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Column   |    
Rehab Rounds: The Michigan Supported Education Program
Carol Mowbray, Ph.D.
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.11.1355

Introduction by the column editors: With the advent of improved pharmacological treatments, empirically tested psychiatric rehabilitation techniques, and an increased emphasis on the empowerment of mental health consumers, many adults with psychiatric disabilities now have a realistic chance of reentering their communities and reestablishing meaningful and productive lives. Because work is a fundamental component of adjustment in adult life, helping individuals obtain and maintain jobs has been viewed as the sine qua non of psychiatric rehabilitation.More recently, however, rehabilitation practitioners have realized that many adults with psychiatric disabilities have the desire and the requisite motivation and educational background to attend college (1). Hence rehabilitation practitioners have recognized that helping individuals restart their postsecondary educational pursuits is a desirable, valid, and viable option (2,3).Supported education is being used increasingly to encourage adults with mental illness to enroll in and complete postsecondary education by providing assistance, preparation, and ongoing counseling (4). Several reports have suggested that supported education programs contribute to positive outcomes such as graduation, acquisition of marketable skills, employment, and positive self-esteem (5,6,7). In this month's column, Carol Mowbray, Ph.D., describes the Michigan Supported Education Program and provides a rationale and empirical validation for its inclusion as an integral modality of psychiatric rehabilitation.

Abstract Teaser
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The Michigan Supported Education Program began as a three-year research demonstration project in the mid-1990s. It was designed to serve adults with psychiatric disabilities in the Detroit metropolitan area who had a range of psychiatric diagnoses. After its evaluation was completed in 1997, the program was incorporated into the array of services offered by the Detroit-Wayne County Community Mental Health Agency through the Southwest Detroit Counseling and Development Center. It now serves 150 consumers each year.

The Michigan Supported Education Program delivers its services on two college campuses: Wayne County Community College's downtown Detroit campus and Henry Ford Community College in Dearborn. To be eligible for the program, a person must have a psychiatric disability of at least one year's duration. Participants must have obtained or be near completion of a high school diploma or general equivalency degree and have an interest in pursuing postsecondary education. Participants in the program must also be willing to use mental health services, if needed, during participation in the program.

The mission of the program is to enable adults with serious mental illness to reach readiness for matriculation at a community college. This objective is accomplished by helping participants choose and attain career and educational goals and acquire the skills necessary to achieve these goals. To promote skill acquisition, most educational services are provided in a classroom format. These noncredit classes meet for two and a half hours twice a week for two 14-week semesters.

The classes provide opportunities to develop and practice skills by using a set of curriculum modules adapted from the model program developed at Boston University (8). The curriculum uses small group exercises and experiential learning. It is organized around three topics: coping with the academic environment, stress management, and developing career choices. The curriculum covers academic and social skills and requires verbal and written assignments focused on the use of the library, the career laboratory, and other campus resources. Students receive help in completing financial aid forms and college admission applications and in selecting courses and dealing with registration materials. In addition, the students receive feedback from peers and staff and learn how to solve common academic problems, such as resolving conflicts with professors.

The Michigan Supported Education Program employs the psychiatric rehabilitation principle that development and practice of skills should occur in a setting similar to that in which the skills will be used. Using this approach helps build participants' confidence in their ability to enter a real classroom in the future. Unlike the procedure in other supported education programs, the curriculum sequence is determined through an assessment of participants' needs at the beginning of each semester, in which the curriculum topics to be covered are prioritized. Each class of 12 to 15 students sets its own agenda.

This process begins when a program staff member leads a discussion about student roles. Participants are asked to think about what help they need to pursue postsecondary education or training. They are then asked to list their needs on a flip chart under one of three categories: information, skills, and support. For example, learning about opportunities for financial aid would be placed in the information category, note taking in the skills category, and help from family in the support category.

Students are then given dots of three different colors, with each color corresponding to a rank: blue dots for the most important items, yellow next, and red for the least important. Students place their dots next to the needs listed on the flip chart. The needs with the most blue dots are given the highest priority. The prioritized list is typed and becomes the curriculum for the next session of the program. This approach provides an empowerment experience and sets the tone for the rest of the class sessions.

The program provides individualized services, including career planning and vocational assessment, information on enrollment in colleges and training programs, assistance in obtaining financial aid, practice in college survival skills, and information on rights and resources for disabled students (9). Follow-up services are available indefinitely. They include individual counseling and scheduled group sessions to help students carry out their educational plans. Students also can participate in an alumni group that provides continuing peer support. All students are encouraged to follow up with their case managers to discuss progress on their educational plans and also to attend periodic refresher sessions and educational field trips, particularly during the summer, when school is not in session.

In 1998 the Michigan Supported Education Program opened a resource room, with computers and software for developing or renewing skills in math, reading, writing, computer literacy, and typing. Tutors are also available in the resource room. These services are open to current and former students.

The full-time director of the program is a master's-level social worker with extensive experience in psychiatric rehabilitation. The direct-service staff includes three full-time employees, at least one of whom is a mental health consumer, for the classroom groups, plus a tutoring coordinator. Often staffing is augmented with a student intern. The program also has a full-time administrative assistant and a part-time clerical support worker. The program budget contains funds to meet a wide range of student needs, such as for transportation, child care, and academic supplies.

System-level coordination has played a significant role in the success of the supported education program. With the permission of program participants, staff members share information with case managers and therapists about participants' progress in the program. Staff members continually provide information about the program to mental health workers and vocational rehabilitation providers both to ensure their cooperation and to ensure that these other providers will echo the hopeful attitudes and encouragement provided by program staff.

A positive relationship with representatives of the community college is necessary because space is at a premium on most campuses and accommodating students with serious mental illness may not be a high priority for college administrators. Staff from the disabled student services office of the community college are invited to the initial orientation session for program participants, where they discuss practical topics such as admission procedures, financial aid applications, and student support services. Later in the semester, as part of the curriculum modules on financial aid or college admission procedures, small groups of program students are introduced to college officials and complete the requisite applications with personal assistance. When a program participant enrolled at the college experiences difficulties, the disabled student services office works with program staff to find the optimal solution for the student's academic or behavioral problem.

To optimize recruitment and ensure that appropriate services are offered, staff members of the supported education program also collaborate with consumer-run programs, self-help groups, family organizations, and other advocacy groups. Program staff often make presentations at monthly meetings of these groups, which helps recruit participants and educates consumers and family members about the how the program works, whom it is appropriate for, and what the program can and cannot do. The prospect of attending college classes can be frightening, even for those who want to, unless they understand the nature of the supports offered by the program.

The Michigan Supported Education Program was evaluated using an experimental design with random assignment of participants enrolled for the programs' first 15 months (N= 397) either to active group treatment in the program or to a control group. Students in the control group did not participate in a structured or scheduled intervention. Instead, they were assigned to a staff person, who, at the student's request, was available to help the student meet his or her own, self-defined needs. Outcomes were measured at program completion and at six and 12 months. Characteristics of the sample have been reported elsewhere (10).

At the follow-up interviews, participants in active treatment but not those in the control group showed significant improvements in quality of life, self-esteem, and social adjustment and greater participation in college or vocational training (11). For example, from baseline to six-month follow-up, participants in active treatment experienced a threefold increase in their level of productive activity. By the 12-month follow-up, participants in active treatment were nearly twice as likely as those in the control group to be involved with school, vocational training, or employment.

Qualitative data analyses based on ratings done by coders who were blind to the participants' treatment data also substantiated the positive effects of the program. Responses to vignettes showed that positive coping behaviors differed significantly for those with high and low attendance rates. The reported use of positive coping behaviors such as problem-solving strategies rather than negative or neutral coping behaviors was positively associated with 12-month outcomes for program participants (12).

Qualitative data showed that for all participants, the specificity of school-related goals increased over time, as did a measure of optimal goal setting. Furthermore, participants who chose "attending school" as their most important goal at program entry were more likely than others to enroll in college after they completed the program (13).

Afterword by the column editors: Although supported education may not be suitable for all persons with serious mental illnesses, for those who have the interest and ability to attend college, supported education offers a number of benefits. They include a new and positive identity as a student —a transformation from being "a patient" to having a different and valued societal role as a student, with the hope and expectation of a better future. Unfortunately, although the empirical evidence for supported education is growing, only a handful of psychiatric rehabilitation agencies have adopted this technology.

The School of Social Work at the University of Michigan was awarded a grant from the Center for Mental Health Services to support dissemination and to assist interested sites in replicating or adapting supported education to their own locale. Within the first six months of the dissemination effort, six locales developed planning committees that involve mental health and vocational rehabilitation professionals, community college staff, consumers, and family members.

A significant barrier to dissemination of supported education programs is stigma about mental illness. Ensuring that more positive information is available to professionals and the general public about the possibilities for rehabilitation and recovery would enable students with psychiatric disabilities to receive more support and face fewer barriers on college campuses. Mental health clinicians and family members could help reduce stigma by encouraging consumers to pursue their educational aspirations.

Supported employment and education should be given priority when consumers have reached the stable phase of their mental disorder. This proposition is in accord with the American Psychiatric Association's Practice Guideline for Treatment of Schizophrenia (14) and with empirical evidence documenting the latency between improvement in psychopathology and regaining the capacity to work and solve interpersonal problems (15,16).

This study was funded by grant HD5-SM-47669 from the community support program branch of the Center for Mental Health Services to the Michigan Department of Community Health. It represents a collaboration between the schools of social work at the University of Michigan, Eastern Michigan University, and Wayne State University and the Detroit-Wayne County Community Mental Health Services Agency. The author acknowledges assistance in the design, implementation, and evaluation of this program from Deborah Bybee, Ph.D., Mary Collins, Ph.D., the late Phyllis Levine, M.S.W., Kaaren Brown, M.S.W., Steve Szilvagyi, M.A., Deborah Megivern, M.S.W., Chyrell Bellamy, M.S.W., Elaine Thomas, M.S.W., and David Moxley, Ph.D.

Dr. Mowbray is the developer and principal investigator for the Michigan Supported Education Program. She is professor and associate dean for research at the University of Michigan School of Social Work, 1080 South University, Ann Arbor, Michigan 48109-1106 (e-mail, cmowbray@umich.edu). Alex Kopelowicz, M.D., and Robert Paul Liberman, M.D., are editors of this column.

Hazel K, Herman SE, Mowbray CT: Characteristics of adults with serious mental illness in a public mental health system. Hospital and Community Psychiatry 42:518-525,  1991
 
Moxley D, Mowbray C, Brown KS: Supported education, in Psychiatric Rehabilitation in Practice. Edited by Flexer R, Solomon P. New York, Butterworth, 1993
 
Unger K: Psychiatric rehabilitation through education: rethinking the context, in Psychiatric Rehabilitation Programs: Putting Theory Into Practice. Edited by Farkas MD, Anthony WA. Baltimore, Johns Hopkins University Press, 1989
 
Bellamy C, Mowbray CT: Supported education as an empowerment intervention for people with mental illness. Journal of Community Psychology 26:401-413,  1998
 
Unger K, Anthony W, Scriappa K, et al: A supported education program for young adults with long-term mental illness. Hospital and Community Psychiatry 42:838-842,  1991
 
Cook JA, Solomon ML: The Community Scholar Program: an outcome study of supported education for students with severe mental illness. Psychosocial Rehabilitation Journal 17(1):83-97,  1993
 
Hoffman FL, Mastrianni X: The role of supported education in the inpatient treatment of young adults: a two-site comparison. Psychosocial Rehabilitation Journal 17(1):109-119,  1993
 
Unger K, Danley D, Kohn K, et al: Rehabilitation through education: a university-based continuing education program for young adults with psychiatric disabilities on a university campus. Psychosocial Rehabilitation Journal 10(3):35-49,  1987
 
Frankie P, Levine P, Mowbray CT, et al: Supported education for persons with psychiatric disabilities: implementation in an urban environment. Journal of Mental Health Administration 23:406-417,  1996
 
Mowbray CT, Bybee D, Shriner W: Characteristics of participants in a supported education program for adults with psychiatric disabilities. Psychiatric Services 47:1371-1377,  1996
 
