Systematic Review of Supported Education Literature 1989-2009 » Disability Research Right to Know

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Systematic Review of Supported Education Literature 1989 – 2009

Suggested Citation: Rogers, E. S., Kash-MacDonald, M., Bruker, D., & Maru, M. (2010). Systematic Review of Supported Education Literature, 1989 – 2009. Boston: Boston University, Sargent College, Center for Psychiatric Rehabilitation. http://www.bu.edu/drrk/research-syntheses/psychiatric-disabilities/supported-education/

Conducted by the Center for Psychiatric Rehabilitation with support from the National Institute on Disability and Rehabilitation Research.

Plain language summary
Contributors
Introduction
Methods and procedures
Results and conclusions
Appendix A
Acknowledgements and statement concerning conflict of interest
References

Review conducted using a system for rating the rigor and meaning of disability research (Farkas, Rogers, & Anthony, 2008). The first instrument in this system is: “Standards for Rating Program Evaluation, Policy or Survey Research, Pre-Post and Correlational Human Subjects” (Rogers, Farkas, Anthony, & Kash, 2008) and “Standards for Rating the Meaning of Disability Research” (Farkas & Anthony, 2008).

Plain language summary

Supported education for individuals with severe mental illness seeks to provide the services necessary to place and keep individuals in integrated post secondary educational settings so that consumers can achieve their educational goals. It can be contrasted both philosophically and logistically with the traditional model in which individuals with psychiatric disabilities were expected to receive training or educational instruction in segregated settings with specialized curricula. In supported education, individuals with psychiatric disabilities are assisted to develop post-secondary educational goals, then resources and services are provided to support the individual in reaching their goals.

Results of this systematic review of supported education suggest that there are a very few well-controlled studies of supported education and numerous studies with minimal evaluation data and less rigorous designs.

As a result, our systematic review concludes suggests that there are limited effectiveness data for supported education programs. There is information to suggest that individuals with psychiatric disabilities, when compared to the general population, have a lower rate of post secondary degree completion. There is also information to suggest that individuals with psychiatric disabilities who are enrolled in supported education programs are younger, more highly educated and less functionally impaired when compared to individuals with psychiatric disabilities in general. Evidence from existing studies suggests that individuals with significant psychiatric disabilities can enroll in and pursue educational opportunities in integrated settings in the community. There is preliminary evidence that supported education can assist individuals to identify educational goals, find and link to resources needed to complete their education and assist them in coping with barriers to completing their education. There is very preliminary but insufficient information that supported education can increase the educational attainment of individuals with psychiatric disabilities. Because many studies are short term and focus on course completion, there is no rigorous evidence to suggest that supported education will lead to a greater number of individuals with psychiatric disabilities possessing advanced degrees or certificates. Further, there is no rigorous evidence that supported education leads to higher employment rates among participants.

If supported education is to become a viable alternative and widespread intervention and if mental health policies are to emphasize educational attainment, more effectiveness research on supported education models is critically needed.

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Contributors

Supported Education Study Group:

E. Sally Rogers,
Marianne Farkas,
William Anthony,
Megan Kash-MacDonald,
Center for Psychiatric Rehabilitation

Lead Reviewer:

E. Sally Rogers, Sc.D. Director of Research
erogers@bu.edu

Center for Psychiatric Rehabilitation
Boston University
Sargent College of Health and Rehabilitation Sciences
940 Commonwealth Avenue Westœ
Boston, MA 02215

Additional Reviewers:

Megan Kash-MacDonald, M.S., Research Associate
Debra Brucker, Ph.D., Consultant

Research Coordinator

Mihoko Maru, M. A.

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Introduction

Rationale for the Review.

In one of the few representative surveys examining the educational attainment of individuals with serious psychiatric disabilities, Waghorn and his colleagues (Waghorn, Still, Chant, & Whiteford, 2004) were able to compare rates of educational attainment among individuals with psychosis to individuals in the general population. While this study was conducted in Australia, other anecdotal information (e.g., Corrigan, Barr, Driscoll, & Boyle, 2008) suggests that the findings would be similar in the United States and other European countries. Waghorn used a population-based, representative, national survey to examine rates of educational attainment. They found that proportionally, more individuals with psychotic disorders left school at a young age when compared to the general population. They also found that a smaller proportion of individuals with psychosis completed post secondary education. These results were also supported by Corrigan in a non-representative survey where he found that only one-third of his sample of individuals with psychiatric disabilities had attempted post secondary education. This compares with data from the US Census reporting that in 2003, 85% of the population aged 25 years or older had completed high school, 53% had attempted college and 27% had completed their Bachelor’s degree (Crissey, 2004).

We know from other threads of research that the rates of unemployment among individuals with psychiatric disabilities are extraordinarily high (Mechanic, Bilder, & McAlpine, 2002; Mueser, Salyers, & Mueser, 2001; Bell & Lysaker, 1995; Twamley, Jeste, & Lehman, 2003). Individuals with psychiatric disabilities are also the least likely to be successful in the state and federal Vocational Rehabilitation (VR) program when compared with individuals with other disabilities (Andrews et al., 1992; National Institute on Disability and Rehabilitation Research, 1997). Work impairment among individuals with serious mental illness has enormous social costs (Cook, 2006; Marcotte & Wilcox-Gök, 2001) and reduces quality of life and life satisfaction (Arns & Linney, 1995; Eklund, Hansson, & Ahlqvist, 2004). Integral to these poor employment outcomes is the need for individuals with psychiatric disabilities to achieve higher levels of educational outcomes as education has repeatedly been demonstrated to predict vocational outcomes.

At the same time, Waghorn and colleagues found that higher education was positively associated with both employment and labor market participation and that unemployment rates were inversely related to educational level among the individuals with psychotic disorders and the general population. The authors also found that vocational training tended to facilitate employment more than higher education, however, due to small sample sizes the authors are not convinced that this is a strong finding (Waghorn et al., 2004).

Clearly educational and vocational attainment are strongly intertwined and linked both theoretically, in policy and in practice, but most importantly, in the lives of individuals with psychiatric disabilities.

Objectives of the Review

The objective of this report is to systematically review all literature related to supported education for individuals with severe mental illness, not limited to randomized clinical trials (RCT’s). The premise for this systematic review was that we believed there to be important and significant research published in the field of supported education that urgently needed to be synthesized for the mental health field at large. It was assumed that valuable information could be gleaned from these articles and that disseminating the findings could be useful to stakeholders, end users, and other constituents in the mental health field.

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Methods and procedures

The study group for this systematic review was guided by the definition of supported education advanced by Collins and Mowbray who defined supported education for the purposes of a national survey as follows: “A specific type of intervention that provides supports and other assistance for persons with psychiatric disabilities for access, enrollment, retention and success in postsecondary education”. They further define supported education as a type of psychiatric rehabilitation intervention that provides assistance, preparation and support to persons with mental illness for enrollment in and completion of postsecondary educational programs. These interventions are designed to assist individuals in making choices about education and training and to assist them in maintaining their “student status” in the program until their educational goal is achieved (Collins & Mowbray, 2005). They describe 4 supported educational models:

The classroom model in which students with psychiatric disabilities attend closed classes on campus designed for the purpose of providing supported education services;
The onsite model which is sponsored by a college or university and provides supported education in an individual rather than group setting;
A mobile support model that provides services through a mental health agency;
And a more recent classification or model they call the “free-standing model” which is located at the organizational setting sponsoring the supported education program, such as a clubhouse or on site at a college.

Waghorn and colleagues defined 10 critical features that are the hallmarks of supported education which appear to overlap with the Mowbray definition. Supported education includes: 1) coordination of supported education with mental health services; 2) use of specialized supported education staff (not just generic case managers); 3) availability of career counseling, vocational counseling and planning; 4) assistance with financial aid; 5) assistance to develop skills needed to cope with a new academic environment; 6) provision of on-campus information about rights and resources; 7) on or off campus mentorship and personal support during the educational training period; 8) facilitation of access to courses and within-course assistance; 9) access to tutoring, library assistance and other academic support; 10) access to general support (e.g. referral for mental health services).

With these features, models and definitions in mind, it was fairly straightforward to apply inclusion and exclusion criteria to existing literature. We did not exclude any particular subpopulations within the larger population of individuals with psychiatric disabilities (such as individuals with substance abuse); however, we found few studies focusing on specific subpopulations.

In terms of exclusion by research design, acceptable study designs included: pre-post evaluations, correlational, experimental or quasi-experimental, observational cohort designs, and survey research. (Determining the type of design was not without problems when designs were poorly described or poorly planned and executed. This led to some difficulties in categorizing the designs used. For example, when correlational methods were used to address questions of effectiveness of an intervention, we coded that design as a pre-post or quasi-experimental design because we were guided by the intention of the researchers).

The study group excluded the following types of studies/publications/documents:

Policy statements
Program models
Process evaluations
Qualitative studies

The rationale for these exclusions was that such documents and articles, while important for the field, could not be subjected to ratings for their rigor and their meaning using our existing methodology.

In terms of searching out the supported education literature, the following search terms were used:

Supported education
Supportive education
Post secondary education

All of the search terms were paired with serious mental illness, psychiatric disability, or mental illness. In addition to searching, pubmed, Medline, psychInfo, and Google Scholar, we examined the citations contained in each article for additional potential articles and reports to review.

Two research assistants were responsible for querying the databases and locating articles. Titles of articles were initially scanned for relevance to the supported education topic by the lead reviewer. If the title appeared relevant, the abstract was reviewed (by the lead reviewer) and if it was deemed likely to meet inclusion criteria, the article was obtained. A checklist of inclusion/exclusion criteria was completed by a member of the review team for each article to facilitate tracking of articles screened. In some cases, once an article had been reviewed, it became clear that the inclusion criteria were not actually met. Occasionally, two or more members of the study group discussed the application of inclusion criteria to a few questionable articles in order to reach a consensus about its inclusion or exclusion.

Once a complete list of articles for review was compiled, that list was sent to individuals deemed to be supported education experts (Mark Salzer, Anne Sullivan, Kathy Furlong- Norman, Mary Collins, Deborah Bybee, Chyrell Bellamy, Barbara Blacklock, Karen Unger, Patrick Corrigan, and William Shriner). We asked those experts to review the list to insure that no relevant article or report was omitted. This step yielded several new citations that were appropriate for review.

In terms of unpublished articles, we did not include conference proceedings and did not locate unpublished reports significant enough to be reviewed. In the end, we considered 40 articles for inclusion. Nineteen articles were excluded from the review as they did not examine a supported education intervention or have outcomes related to supported education, were review articles or policy statements, or did not have sufficient evaluation information to be rated. Thus, 21 articles were rated for research rigor and for meaning.

Of the 21 articles reviewed for rigor and meaning, the breakdown of research designs was as follows: pre-post (n=4), experimental (n=3), quasi-experimental (n=1), correlational, survey or observational designs (n=9), and post only designs (n=4). The 4 post only design studies were excluded from the narrative synthesis after rating for quality because methodology scores were so low that conclusions from these studies could not be considered robust or valid. Issues included major threats to internal validity, retrospective measurement, and/or very high attrition of study subjects all of which constituted reasons for exclusion from this synthesis. The major methodology item from the research rigor rating scale (“Study/research uses rigorous or sound research methods that allow the questions of interest to be addressed”) was the focal item used to determine inclusion into this synthesis (after being reviewed for meaning and rigor overall), such that any study which scored a 2 out of 4 or below on this item was excluded from the narrative synthesis. (Note: the excluded articles appear in the reference list as italicized citations.)

In addition to rating supported education studies for rigor and meaning, we examined the congruence of the supported education intervention being studied to the definitions put for by Mowbray and colleagues and listed above. We excluded articles that did not conform to that definition.

Ratings of the Quality of the Research

Quality of the research reviewed was determined by examining both the rigor (traditional indicators of quality and appropriateness of the methodology) and the perceived meaning of the research (that is, the perceived utility and meaning the research has for the field, for policy makers and providers, for consumers and family members).

Of the 17 articles that were rated for rigor and included in the synthesis (see Appendix for Rigor Scale) scores ranged overall from approximately 2 on the 4 point scale (indicating that the authors did a “Minimally” adequate job covering the topic) to approximately 3.6 (indicating a score between “Somewhat Adequate” and “Definitely Adequate”). The highest average scores were for the Introduction section of the paper which covers the background and rationale for the study. That is, most authors were able to effectively convey the need for their study and review extant literature in the field.

The methodology and the discussion sections resulted in the lowest ratings (Mean=3.00 out of 4.00); some articles scored ratings that would be considered barely adequate in that they lacked sufficient information or rigorous enough designs to be confident in the study’s findings (Mean?=3.00 out of 4.00). Most concerning was the number of studies that evoked questions about the soundness of the chosen research methods and procedures, often caused by poorly described or problematic handling of data (including the handling of missing data), scant or absent descriptions of the control conditions and inadequate information provided on the measures used in the study.

Many authors also did not adequately describe the limitations of their research and the parameters of their ability to generalize their findings, resulting in ratings for the discussion section that were on average, lower than adequate. Authors also did not describe the impact of their findings for policy.

Because we are using an innovative approach to rating meaning or perceived utility for this project, ratings of meaning (see Appendix for Meaning Scale) were not used to exclude articles from the narrative synthesis but rather to form a preliminary assessment of whether and how the meaning of the studies could be rated using this newly developed scale. The first section of the Meaning Scale rates the degree to which consumers are involved in designing, conducting and evaluating research study (not as participants in the research).

Overall, results suggested that consumers are infrequently involved in the conduct of the studies. About 72% of the time they are not involved in the conduct or design of the study and about 95% of the time they are not involved in determining the research question or reviewing the results of the study (or that information is not being reported by authors). We also examined whether information on functioning and disability was collected and presented. We used the World Health Organization framework for reporting functioning, disability and health. Ratings in that section suggested that data are presented on indicators of health and role functioning quite often (78% of the time and 100% of the time respectively). But data were presented much less frequently on environmental factors (44%) related to activity or participation. We also rated whether the authors of the article articulated implications of the research for various levels of stakeholders, including policy makers, service providers, practitioners, consumers, and families. Implications of the research for policy and for practitioners are fairly frequently presented in the articles (44% of the time for each) and much more frequently for programs and services (83% of the time). More infrequent were “implications presented for the daily life of the individual with the disability” (39% of the time), for their family members (6% of the time), or for underserved consumers (i.e., consumers receiving services in rural areas for example-0.0% of the time). The final section of the Meaning Scale items about is the availability of information, tools or other supports which could be used to implement the intervention or apply the information studied in the field. We found that about 94% of the time the authors spelled out one or more values underlying the intervention or service being studied (e.g., independence, self-reliance). However, further supports for implementing the study results were infrequently present in the article, such as materials or tools for implementation (33% of the time). Costs of implementation or maintenance, help with translating the findings into practice or support for underserved populations, were present in less than 20% of the articles.

Time Period of the Studies and Research Covered.

We considered any study published in the 20 years prior to the date of the systematic review (1989-2009). We used a 20 year window in part because of the scarcity of articles available overall.

Training of Reviewers.

A total of 3 raters were used for this systematic review. All were individuals affiliated with the Center for Psychiatric Rehabilitation and all were trained researchers.

Each individual acting as a rater was knowledgeable about research methods prior to the beginning of the project so that the training in the use of the Rigor and Meaning Scales focused on what kind of evidence for research quality might be encountered in a published article and what would be an acceptable indicator rigor or meaning had been achieved. All individuals were trained in the use of the rating scales by reviewing each item in the scale and discussing the meaning of the item and the evidence that could be considered for each indicator. Research articles were used as training devices by having each rater independently review articles and then discuss their ratings until agreement was achieved. Formal tests of inter-rater reliability were conducted and 75% agreement was reached between raters.

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Results and conclusions

Background

In the process of searching for articles to include in the systematic review, several articles were located that were not suitable for ratings of rigor and meaning because they were review articles themselves. Because these articles provided invaluable background information for the context of this review, we elected to summarize those articles and their findings here.

History of Supported Education

In the 1970’s the deinstitutionalization movement took hold and individuals with psychiatric disabilities began to be discharged to live in residential settings in the community. Day services began to emerge, including clubhouses, day treatment programs, partial hospitalization programs and vocational rehabilitation services. Eventually, more normalized approaches to services began to evolve that included programs that were integrated into the community and that lead to steady jobs and integrated educational opportunities (Anthony & Blanch, 1987; Anthony & Unger, 1991). The Community Support Movement initiated by the Center for Mental Health Services also helped to spur innovative models for rehabilitation including supported employment and housing (Mowbray, Brown, Furlong-Norman, & Soydan, 2002). In the early 1980’s, the Boston University Center for Psychiatric Rehabilitation received a federal demonstration grant for a supported education program (Unger, Anthony, Sciarappa, & Rogers, 1991). Subsequently the Massachusetts Department of Mental Health and the community college system in California (with assistance from the Department of Mental Health) provided funding for supported education (Unger et al., 1991; Unger, 1993). Since that time, supported education programs have evolved in many states across the country and internationally (e.g., Waghorn et al., 2004).

The first review of supported education studies was published by Mowbray and Collins (2002) and includes a synthesis of all published evaluations of supported education through 1996. The authors examined a total of 11 publications, some of which are included in this systematic review. The studies examined outcomes for a range of individuals from a low of n=27 to a high of n=397. Follow-up periods varied from 2 semesters to 6 years. Many of the designs used were pre-post. Several studies found that enrollment in a supported education program lead to an increase in enrollment in a post secondary course although the results were modest in many studies. In addition, methodologically, the studies used a different time frame for follow-up, and in some cases did not adjust for the fact that individuals were engaged in programs at baseline (that is, they did not adjust for baseline educational engagement). The range of involvement in educational programs was 27% to 75% (three studies reported percentages of 69-75% and one study reported 42%). Mowbray reported 24% engagement at a 12 month follow-up and Unger reported a gain over baseline of 25%.

Several studies reported on employment outcomes but unfortunately did not describe whether they had statistically adjusted for baseline employment. The authors reported gains in achieving or maintaining independent employment, although these results must be interpreted very cautiously. One study reported a gain over baseline of 13% in individual placements and 10% over baseline in their “own” jobs (presumably competitive employment). Mowbray reported a combined “productive activity” rate (which includes education, training or employment) of 14% over baseline. All told, any educational gains appear moderate at best, while any gains in employment appear very modest. Methodological limitations made it difficult to draw strong conclusions about the impact of supported education on educational or employment measures at the time of the Mowbray review.

Self-esteem and mastery are reported to have improved in the face of a supported education intervention in at least three studies and quality of life in one. Satisfaction with supported education was reasonably high in a few studies. One study reported a decrease on hospitalization stays.

Measurement of Supported Educational Outcomes.

As noted by Mowbray and Collins (2002) and in our examination of the supported education literature, evaluations have focused on a variety of educational processes and outcomes. In fact, there appears to be a lack of clarity about process versus outcomes measures in supported education. One example of this lack of clarity is whether enrollment itself in an educational program constitutes a process or an outcome measure. The typical processes/outcomes noted in studies of supported education programs include the following: educational engagement, educational attainment, employment, productive activity (either educational or employment activity), self-perceptions, quality of life and satisfaction with the supported education intervention.

Educational enrollment or engagement is often measured by the percentages of individuals who enroll in post-secondary educational programs, regardless of whether the program is completed, while some researchers focus on the percentage of those who enroll in educational preparation classes that help to clarify goals and assist them in the achievement of educational goals. Educational engagement has also been measured by the number of supported education intervention sessions attended (as opposed to actual post-secondary educational classes). This indicator also might be considered a process rather than an outcome measure.

Educational attainment is usually recorded as the percentage of individuals who complete courses in community colleges, 4 year colleges or other post secondary technical training programs. Courses completed, grades attained, certificates achieved or diplomas received are also reported in some cases as a measure of educational attainment. However, attainment of degrees is less frequently reported, perhaps because of the limited length of the follow-up periods in the studies examined.

Employment is considered a by-product of educational attainment and is considered an outcome in several studies. Employment measures include: type of work attained, hours worked, wages earned, and so forth.

Self-perception is another type of outcome measure found in supported education studies. Self esteem, mastery, self-efficacy (including school self-efficacy), quality of life and social adjustment are the most frequently measured self-perceptions. Hospitalizations and consumer satisfaction with the intervention are also frequently measured outcomes.

A consensus on a primary outcome or set of measures that are critical to supported education interventions and that could be used across studies would be very helpful to facilitate a meta-analysis based on future studies. Consensus on a set of secondary outcomes would also be very useful for the field.

Results of the Systematic Review.

A brief note is in order prior to delving into the results of the systematic review on supported education. First, the number of research studies that focus on effectiveness questions is quite limited. We found only two trials that could be considered rigorous, one an experimental trial and the second a high quality quasi-experimental trial. Secondly, the majority of publications in the field are based up one dataset: the Michigan Supported Education Research Project study (MSERP) conducted by Mowbray, Collins and their colleagues in the 1990’s. This is problematic for a variety of reasons. The first has to do with the limited number of supported education models that have been adequately tested. Mowbray and colleagues tested two models of supported education (classroom and group-based) and only one other rigorous study examines the effectiveness of a supported education model. The preponderance of published articles therefore appears skewed toward the two models tested by Mowbray and her colleagues, obscuring the number of alternative models which have not been adequately tested. Second is the limited generalizability of the Mowbray findings. Replication is one way of increasing certainty in research studies, and since so many publications have been based upon one study, there is limited replication, which makes it difficult to ascertain whether the findings could apply to any setting or location other than those studied in the MSERP. Third, there were significant methodological problems with the MSERP. study and the analyses reported by Mowbray and colleagues. These include: high attrition, the questionable approach taken to collapsing groups for analyses (that is, the lack of use an intent-to-treat design despite random assignment) and analyses of those groups, as detailed below. This makes the findings from this study, in its different iterations and presentations, difficult to interpret with confidence. Further, the over-representation of this one study among the overall body of supported education research gives an illusion that supported education has more studies of its effectiveness than the data support.

Results of the Systematic Review: Experimental and Quasi-Experimental Design Studies

Reviewed in this category were studies with all of the following:

an experimental design (including random assignment) or a quasi-experimental design;
a supported or supportive education intervention, or an intervention designed to affect educational status; and
education as the primary outcome.

In this section, 4 studies are reviewed, all of which used either experimental or quasi-experimental designs. These designs include a randomized control group (in the case of an experimental design) or a well constructed comparison group that was not randomized (in the case of a quasi-experimental design.

Experimental and Quasi-Experimental Studies Focusing on Effectiveness of Supported Education

In one of the few rigorous and well-designed studies of supported education, Collins, Bybee, and Mowbray (1998) examined the effectiveness of supported education for individuals with psychiatric disabilities in an urban setting. They targeted individuals with a psychiatric disability of at least one year duration, who had a high school diploma and an interest in pursuing higher education. Individuals were recruited from the public mental health system. In total, they randomly assigned 269 individuals to two experimental conditions and 128 individuals to a control condition. There were 2 experimental conditions: a classroom intervention and a group model intervention. Both models had meetings which occurred twice a week for 2.5 hour sessions over two 14-week semesters and one intervention used the Boston University supported education model program curriculum. The overarching goal of the supported education services was to help participants establish an educational or vocational plan, access supports and resources to achieve the plan, and cope with specific problems related to having a psychiatric disability. Services included career planning, vocational assessment, information on college or training enrollment, assistance in obtaining financial aid, stress management, time management, rights and resource information, contact with campus student services and vocational rehabilitation. They also provided on-site mentorship and access to contingency funds for school-related expenses. The third (control) condition was an “individual” service that did not include an active intervention. Students assigned to this group were provided a staff person’s name and contact information and told to call him/her when they needed help. If they chose, they (along with the active intervention participants) could receive any of the other support services available from the college. (Note that a description of these interventions appears in the appendix. Since so many additional studies we reviewed relied on this study and data, we chose not to repeat a description of the intervention with each study description, but rather to append it.)

The authors only analyzed data for 293 (out of 397) subjects for whom post test data were available; this equates to a very significant attrition rate of 26%. They found that satisfaction was significantly higher among those in the group intervention than among those in the control group. This was the only significant finding reported on the analyses comparing the group assignment at baseline. The bulk of results reported on this study were comparing the different levels of participation in the supported education intervention, regardless of model or comparison condition. Thus, “high attendance participants” include individuals who frequently attended either of the two experimental conditions or the control condition (i.e., the individual condition -meaning they met individually with their assigned mentor more frequently than others assigned to the control or individual condition). Satisfaction was also higher among the high attendance participants than the non-participants. Significant differences were found between the no, moderate and high participation groups for enjoyment and self-reported learning. Degree of social support from mental health workers was significantly higher among high attendance participants, followed by moderate attendance participants and non-participants. Of those who attended at least one supported education session (i.e. one class, group meeting or individual meeting, for the classroom, group and individual conditions), empowerment and school efficacy was significantly higher among the classroom attendees than among those in the control (individual) condition. High level participation individuals were significantly more likely to have taken either college or vocational classes (34%) compared to moderate participants (12%), while 23% of non-participants completed college or vocational courses. Participation level was only significant in predicting educational attainment within the group condition, with 35% of high level participation individuals taking a college or vocational class.

Several limitations with this study exist. First, there was greater attrition among non and low participation subjects which may have created biases due to attrition. Secondly, analyses only included participants who completed a post interview, thus potentially biasing the findings toward those who were better functioning and able to reached and complete a post assessment. In addition, the inclusion of the control (individual) group subjects in the high, medium or low participation classifications confound the supported education intervention as an independent variable, distorting any effects among the groups (classroom, group and individual) by focusing on the level of participation rather than supported education model. As the intention of the study was to evaluate a supported education intervention (initially outlined to include the classroom and group condition), the authors resultantly incorporate the impact of a generic support intervention into their assessment of the impact of the supported education intervention by including the control group subjects in their participation groups. Thus, the participation level outcomes do not provide effectiveness information for the supported education per se, but rather show the effect of generic supportive services. Another significant limitation is the fact that the authors also failed to conduct statistical analyses that took into account the multiple time points and the correlations among those time points.

Mowbray, Collins, and Bybee (1999) examined the long term outcomes of a supported education intervention for individuals with psychiatric disabilities, specifically the Michigan Supported Education Research project (described above) which was unique in using open enrollment for eligible participants from a large urban area and testing the intervention with a true experimental design. The authors hypothesized that receipt of supportive education would be associated with improved behavioral, functional, and self-perception of outcomes. They examined outcomes for 135 experimental subjects (who received one of two types of supported education, group or classroom) and 128 control subjects (who received an elective supportive-type “individual” intervention with no scheduled classes or meetings). The sample analyzed only included 66% of the original sample. The two experimental groups and control group are described fully in Appendix A. (We chose to describe the MSERP there to avoid repetition in this report and because it is used in numerous studies.)

Results showed that for classroom participants, the number employed or in school increased significantly from 24 percent to 39 percent from baseline to follow-up; for the group participants, the increase was from 19 percent to 46 percent, which represents a non-significant change from baseline. Involvement with the state vocational rehabilitation services did not increase significantly over time for any of the conditions, although change for the group condition from 17 percent to 29 percent was marginally significant. Rates of paid employment remained stable across time and condition.

Attrition was a significant problem for the study—only 69.3 percent of the 378 reported (note that 397 participants are reported on in another article; this article does not explain the discrepancy between the 397 and the 378). Another limitation is that the main analyses do not represent an intent-to-treat approach where the experimental groups are compared to the control groups, but rather comparisons are made on within-group changes from baseline to follow-up. A longer follow-up period of more than 12-months could have provided better evidence of any sustained changes.

Hoffman and Mastrianni (1993) examined a supported education intervention for inpatients who were 18-24 years of age. They compared outcomes of two inpatient settings using a matched sample—one with a specialized inpatient supported education service (referred to herein as the “college unit”) and one with a more traditional approach to inpatient treatment. The experimental inpatient setting integrated opportunities for patients to initiate, maintain, or advance their educational goals into the range of intensive individual and group psychotherapies of their regular inpatient treatment. College unit patients participated in individually tailored academic activities in conjunction with a neighboring community college or the student’s home institution. In the comparison condition, the full range of intensive individual and group treatment modalities offered at the site were available, but without the supported education component. Otherwise, the two settings had comparable treatment approaches to therapy. The authors examined rate of return to work/college, strength of student identity and aspirations for educational achievement, rate of re-hospitalization, the type of follow up care received and satisfaction with hospital experiences. They hypothesized that participants receiving the experimental intervention, when compared to the matched sample would: 1) return to college at higher rates, 2) report easier transitions from the hospital to college, and 3) maintain stronger student identities and aspirations. They followed individuals on average for 16 months from date of hospital discharge.

The experimental supported education group had a higher rate of college enrollment (69%) compared to the comparison group (47%). Of those who enrolled in college, experimental participants were more likely to return full time or have returned part time and progress to full time than the comparison group (88% vs. 58%).

Some of the limitations of this study arise from the non-randomized design. A total of 37% of the participants in the comparison group were diagnosed with primary Axis 2 diagnoses compared to 0.0% in the experimental group. This difference was attributed to differences in the diagnostic styles and policies of the two settings rather than differences in study participants. No data were provided on the amount of time that elapsed between discharge and the follow-up assessment, making it impossible to determine whether the control or experimental group had a longer follow-up period which could potentially be a major bias in the results. All analyses compared the data at post-test only, so it is not clear if the analyses adjusted for baseline differences. Because no data was reported for the baseline/initial assessment, interpretation of the experimental vs. control group comparisons is limited. Further, the authors chose only to report percentages and did not analyze their data to determine whether their findings were statistically significant. Finally, very little information about the instruments used was provided, giving the impression that open-ended, non-standardized interviews were used; this lack of standardized measures also hinders the confidence one can have in the reliability of such measures.

Experimental Study where Supported Education is Not the Primary Outcome

There was one experimental study in which the supported education outcomes were not examined. It is included in this category of studies.

Collins, Mowbray, and Bybee (1999a) examined goal-setting within a supported education intervention. The target population was individuals with a psychiatric disability of at least one year duration, who had a high school diploma and an interest in pursuing higher education and who were recruited from the public mental health system. There were 397 individuals enrolled in the study overall however, there was no mention of N’s in each condition.
However, given that the study groups are defined elsewhere and that the authors examined differences by the experimental and control groups, we considered this an experimental study with three groups, two experimental interventions (one group, one classroom) and one control condition, all of which are described in Appendix A.
Clients participating in the clinical trial investigating the effectiveness of MSERP (Collins et al., 1999a) were interviewed qualitatively to determine their goal status. Goal questions were posed in an open-ended format, then coded for type of goal (school, vocational training, job, school preparation, job preparation, and personal); specificity in terms of how detailed the goals were (none, low, moderate and high); stage of goal status (none, choose, begin, maintain and complete); belief that goals were attainable; importance of goals; and types of resources they felt they needed to accomplish goal (financial, transportation, etc.) The authors hypothesized that goals and changes in goals could be measured and whether setting a goal (as opposed to attaining it) is an important short-term outcome of a supported education intervention. They also examined whether goal setting and certain characteristics of goals were related to goal attainment.

Only those completing follow-up interviews were included, although analyses showed no significant differences in type, specificity or status of goals at baseline among completers versus dropouts of the supported education intervention. Being in the experimental versus control condition had no effect on goal type—participants in the active conditions were just as likely as participants in the control condition to have school, job, and vocational training goals. There was also no difference between conditions on the belief that goals are attainable. However, significant effects were found for goal specificity and percentage of “optimal” goals. . Those in the active conditions (classroom and group) were more likely to report more specific goals and report a higher percentage of optimal goals (“optimal goals” included goals that were more appropriate, more substantively difficult, more specific and more advanced in terms of progression). As in the previously discussed study by Collins, Bybee, and Mowbray (1998), analyses were also conducted in this article by level of participation. Participation was defined regardless of original experimental and control group assignment and as none, moderate or high levels of participation. (The methods for classifying individuals by participation are described more fully in Appendix A.) Individuals with higher levels of participation were more likely to have school and vocational school goals at 12 months. High levels of participation were also related to more specific goals. There were no differences between the levels of participation on the outcomes of percentage of optimal goals or in the belief that goals are attainable.

Several variables did predict enrollment in college, but the most important seemed to be: decreased symptomatology; recent enrollment in college; involvement with state vocational rehabilitation services; higher social support; high intervention participation; and stating that education was of strong importance at baseline. The authors also examined predictors of college enrollment after program completion (i.e., at 6 or 12 months). The sample size for these analyses was decreased (N = 233) and three sets of variables were used: baseline variables (e.g., symptomatology, empowerment), graduation variables (e.g., school seen as most important goal), and program variables (e.g., participation level). They found six variables to be significant predictors of postprogram college enrollment. The strongest predictors were earlier college enrollment during the supported education program, empowerment at baseline and optimal goal-setting at graduation. Finally, two baseline variables demonstrated marginal significance: mental health worker’s encouragement for education and having stated school to be the most important goal at graduation.

In terms of limitations, there was no mention of the N of each condition despite testing for differences by condition. In addition, some measures were not standardized and were created for this study. Additionally, the inter-rater reliability on the coding of goals had somewhat weak kappas (some with a low-end of .57 and .64). Measures used to examine goal characteristics were coded nominally, limiting the strength of statistical analyses to nonparametric tests which could be performed. In addition, some measures were weak, e.g., confidence in completing goals was measured with one item.

Results of the Systematic Review: Correlational Studies

Reviewed in this category were studies with all of the following:

A correlational design
A supported or supportive education intervention, or an intervention designed to affect educational status
Education as the primary outcome.

In this section, 3 studies are reviewed, all of which used correlational designs. These designs did not rely on effectiveness questions or an experimental design in which the intervention was manipulated. The intention of these designs is to uncover relationships among variables and constructs.

Mowbray, Bybee, and Shriner (1996) examined the characteristics of participants in a supported education program for adults with psychiatric disabilities to determine the extent to which ‘typical’ clients with severe mental illness could participate in a supported education program. The intervention has been described in numerous other Mowbray and Collins articles on the MSERP randomized study (and appears here in Appendix A) and included two active supported education interventions and a control condition. Baseline interviews with participants in a supported education program in the metropolitan Detroit area gathered demographic data, as well as information about school, work, and psychiatric history; social adjustment and support, psychiatric symptoms, and self-perceptions in the areas of school efficacy and self-esteem.

The authors performed cluster analysis on 263 of the participants in the study (135 individuals who had participated in one of the two experimental interventions and 128 in the control intervention) using five variables (sex, age, educational attainment, work background, and symptoms) to produce a client typology. Results yielded 5 clusters: well-functioning young men, young aspiring women, young dependent men, well-functioning but unemployed participants, and distressed unemployed participants. The clusters also differed on a large number of variables not used in the cluster analysis. However, members of all clusters had similar rates of program participation and first-semester attendance. Overall, the supported education participants were younger, better educated, and higher functioning than subjects in general samples of persons with severe mental illness. Marital status, gender distribution, and living arrangements were similar to those in other samples. Although many participants had significant problems with symptoms, social adjustment, and substance abuse, they were able to remain active program participants. The authors concluded that supported education is a feasible alternative for many individuals to meet the goals for educational advancement, personal development, and better jobs.

Two limitations of this study are: 1) the data used were only collected at baseline and through the first semester of attendance, and 2) it is unclear how the sub-sample used in this study differs from the larger sample used in the other published articles drawing from the same data and thus whether the findings would have been different if the entire sample was used.

Collins, Mowbray, and Bybee (1999b) performed correlational analyses using data from their previously discussed randomized trial of supported education to examine the types of coping strategies used by individuals with psychiatric disabilities enrolled in supported education programs.

To test coping strategies, study participants were given 9 vignettes and interviewers were asked to probe for up to three “coping” responses per vignette. A coding scheme was developed based on a review of the literature on coping behavior; and three classifications of coping strategies were identified: appraisal strategies, problem-oriented strategies and emotion-oriented strategies. Inter-rater reliability for the coding was .51-.76. To examine multiple responses, data were summed by coding strategy, first for each vignette, then across 9 vignettes. The goals of the study were to examine the extent to which coping is context-specific, whether interventions influence coping strategies, and whether coping strategies are related to later outcomes.

The sample size for this study included the subset of participants initially randomized to condition (N=387) who were available for assessment at the midterm assessment (N=313) and those available at “graduation” (N=293). Results showed no effect for condition on use of coping strategies (that is, of being in the experimental or control groups) or participation level at the midterm assessment point. At graduation, participation level was related to use of positive coping strategies. It appears that there were no effects of condition on coping strategies at graduation. Emotional responses were the least frequently mentioned coping strategy and problem-solving strategies (specific and non-specific) were the most frequent at both assessment points. Problem-solving was viewed as a positive strategy. When they examined participation level (see Appendix A for a description of how the authors determined no, moderate or high participation level) in the program they found it related to help seeking from supported education and vocational rehabilitation programs as well as for use of positive coping strategies at graduation. High level participation individuals most frequently used help-seeking strategies. Use of problem-solving strategies was correlated with both objective and perceived outcomes including school efficacy, social support and adjustment problems (that is, problem solving was negatively correlated with adjustment problems) as well as objective outcomes such as enrollment and involvement with VR. Emotional coping led to more social adjustment problems. Coping strategies were related to later functioning, but were less successful at predicting behavioral outcomes than perceived outcomes. Authors say that this research demonstrates that possible stressors encountered in an education setting can be proactively identified and students can be taught to prepare for handling those stressors which in turn can influence later outcomes.

The main limitation of this study related to the analyses presented using participation levels was described earlier and emanates from the way that the authors collapsed the experimental and control groups for those analyses. The “control” group was a group in which the individuals were given the name of someone they could call who was not specifically trained in supported education. The authors then calculated participation rates and included control participants as having a high participation rate if he or she had 120 minutes in contact time. This approach does not shed light on the relationship between receiving a supported education intervention and coping strategies, but rather the relationship between a generic support intervention and coping strategies.

Collins, Mowbray, and Bybee (2000) examined characteristics predicting successful outcomes of participants in the aforementioned supported education trial, MSERP (described in detail in Appendix A). Sub-analyses of this dataset used only the participants who were assigned to one of the two supported education interventions (classroom condition or a group condition). A total of 147 persons who completed one of the two supported education programs were interviewed six and/or twelve months later to determine whether they were involved in productive activity, (defined as engaging in college, vocational education or paid employment). Variables examined as predictors of productive activity were demographic characteristics; education and work background; social support; self-perceptions related to self-esteem, empowerment, quality of life, and school self-efficacy; and illness-related variables, including diagnosis, symptoms, and length of illness. The authors hypothesized that regardless of program participation, demographic characteristics, education and work background, social support, self-perceptions, and illness-related variables would impact productive activity at 6 and 12 months after enrollment.

Of the 147 participants in the sample, 77 (52%) reported engaging in productive activity at follow up Productive activity at baseline was the strongest predictor of later productive activity. Marital status was the only significant demographic variable in the model; single participants were less likely to be engaged in productive activity. For participants who reported more frequent contact with their social network, the likelihood of engagement in productive activity was higher, and for those who reported more encouragement for education from their network, the likelihood was lower. A lower level of adjustment in the financial domain decreased the likelihood of productive activity, and a higher level of problems with housework increased the likelihood. No illness-related or self-perception variable was a significant predictor of productive activity. The authors concluded that factors related to a successful outcome from a supported education program for persons with severe mental illness are also likely to be important factors for nondisabled populations. The authors concluded that among those with mental illness, social support is a key factor in attaining educational and vocational goals.

One of the major limitations of the study is attrition—of the 269 participants assigned to one of the two supported education programs; final sample size was only 147. Also problematic was the incomplete information on diagnosis and other illness related details that were used as predictors.

In another analysis of the MSERP, Bybee and colleagues (2000) examined self-reported barriers to attendance and covariates of participation in a supported education program. A total of 397 individuals completed an intake and were randomly assigned, but given that the focus was on predictors of participation, the authors conducted some analyses using the individuals for whom they had participation and outcome data and some analyses with the entire. Participants in the two active intervention groups, (classroom and group intervention, N=187) and the control group (an individual condition with no scheduled meeting times, N=81) as described in Appendix A, were included. In addition, focus groups were held specifically to learn about barriers among those who did not participate in the intervention at all. The outcome examined was attendance in the supported education intervention, which included the control intervention with participation coded as none, moderate or high. (As mentioned earlier, the problem with coding participation levels is the fact that the control group was included in this classification, confounding the measure of participation with the experimental intervention).

Results showed a curvilinear relationship between number of barriers to participation and actual participation where individuals with a moderate level of participation in any of the interventions (group, classroom or “individual”/control) reported more barriers to participation compared to those who did not participate at all or those who participated to a high degree. They examined predictions of participation and found that having moved a lot as a child was related to not participating in any sessions, while having parents’ encouragement about college and living alone was associated with participating in at least one session of the experimental or the control condition. Receipt of Social Security income was related to non participation. Parental encouragement about college was associated negatively with number of sessions attended among those in the active intervention groups (classroom or group), which is contrary to previous findings that parental encouragement was positively associated with attendance. Presence of a substance abuse problem was associated with lower attendance in an active intervention group as well. Number of hours worked for pay in most recent job, individual’s rated quality of life in the residential domain, and the number of people in their social network were all positively related to attendance in an active intervention group. Individuals also mentioned external barriers to participation such as lack of transportation, personal barriers such as lack of support from family and friends, personal problems, and programmatic barriers such as loss of interest in the intervention.

One major limitation of this study was the incomplete information about the number of participants assigned to each of the experimental conditions. (This information does appear in other articles published about this study, but not in this paper.) Attrition was another major weakness of this study. The specific number of participants who dropped out of the study is not mentioned, and there is no information provided about whether there was differential attrition among conditions. What is stated is that about one-third of those participants assigned to a condition did not attend any sessions after completing a baseline interview, but this is only reporting the participation in the intervention, not the follow up assessments. It is unclear if the individuals who did not take part in the intervention after being randomly assigned also did not complete any follow up interviews, but it is clear that the data here only include those that did complete some part of the intervention. No attempt is made to examine whether those who dropped out were different from those remaining (Except in terms of participation level). Therefore the generalizability of the analyzed subset to the larger set of individuals in the study can not be determined, meaning that those who dropped out may have had different predictors for their non-participation which cannot be determined in this study.

Mowbray, Bybee, and Collins (2001) performed correlational analyses on the data collected as part of their experimental study described above and in Appendix A (Collins et al., 1998). Their purpose was to describe what completers of the supported education intervention (N=264) found most valuable about the supported education program and to examine gaps and needs that individuals experience following completion of a supported education intervention. Their analysis included individuals who were initially assigned to the control or “individual” condition as well as the two experimental conditions (class and group). They examined satisfaction retrospectively (12 months after program termination) and examined barriers to carrying out educational plans; personal difficulties (life events) which may have affected one’s ability to carry out educational plans; current needs (in terms of helping one carry out their educational goals); and level of follow up contact (with supported education staff or students, mental health worker, family member or vocational rehabilitation agency). The authors hypothesized that participants with higher participation levels (in any of the three groups) and assignment to one of the two treatment conditions would be related to greater satisfaction, more follow-up contacts, fewer barriers, fewer difficulties and fewer needs in their educational program. The groups showed significant differences in satisfaction at the 12 month follow-up with the group condition being perceived as more satisfactory than the control condition on several items (e.g. helping to choose a college major) than the classroom condition. Participants in the classroom condition perceived more support. High levels of participation were related to greater satisfaction across the board. Results suggested that participants in the supported education program reported finding information most helpful in the areas of: applying to college, financial aid, types of counseling available on campus, and how to find tutors. Information on applying to college and financial aid were significantly more helpful than information provided on effective study habits, how to choose a job or career, or how to schedule classes.

One limitation is the high degree of attrition; data were only analyzed for those who completed a 6 or 12 month assessment (199 of the 396 who were randomized). In addition, participants with high participation in the program were more likely to complete follow up assessments leading to potential bias in analyses toward those with fewer problems with the program. The creation of groups based on participation levels is problematic, as stated above and in Appendix A as the authors used the control subjects to create levels of participation, confounding that variable with the experimental intervention. Additionally, the authors’ use of one-tailed statistical tests could be interpreted as presumptive. Finally, their use of unstandardized measures makes the reliability of their data uncertain.

Results of the Systematic Review: Pre-post Studies

Reviewed in this category were studies with all of the following:

A pre-post design
A supported or supportive education intervention, or an intervention designed to affect educational status
Education as the primary outcome.

In this section, 4 studies are reviewed, all of which used a pre-post design. These designs attempt to address an effectiveness question but lack the controls on internal validity afforded by an experimental design.

In an early study of supported education, Unger et al. (1991) conducted a pre-post study of individuals participating in a supported education program within a university setting. They targeted young adults with severe mental illness, above average intelligence, and a willingness and ability to utilize a classroom-based supported education program. The intervention consisted of class meetings for 16 months, three times per week and was based on psychiatric rehabilitation principles. The intervention aimed to teach skills needed to choose, plan and implement a career/education plan. The program also included providing students with resources they needed to succeed, such as assistance with obtaining Social Security benefits, housing, recreation, and referrals for mental health services. Outcomes examined included self-esteem, involvement in education and employment, and hospitalizations. The authors hypothesized that individuals receiving supported education services would experience an increase in self esteem and educational or employment activity and a reduction in hospitalizations.

Participants improved in their level of employment and educational status, with 19% of students employed or enrolled in an education program at the start of CEP, compared with 42% after the intervention. Endpoint analyses suggested statistically significant change in Employment (N=44) and Education status (N=43). Hospitalization rates appeared to decrease from the year prior to the program to the first year of being enrolled in the program. Using statistical tests, however hospitalization data was only reliably available for students completing two semesters online. Self esteem also increased significantly from baseline to the “end point.”

There were several limitations of this study. One has to do with the timeframe for when the follow-up (“end point”) assessment was completed, which sometimes took place before the intervention was actually completed; making it difficult to conclude that the full effect of the program is even being measured here. Secondly, only hospitalization data on participants who had been in the program two semesters or more and with “regular” attendance were included, potentially biasing the results in favor of the intervention being effective. The pre-post design without a control group also constitutes a major limitation.

Cook and Solomon (1993) conducted a pre-post study of a supported education program (Community Scholar Program, or C.S.P.) for individuals with severe mental illness. The purpose of this study was to describe one such program at Thresholds, a psychosocial rehabilitation agency located in Chicago, Illinois. Focusing on program components and outcomes, this study highlighted the changes and accomplishments experienced by 125 urban psychiatric rehabilitation clients as they prepared for and entered post-secondary academic and vocational/trade school settings. The intervention included existing supported education technology (preparatory coursework, case management support, and a client-driven philosophy) as well as a set of individual and group supports (mobile educational supports, supportive individual counseling, and a support group). The authors hypothesized that receipt of supportive education services would improve education and vocational outcomes, self-esteem, coping mastery, and level of anxiety. Length of program involvement varied but no information is provided about average length of time involved for participants.

Follow up data were collected for 82% of the initial sample completing the supported education intervention (102 of the 125 participants). By the end of the 36-month follow-up period, 42% (N=43) of the participants had completed at least one class at a post-secondary school. The average number of classes completed by CSP students was 3.6. Seventy-eight percent (N=79) of clients held at least one job during participation in CSP, but only 47% (N=48) were employed at the time of their follow-up interview. Mean numbers of hours worked per week increased significantly (p=.006) from 17 hours at intake to 21 hours at follow-up. Mean hourly salary increased significantly from $4.35 at intake to $4.76 at follow-up (p=.03). Mean self-esteem scores (p<.001) and coping mastery (p<.01) rose significantly. Level of anxiety did not change significantly between intake and follow-up.

The limitations of this study include a non-experimental design and insufficiently explained recruitment methods. Additionally, there was no explicit discussion of how the education and vocational results compare with other study results or populations.

Unger, Pardee, and Shafer (2000) and Unger and Pardee (2002) examined outcomes for post-secondary supported education programs for 124 students from three supported education sites (n=55, n=46, n=23). Participating supported education students were surveyed for 5 semesters from 1995 until 1997. A total of 105 students remained in the study throughout the five semesters, an attrition rate of 15%. The authors assessed demographic information, service utilization, as well as educational and employment outcomes. In addition, the authors attempted to examine predictors of school completion, and the job/education fit.

The study showed that students surveyed completed 90% of their college course work and achieved an average grade point of 3.14. However, over the course of five semesters 78% of the 105 students enrolled had removed themselves from school. Twenty-one students who remained in the study for 34 years completed programs of study and attained certificates or degrees. There were no increases in self esteem or quality of life. Increases were noted in the number of students living independently as well. As for the predictors of school completion, psychiatric diagnosis was not a predictor, but having a car and a greater number of previous psychiatric hospitalizations prior to program participation were. The school retention rate was comparable to the general population of part-time students; employment rates (42%) during the study were lower than the population of other part-time students, but higher than the population of people with mental illness generally.

Twenty percent (n=21) of the 105 students who remained for the full three years completed programs of study and during the course of the project attained academic certificates or degrees. The authors found that the mean number of credits attempted was 7.10 and number of credits completed was 6.43, a completion rate of 90%. Students maintained an average grade point average of 3.14 (out of 4). Over the course of 5 semesters of data collection, 82 students (78%) of the 105 students enrolled had removed themselves from school. The presence or absence of major psychiatric diagnoses had no effect on the likelihood of maintaining enrollment in post-secondary education. During the last semester of the project, an average of 42% of the students reported working with an average salary of $7.85, a $1.62 per hour increase from initial assessment. No significant change in self esteem or quality of life from initial assessment to the last semester of the project was found. In terms of program fidelity and faithfulness to tenets of supported education, Unger and Pardee (2002) reported that their conclusions about program congruence with supported education were based on on-site observations and extensive interviews with staff and students.

This study had significant limitations including no comparison group and a low number of participants at each site.

Best, Still, & Cameron, (2008) describe a supported education program that reflected a partnership between the Division of Mental Health and a technical institute in Australia. A total of 61 public mental health clients participated in the supported education program which was implemented as a self-contained classroom located at the technical institute. The program was only offered to eligible students who were taking courses in horticulture, computing or hospitality. In-class assistance for students focused on: supportive counseling and symptom management strategies; in-class facilitation of student’s comfort with the classroom environment, particularly at course commencement; goal-setting and vocational planning; and liaison with clinical care coordinators to provide continuity and support. Concurrently, staff were provided support in the following ways: assistance with in-class strategies to accommodate students with cognitive deficits, provision of specialist knowledge on working with students with psychiatric disabilities, in-class advice about mental health issues, assertive follow-up of absenteeism and identification of potential student barriers to course completion.

The results showed that of 71 course enrollments by 61 students, 51 course completions were attained (for a mean course completion rate of 72%).

This descriptive analysis had many limitations primarily a small N, no control group, and a reliance on purely descriptive information for the outcome assessment. The authors report, despite the lack of a control group, that the course completion rate was similar to the rate in the general student population of the school.

Results of the Systematic Review: Needs Assessment Studies

Several of the studies listed below were components of larger studies. A needs assessment study is generally one involving surveys or qualitative research where the goal is to document unmet needs in a population.

Collins and Mowbray (2005) performed a national survey of students with psychiatric disabilities who were registered with campus disability offices to examine the services they had available and the extent to which they used these services. This article reported these results collected from disability services offices at colleges and universities in 10 states in 2002. Surveys were returned from 275 out of 587 schools contacted (47% response rate). The schools included in their sample were: 127 two-year public, 61 four-year public, and 83 4-year private post-secondary schools. Surveys assessed schools about the number of students with psychiatric disabilities seeking assistance from disability services offices, characteristics of these offices, and the types of services they provide. Survey data also sought to identify barriers to full participation of these students in academic settings. This study is unique in that the unit of analysis is the school, rather than the individual.

Findings from the survey showed that total of 40% of schools had a specific office for disability services and 62% of schools employed staff members with specific qualifications to serve individuals with psychiatric disabilities. Only 25% of respondents reported that someone in disability services office had formal supported education training. Most (72%) of supported education programs were located off campus. They found that the most frequent issues for students with psychiatric disabilities were: issues related to obtaining accommodations and supports; general coping with school; attendance issues; specific issues related to the person’s diagnosis; general anxiety; low self esteem; test anxiety; social skills; personal issues; memory and concentration troubles; and conflicts with faculty. The most common questions or problems posed by faculty or staff at the schools were regarding: strategies for working with a student with a psychiatric disability; general behavior problems in the classroom; attendance problems; and questions about the ability of a particular student to handle the workload for their course or post-secondary education in general. The primary barrier of students with psychiatric disabilities to accessing services was overwhelmingly reported as a fear of disclosure. Other common reasons for students to not access supports included a lack of knowledge about what services might be available or their eligibility for services, a fear of being stigmatized, the university’s lack of a specific supported education program or intervention, and a person not seeing themselves as having a disability.

Limitations of the study include the fact that only 10 states were targeted for inclusion in the study because they identified those states as where significant supported education interventions had been developed. This is a limitation because the authors do not explain clearly their inclusion criteria for the states. Also, there was a significant non-response rate (more than half) and no discussion as to whether non-response could have been related to a lack of any disability services at the non-responsive schools. There was also confusion about the number of schools in the dataset as tallies of the numbers of schools (reported in the text) do not equal the total number reported in tables.

Survey

Collins and Mowbray (2008) conducted a national survey of supported education programs; the purpose was to test bivariate relationships and a multivariate model to predict the number of students with psychiatric disabilities served by disability services offices in a national sample of schools. Targeting two year, four year public and private post secondary schools, the final sample included 587 schools. No intervention was studied and the schools formed the unit of analysis. The independent variables included: size of school; type of school (2 vs. 4 year; public vs. private); and the disability student services available. The 587 schools were located in Utah, Indiana, North Carolina, California, Oregon, Iowa, Georgia, Maryland, Michigan, and Massachusetts. The authors hypothesized that the number of psychiatrically disabled students served at a particular school could be predicted by the school type, school size, visibility of the disabilities services office and the services provided. The dependent variable was the number of students with psychiatric disability served. A paper and pencil survey was constructed for the purpose of this study with a majority of closed ended questions regarding the independent and dependent variables and some open ended questions.

Analysis of the survey results showed that the size of school was important in predicting whether students with psychiatric disabilities seek assistance at their university’s disabilities services office; this was presumed to be due to the greater amount of resources available at larger institutions. Two-year public schools play an important role in providing access to higher education. Having an outreach/recruitment policy for students and fostering a perception that the environment is supportive of these students is similarly important in predicting an increased likelihood that students utilize on-campus disabilities services. Also, disabilities offices that were larger in size, employed staff with training in supported education and had experience with psychiatric disability were factors predicting greater utilization by students of their services. The number of services provided by the disabilities office was not a significant predictor of student utilization of services.

There are numerous study limitations complicating the interpretation of these data. The rationale for the initial sampling of universities in 10 states (5 states with three or more supported education programs and 5 “comparable” states) is only explained as choosing a “similar state” in terms of geographic area and population size, and in “no known supported education programs.” Also, the low response rate (ranging from 39% for four year institutions to 51% for 2 year public schools) is not examined and is presumed to bias the outcomes. Another problem is the validity and reliability of the survey developed for the study. It is unclear whether experts were used to assure appropriate content for the survey items. There is no report or description of the instrument being field tested. Finally, the statistical analyses are very problematic. The authors use average number of students served as the dependent variable, but a more appropriate measure would seem to be the number of students served as a proportion of the entire student body. Mean number served is confounded with size of the institution and it does not appear to be a valid measure (Although it is not likely to have affected the results, the N’s of the schools are not consistently reported). With this qualification, the findings are congruent with other anecdotal information about the relationship between the size of institutions and the degree of utilization of supported education programs.

Arguing that the educational goals of individuals with psychiatric disabilities had not been formally studied, Corrigan and his colleagues (2008) conducted a survey to understand these goals as well as to identify barriers to seeking higher education. They obtained consent from 120 individuals with a psychiatric disability to complete a survey in a large Midwestern mental health center.

They found that the individuals surveyed did not have a high level of educational accomplishment: more than a third did not complete high school and another third did not get beyond high school. About a third also attempted some kind of post secondary education. More than half of the sample (55%) said they would like to return to school and 57% believed that they could return to school. Reasons for wanting to return to school were most commonly to get a new job, to gain a sense of accomplishment, to develop a sense of pride or to meet people. The top three most frequently mentioned barriers to seeking additional education were cited by more than half the sample and interpreted to be common to adult learners and many groups of students—financial aid, transportation, and study skills. The next three reasons were cited by about one-third of the sample and included things that may be particularly relevant to being a person with a psychiatric disability including: needing stress management skills, personal support, and help coordinating mental health and educational services. Other barriers cited that were specific to having a psychiatric disability included help with: memory problems, determining whether to disclose their mental illness, accessing the disability support office; stigma issues, and substance abuse issues.

Several limitations to this study were apparent. The authors provide little information about the rationale for the data collection site and how representative the study sample is to the characteristics of the study site and the larger population beyond a Midwestern mental health center. They do not address how representative they believe the sample is among individuals with psychiatric disabilities and whether bias could have been created when approaching the individuals for the data collection (for example, if the person was told it was a survey about education, those interested in furthering their education may have been more inclined to agree to participate). Also, the authors fail to include information about the number and percentage of individuals approached who agreed to complete the survey. Another oversight in the description of the study methods was the lack of detail about data collection procedures (for example, did the individual complete the survey him or herself, or was an interviewer present?). The data can only be interpreted very cautiously because of these limitations.

Conclusions from the Systematic Review

Effectiveness of Supported Education

There is no evidence from a randomized trial or well controlled quasi experimental trial that participation in a supported education intervention results in significantly greater educational engagement or enrollment (Mowbray et al., 1999).
There was no significant difference in the employment rates at follow-up of individuals participating in a supported education intervention versus those not participating (Mowbray et al., 1999).
There is suggestive evidence from uncontrolled evaluations that participants improved in their level of employment and educational status as a result of participation in a supported education intervention (Unger et al., 1991; Hoffman & Mastrianni, 1993; Unger et al., 2000; Unger & Pardee, 2002; Best et al., 2008; Cook & Solomon, 1993).
No significant changes in self esteem or quality of life as a result of participation in supported education were found (Unger et al., 2000; Unger & Pardee, 2002).
Individuals who remain engaged in supported education are able to complete courses and achieve as satisfactory grade point average (Unger et al., 2000; Unger & Pardee, 2002; Cook & Solomon, 1993; Best et al., 2008) however, the strength of this evidence is weak due to the poor research designs used.
A supported education intervention (classroom model) was more effective than a control group in improving empowerment and school efficacy (Collins et al., 1998).
Satisfaction with supported education was significantly higher among those in a group supported education intervention when compared to a control group. (Collins et al., 1998).
High levels of participation in a supported education intervention did not predict goal attainment or the belief that goals were attainable (Collins et al., 1999a).
In terms of goal specificity being in a supported education intervention lead to setting more specific and optimal goals (Collins et al., 1999a).
Supported education is a viable intervention for many individuals to meet their goals for educational advancement, personal development, and better jobs (Mowbray et al., 1996).

Barriers to Participation in Supported Education

There was a curvilinear relationship between reported number of barriers to participation and actual participation where individuals with a moderate level of participation in supported education programs reported more barriers to participation compared to those who didn’t participate at all and those who participated to a high degree (Bybee et al., 2000).
Presence of a substance abuse problem was associated with lower attendance in an active supported education intervention (Bybee et al., 2000).
Number of hours worked for pay, individual’s rated quality of life in the residential domain, and size of one’s social network were all related positively to attendance in an active supported education intervention group (Bybee et al., 2000).
Participants reported that practical help such as help applying to college, applying for financial aid, and help finding tutors is useful in a supported education program. Assistance with applying to college and for financial aid were significantly more helpful than information provided on effective study habits, how to choose a job or career, and how to schedule classes (Mowbray et al., 2001).
Use of positive coping strategies (e.g., problem solving strategies) among students enrolled in supported education were related to later functioning, but were less successful at predicting behavioral outcomes than perceived outcomes (Collins et al., 1999b).
Research on coping strategies suggests that it is possible to identify potential stressors encountered in an education setting and prepare students to be able to handle them which in turn can influence later outcomes (Collins et al., 1999b).

Characteristics of Supported Education Participants

Supported education participants were younger, better educated, and higher functioning than subjects in general samples of persons with severe mental illness. Although many participants had significant problems with symptoms, social adjustment, and substance abuse, they were able to remain actively involved in the supported education program (Mowbray et al., 1996).
More than half of individuals surveyed in a mental health center (55%) said they would like to return to school and 57% believed that they could return to school (Corrigan et al., 2008).

Predictors of Involvement in Work or School (“Productive Activity”)

Productive activity (i.e., work or school) was the strongest predictor of later productive activity (measured as involvement in work or school) (Collins et al., 2000).
Marital status was the only significant demographic variable of later productive activity with single participants less likely to be engaged in productive activity. More frequent contact with a social network was associated with the likelihood of engagement in productive activity. A lower level of adjustment in the financial domain decreased the likelihood of productive activity (Collins et al., 2000).
No illness-related or self-perception variable was a significant predictor of productive activity (i.e., involvement in work or school), (Collins et al., 2000).
The presence or absence of major psychiatric diagnoses had no effect on the likelihood of maintaining enrollment in post-secondary education (Unger et al., 2000; Unger & Pardee, 2002).

Outcomes by Varying Levels of Participation in Supported Education

High level participation subjects (those participating in the supported education intervention at a high level as defined in Appendix A) were significantly more likely to have taken either college or vocational classes (34%) compared to moderate level participants (12%), while 23% of non-participants did so (Collins et al., 1998).
Satisfaction was higher among the high attendance participants (as described above) than the non-participants (Collins et al., 1998).
Individuals with higher levels of participation in supported education interventions were more likely to have school and vocational school goals at 12 months and more specific goals (Collins et al., 1999a).
At midterm or graduation from the supported education program, several variables did predict enrollment in college but the most important seemed to be: decreased symptomatology; recent enrollment in college (prior to the study); involvement with state vocational rehabilitation services; higher social support scores; higher participation in the intervention; and stating that education was of strong importance at baseline. (Collins et al., 1999a)
The strongest predictors of enrollment in college after program participation in a supported education intervention were earlier college enrollment, empowerment at baseline and optimal goal-setting at graduation. Two variables were marginally significant: mental health worker’s encouragement for education and having stated at graduation that school was the most important goal (Collins et al., 1999a).

Needs for Supported Education Interventions

The most frequent challenges for students with psychiatric disabilities in post secondary educational settings are: providing accommodations and supports; general coping with school; attendance issues, specific issues related to the person’s diagnosis; general anxiety; low self esteem; test anxiety; social skills; personal issues; memory and concentration difficulties, and conflicts with faculty (Collins & Mowbray, 2005).
The most common concerns raised by faculty or staff at post secondary schools working with individuals with a psychiatric disability are: how to work with a student with a psychiatric disability; how to deal with general behavior problems in the classroom; attendance problems, and questions about whether the student can handle the workload or should be enrolled in school (Collins & Mowbray, 2005).
The most commonly cited barrier to accessing disability services among individuals with psychiatric disabilities was a fear of disclosing (Collins & Mowbray, 2005).
Barriers to accessing disability services for individuals with psychiatric disabilities in post secondary educational setting include: a fear of disclosing, a lack of knowledge of what services might be available or their eligibility for services; a fear of being stigmatized; lack of a specific supported education program or intervention, and a person not seeing themselves as having a disability (Collins & Mowbray, 2005).
In terms of predicting whether students with psychiatric disabilities will be served in post secondary educational settings, size of school may be important because of the resources available at larger institutions (Collins & Mowbray, 2008).
Two-year public schools play an important role in providing access to higher education for individuals with psychiatric disabilities. Other contextual features important in serving individuals with psychiatric disabilities are: having an outreach/recruitment policy for students; conveying a perception that the environment is supportive; having a larger disability office; increasing the number of staff members with training in supported education and with experience with psychiatric disability, (Collins & Mowbray, 2008).
The number of services provided by a post secondary school did not make a difference in terms of the number of individuals with psychiatric disabilities the school served (Collins & Mowbray, 2008).
Having someone in a student disability office with supported education training is important in serving students with psychiatric disabilities because it shows a commitment to helping such students (aid, transportation, and study skills) (Corrigan et al., 2008).
Barriers to seeking further education cited by individuals with psychiatric disabilities that were relevant to being a person with a psychiatric disability included: needing stress management skills, personal support, and help coordinating mental health and educational services. Other barriers included: help with memory; help with whether to disclose their mental illness; help accessing the disability support office; help with stigma, and help with substance abuse issues (Corrigan et al., 2008).

Appendix A

The MSERP (Michigan Supported Education Rehabilitation Program is defined as follows: There were two active intervention groups, a classroom and a group intervention (n=269) and a control group (n=128). Both of the experimental groups (E group 1, N=135; E group 2, N=134) met on a community college campus twice a week for 2.5 hours for 14 weeks. Classroom condition used academic support curriculum adapted from the Center for Psychiatric Rehabilitation curriculum (Unger et al., 1991) covering both academic and social skills that included verbal and written assignments addressing issues such as financial aid, course selection and registration. It also incorporated practice using campus resources such as the library and career lab. The group support condition aimed to create a supportive environment for students to explore academic and career options and was consumer-driven. The 4 consumer-driven steps of the program were: 1) identify resources and gain knowledge/skills needed for making education/career decision, 2) create an agenda to address the group’s learning goals, 3) work together to take advantage of community resources, 4) ongoing evaluation of group’s progress in meeting learning goals. The group support condition included a needs assessment, prioritized curriculum, group work on using school and community resources, and ongoing evaluation of the group’s success. Two staff (one of whom was a consumer) acted as group facilitators. The individual condition (control group) had no structured or scheduled interventions, but students in this group were given a staff person’s name and instructed to contact him or her when they desired help.

The “individual” condition did not include any active intervention but rather students assigned to this group were provided a staff person’s name and contact information and told to call him/her when they needed help. If they chose, they (along with the active intervention participants) could receive any of the other support services available at the college.

Participation in the intervention was calculated by the authors and used in many analyses possibly because of the limited findings by experimental condition. Three levels of participation were defined. In the class and group conditions moderate participation was defined as having attended less than 20 sessions; high participation as attending 20 or more sessions. In the individual condition (control group) high participation was defined as 120 minutes of contact over two sessions; moderate participation was defined as less than 120 minutes but more than zero contact. The “No participation” group included those individuals who did not partake of the intervention at all. The problematic issue with this classification is that the control group subjects were classified in this way, thereby confounding the intervention effects with participation levels.

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Acknowledgements and statement concerning conflict of interest

Acknowledgments

The supported education study group would like to thank the staff of our funding body, the NIDRR for their support of this undertaking including our project officer, Pimjai Sudsawad. In addition, our consultant panel of individuals during the startup of the grant was invaluable in reviewing versions of the rigor and meaning rating scales. Those individuals included: Mark Salzer, Judith Cook, Lisa Razzano, Krista Kutash, Nancy Koroloff, Fabricio Balcazar, Judi Chamberlin, Ken Duckworth.

Finally, the supported education experts we consulted were helpful in insuring that we consulted all of the relevant literature and gave generously of their time to assist this systematic review.

The study group would also like to thank the staff of NCDDR including John Westbrook and Joann Starks for their efforts to further the use of systematic reviews by disability researchers.

Statement Concerning Conflict of Interest.

No study group member has a conflict of interest in this area of supported housing. The Center does not have a supported housing grant at this time and no individual has a fiduciary interest in the delivery of supported housing services.

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