not expect the population of mentally ill to be any different.  This concept became more evident as articles were searched for this review, with successful academic programs commonly restricted to the more highly educated mental health consumer.

Within a hospital and community setting, the cross-sections of mental health consumers are microcosms of society at large.  The provision of psychiatric services must therefore mirror this diversity.  Whether dual diagnosis, forensic, geriatric or acute care, each hospital ward embodies not only different diagnoses but also contains many types of individuals of different economic, social, intellectual and educational backgrounds.

The student service should address the needs of the individual student.  Sometimes the needs are limited by the nature of the residential program or ward a client is assigned to.  For example, forensic clients are often in hospital for longer periods and do not have privilege levels that allow them to travel to other areas of the hospital or outside the hospital grounds.  Education should therefore be available in an acceptable format within their restricted territory; otherwise we risk the pitfall of condemning the offender to a worse fate, that is, of being uneducated simply because of his incarceration.

Similarly, a short-term client on an acute care ward, struggling through a complex of crisis events may find short-term guidance vis-à-vis viable educational pathways to be a crucial component within the parcel of critical care services offered.  For this student, educational counselling and psycho-educational support might highlight the need for a new or changing direction in continuing education or career.

In dual diagnosis clients with low baseline educational levels, assessment of individual needs can be followed-up with basic literacy and numeracy instruction which provides structure to daily living, while remediating lost math and language skills necessary for successful independent living.  In a group setting, such learning in a classroom environment builds social skills through the normalizing influences of “appropriate school behaviour”.
 
Match the Intervention to the Students Ability and Preference:
Effective college and prevocational training programs that persist for more than one month in length have been found to benefit high functioning clients with mean educational attainments of at least 13 years (Unger et al., 1991), (Hoffmann & Mastrianni, 1993).  It is possible therefore, that many issues addressed in prevocational training programs may be too challenging for clients whose language reasoning and other academic skills are inadequate or whose preference is to work but not to attend training sessions.  Prerequisite cognitive abilities can be assessed through transcript information or academic testing.  Lack of pre-course screening for functional level result in lower-functioning students feeling alienated from the rest of the group, leading to negative effect such as depression and disruptive behaviour.  Clients with poorer educational backgrounds who are found unsuitable for an extended prevocational training period could instead be offered adult basic education to upgrade skills.  Some of these properly-assessed students might even progress on to secondary school courses, with courses containing subjects of unique interest to them rather than subjects that the instructor feels they need to take.  Clients with low functional ability may at the same time, be served better by shorter prevocational preparation periods of no longer than one month and assisted by a job development specialist and a supported employment specialist to find and keep a personally meaningful job.  Sheltered workshop environments may be more appropriate for the lowest functioning clients, who may never be able to reasonably compete for mainstream employment because of chronic psychiatric disability and/or profound cognitive disability.

Integrate into Mainstream Education System Whenever Possible:
Repeated examples of on-campus supported education such as the Houston Community College Model (Housel & Hickey, 1993) emphasize the need for high functioning clients with psychiatric disabilities to move towards describing themselves as students rather than patients.  Such transformations, from being a passive recipient of treatment to becoming an active learner who purposefully and independently seeks out experiences for erudition do not logically occur within a hospital setting, where clinicians commonly reward absence of volition.  Such transformations to active learning are, at the same time, not magical processes, nor do they happen over night.  Instead, they require coaching, instruction and encouragement from a supportive teacher who also possesses the counselling skills necessary to facilitate change (Unger et al., 1991).

The Development of Working and Funding Partnerships Between Community Colleges and Hospitals:
In most of the settings examined, community colleges and universities were located in the same community and therefore retained an obvious advantage over mental health facilities located in rural areas (i.e., away from post secondary institutions).  Wherever possible, mental health facilities need to foster close ties with colleges and universities to provide on-campus courses and broaden educational opportunities for psychiatrically disabled students both in mainstream and special education classes.  The Boston, Houston, Tacoma, Saratoga Springs, and Toronto models all demonstrate a close and interactive participation between mental health facilities and colleges and universities that demand inventive approaches to joint funding.  These funding approaches may incorporate separate provincial ministries or state departments or offices into the funding formula and, as with the Houston model, may involve municipal, community college, private industry, federal and state/provincial government funding.  The challenge may, in some cases, be to overcome the barriers to inter-ministry cooperation.  It may also be more cost effective for one ministry (because of existing programming) to provide educational and prevocational opportunities to clients who’s training is normally funded through another ministry (because of psychiatric diagnosis or developmental challenge).

An Emphasis on Developing the Role of the Job Development and Supported Employment Specialists:
Because of the wide body of literature and the large number of controlled, randomised trials comparing supported employment to other methods of vocational rehabilitation, it was inevitable that searches for supported education would reveal much in the literature in the area of supported employment.  Without exception, all such meta-analyses stress the value and efficacy of supported employment over other methods of vocational rehabilitation.  “Clients who were placed directly into jobs with training and support had higher rates of employment than those who had extended prevocational preparation” (Goering et al., 1997).  Some information suggests further research into the role and effectiveness of the “Job Development Specialist” separating this role entirely from that of the “Employment Support Specialist”.  Employment support should be ongoing and should only cease when both the employer and the employee mutually agree that support is no longer needed.

Further Research
Little formal research exists in the area of SEd, especially in the area of randomized controlled experiments.  However, within the limited research that does exist, there is much to suggest hope that future research would in fact find SEd to be both popular and effective.  Future research should clearly determine the benefits of supported education, while individual studies should take into account the functional level of the subjects through the careful matching of controls and treatment subjects.  In particular, more attention should be given to education as an intervention for lower functioning students with psychiatric disabilities.  Most of the existing studies involved clients with mean levels of education of 13 or more years.  Such academic levels are not representative of publicly funded state or provincial psychiatric facilities. Except for the meta-analyses reviewed here, most study samples have been somewhat small.  Therefore larger studies are needed.
 
