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).
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