Mowbray CT, Collins ME, Bybee D: Supported education for individuals with psychiatric disabilities: long-term outcomes from an experimental study. Social Work Research 23:89-100,  1999
 
Collins ME, Bybee D, Mowbray CT: Measuring coping strategies in an educational intervention for individuals. Health and Social Work 24:279-290,  1999
 
Collins ME, Mowbray CT, Bybee D: Establishing individualized goals in a supported education intervention: program influences on goal-setting and attainment. Research in Social Work Practice 9:483-507,  1999
 
American Psychiatric Association: Practice Guideline for Treatment of Patients With Schizophrenia. American Journal of Psychiatry 154(Apr suppl):1-61,  1997
 
Mintz J, Mintz LI, Phipps C: Treatments of mental disorders and the functional capacity for work, in Handbook of Psychiatric Rehabilitation. Edited by Liberman RP. New York, Macmillan, 1992
 
Sullivan G, Marder SR, Liberman RP, et al: Social skills and relapse history in outpatient schizophrenics. Psychiatry 53:340-345,  1990
 
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References

Hazel K, Herman SE, Mowbray CT: Characteristics of adults with serious mental illness in a public mental health system. Hospital and Community Psychiatry 42:518-525,  1991
 
Moxley D, Mowbray C, Brown KS: Supported education, in Psychiatric Rehabilitation in Practice. Edited by Flexer R, Solomon P. New York, Butterworth, 1993
 
Unger K: Psychiatric rehabilitation through education: rethinking the context, in Psychiatric Rehabilitation Programs: Putting Theory Into Practice. Edited by Farkas MD, Anthony WA. Baltimore, Johns Hopkins University Press, 1989
 
Bellamy C, Mowbray CT: Supported education as an empowerment intervention for people with mental illness. Journal of Community Psychology 26:401-413,  1998
 
Unger K, Anthony W, Scriappa K, et al: A supported education program for young adults with long-term mental illness. Hospital and Community Psychiatry 42:838-842,  1991
 
Cook JA, Solomon ML: The Community Scholar Program: an outcome study of supported education for students with severe mental illness. Psychosocial Rehabilitation Journal 17(1):83-97,  1993
 
Hoffman FL, Mastrianni X: The role of supported education in the inpatient treatment of young adults: a two-site comparison. Psychosocial Rehabilitation Journal 17(1):109-119,  1993
 
Unger K, Danley D, Kohn K, et al: Rehabilitation through education: a university-based continuing education program for young adults with psychiatric disabilities on a university campus. Psychosocial Rehabilitation Journal 10(3):35-49,  1987
 
Frankie P, Levine P, Mowbray CT, et al: Supported education for persons with psychiatric disabilities: implementation in an urban environment. Journal of Mental Health Administration 23:406-417,  1996
 
Mowbray CT, Bybee D, Shriner W: Characteristics of participants in a supported education program for adults with psychiatric disabilities. Psychiatric Services 47:1371-1377,  1996
 
Mowbray CT, Collins ME, Bybee D: Supported education for individuals with psychiatric disabilities: long-term outcomes from an experimental study. Social Work Research 23:89-100,  1999
 
Collins ME, Bybee D, Mowbray CT: Measuring coping strategies in an educational intervention for individuals. Health and Social Work 24:279-290,  1999
 
Collins ME, Mowbray CT, Bybee D: Establishing individualized goals in a supported education intervention: program influences on goal-setting and attainment. Research in Social Work Practice 9:483-507,  1999
 
American Psychiatric Association: Practice Guideline for Treatment of Patients With Schizophrenia. American Journal of Psychiatry 154(Apr suppl):1-61,  1997
 
Mintz J, Mintz LI, Phipps C: Treatments of mental disorders and the functional capacity for work, in Handbook of Psychiatric Rehabilitation. Edited by Liberman RP. New York, Macmillan, 1992
 
Sullivan G, Marder SR, Liberman RP, et al: Social skills and relapse history in outpatient schizophrenics. Psychiatry 53:340-345,  1990
 
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