Another concern is the clouding of definitions and the uncertainty over protocols for outcome measurement.  Researchers need to work more closely together to develop definitional consensus around what is meant by terms such as pre-vocational training and community care, thus studies related to educational interventions will more precisely target each individual intervention.  Similarly, increased standardization of outcome measures is needed so that future studies can continue to replicate and validate results.

Conclusion
Many of the cited approaches to academic education were drawn from pristine examples where unrealistically ideal conditions exist for supported education.  These centres of pre-eminent practice champion unrealistic paradigms of funding, cooperation, and multi-service provision.  Many are located in areas where hospitals are in close geographical proximity to educational facilities and can easily accommodate on-campus education.  In the real world, such conditions rarely if ever exist.  Instead, practical solutions should be formulated to provide potential students having a psychiatric disability, with effective educational opportunities within the hospital setting and should always strive for the ultimate aim of integration into mainstream education.  The flexibility of the educational programming should allow for careful planning based on an assessment of the patient populations needs, specific to its particular history, problems, expectations and expressed needs.

Educational or psycho-educational planners and facilitators should keep in mind the quality practices underlying evidence-based practices, specifically that the nature and quality of the therapeutic relationship will remain crucial to success; and that quality practices of necessity must be inclusive, continuous and individualized, thus matching services to the needs, strengths, preferences and values of the recipient.  Quality practices in supported education should also be dynamic, promote responsible partnerships, involve quality practitioners, be culturally competent and outcome oriented ("Creating An Environment of Quality Through Evidence-Based Practices", 2006).


References

Bond, G. R., Drake, R. E., Mueser, K. T., & Becker, D. R. (1997). An update on supported employment for people with severe mental illness. Psychiatric Services, 48(3), 335-346.

Bruer, R., Cloninger, C., & Spitznagel, E. (2006). The temporal limits of cognitive change from music therapy in elderly persons with dementia or dementia-like cognitive impairment: A randomized controlled trial. Manuscript submitted for publication.

Cook, J. A., Leff, H. S., Blyler, C. R., Gold, P. B., Goldberg, R. W., Mueser, K. T., et al, (2005). Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness. Arch Gen Psychiatry, 62(5), 505-512.

Creating An Environment of Quality Through Evidence-Based Practices. (2006).   Retrieved August 14, 2006, from http://www.omh.state.ny.us/omhweb/ebp/index.htm

Crowther, R., Marshall, M., Bond, G., & Huxley, P. (2001). Vocational rehabilitation for people with severe mental illness. Cochrane Database Syst Rev, CD003080.

Dougherty, S., Kampana, K., Kontos, R., Flores,M., Lockhart, R., & Shaw, D. (1996). Supported Education: A qualitative study of the student experience. Psychiatric Rehabilitation Journal, 19(3), 59-70.

Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry, 33(6), 766-771.

Freire, P. (1972). Pedagogy of the Oppressed. New York, NY: Herder and Herder.

Gilbert, R., Heximer, S., Jaxon, D., & Bellamy, C. (2004). Redirection Through Education: Meeting the Challenges. American Journal of Psychiatric Rehabilitation, 7(3), 329 - 345.

Gilmur, D., (1997). A hospital based education program: The sequel to community supported education. The Journal of the California Alliance for the Mentally Ill, 8(2), 28-30.

Goering, P., Boydell, K., Butterill, D., Cochrane, J., Durbin, J., Rogers, J., et al. (1997). Review of Best Practices in Mental Health Reform.   Retrieved September 9, 2006, from http://www.phac-aspc.gc.ca/mh-sm/pubs/bp_review/pdf/e_bp-rev.pdf

Heinrichs, D. W., Hanlon, T. E., & Carpenter, W. T., Jr. (1984). The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. Schizophrenia Bulletin, 10(3), 388-398.

Hoffmann, F. L., & Mastrianni, X. (1993). The role of supported education in the inpatient treatment of young adults: A two-site comparison. Psychosocial Rehabilitation Journal, 17(1), 109-119.

Housel, D., & Hickey, J. (1993). Supported education in a community college for students with psychiatric disabilities: The Houston Community College Model. Psychosocial Rehabilitation Journal, 17(1), 42-50.

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.

Overall, J. E., & Gorham, D. R. (1988). The Brief Psychiatric Rating Scale (BPRS): recent developments in ascertainment and scaling. Psychopharmacology Bulletin, 24, 97-99.

Pettella, C., Tarnoczy, D.L., & Gellar, D. (1996). Supported education: Functional techniques for success. Psychiatric Rehabilitation Journal, 20(1), 36-41.

Quinsey, V.L., Harris, G.T., Rice, M.E., & Cormier, C.A. (1998). Violent Offenders: appraising and managing risk. Washington, DC: American Psychological Association.

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press.

Unger, K. V. (1998). Handbook on supported education: providing services for students with psychiatric disabilities. Baltimore: P.H. Brookes Pub. Co.

Unger, K. V., Anthony, W. A., Sciarappa, K., & Rogers, E. S. (1991). A supported education program for young adults with long-term mental illness. Hosp Community Psychiatry, 42(8), 838-842.

Zwicker, N. & Myers, M. A., (1991). Patient Education Survey: A Review of Academic Programs in the Ontario Psychiatric Hospital System and Abroad. Penetanguishene, ON: Educational Services, Penetanguishene Mental Health Centre.

 



Copyright © 2006 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
      All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras