Raising our sites: dissemination of supported education.

In order to promote replication of supported education, an exemplary rehabilitation model for adults with psychiatric disabilities, funds were accessed through a Community Action Grant from the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration. Three communities in Michigan participated in a multistage process designed to maximize community ownership by encouraging local adaptations involving all stakeholder groups and providing technical assistance. The stages in the process were organizing the community for supported education development, acquiring knowledge about supported education basics, collecting information (needs assessment and barrier identification), and developing the plan. All three sites have begun implementation, providing services to adults with psychiatric disabilities who wish to pursue post-secondary education. The approach employed has applicability for other local communities.

Follow-up client satisfaction in a supported education program.

Satisfaction data have recently returned to popularity, as an outcome measure in managed behavioral healthcare systems. However, there are few examples of management uses of such data. We collected data 12 months after participants had completed a supported education program, concerning their retrospective satisfaction and the barriers, needs, and personal difficulties currently experienced in their attempts to pursue post-secondary education or training. Data on follow-up supportive contacts were also obtained. Results supported participants' continuing satisfaction, and identified particular information items which were endorsed as most helpful. However, the data indicated that personal difficulties presented obstacles to many and that a majority of participants had current needs for financial aid, tutoring, job placements, support groups, and transportation. Following completion of the supported education program, many participants had continuing contacts in support of their educational plans. The amount of contact was generally low, however. In the future, supported education programs need to build in mechanisms to ensure students receive ongoing support for education, since this support was found to positively and significantly affect individuals' enrolling in college or training.

Life circumstances of mothers with serious mental illnesses.

Individuals with a severe mental illness now have greater opportunities to pursue normal adult roles, including parenting. The research reported involved 379 women carrying out parenting responsibilities, recruited from the public mental health system in an urban area. The sample displayed great heterogeneity in educational levels, number of children, number of fathers for their children, and family living arrangements, except that most women were very poor. These women faced many significant stresses: living alone with their children, significant child behavior problems, and financial worries. Still, most of the women endorsed the significance of motherhood in their lives. Inattention by most mental health providers to parenting issues leaves many important needs unmet and is likely to have adverse consequences for these women and their children. Implications for psychosocial rehabilitation practice are discussed.

Parenting among mothers with a serious mental illness.

In the past few decades, deinstitutionalization and community-based rehabilitation and support programs have increased the likelihood that women with serious mental disorders will be parents and will raise their children. This review describes what is known about the parenting of these women, focusing on diagnosis, child characteristics, and other contextual effects.

Longitudinal effects of integrated treatment on alcohol use for persons with serious mental illness and substance use disorders.

A randomized experimental design was used to assign participants to an integrated mental health and substance use treatment program or to standard hospital treatment. A multilevel, nonlinear model was used to estimate hospital treatment effects on days of alcohol use for persons with serious mental illness and substance use disorders over 18 months. The integrated treatment program had a significant effect on the rate of alcohol use at 2 months postdischarge, reducing the rate of use by 54%. Motivation for sobriety at hospital discharge, posttreatment self-help attendance, and social support for sobriety were also found to reduce the rate of use during the follow-up period. Implications for mental health treatment and aftercare support are discussed.

Characteristics predicting successful outcomes of participants with severe mental illness in supported education.

OBJECTIVE: The study sought to identify characteristics of participants in a supported education program that were related to a successful outcome. Supported education programs provide rehabilitation and support services to help people attain postsecondary education. METHODS: A total of 147 persons who completed such a program were interviewed six or 12 months later, or at both times, to determine whether they were involved in productive activity, which was defined as engaging in either college or vocational education or in 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. RESULTS: Multivariate logistic regression identified the strongest predictor as productive activity at baseline. 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 variable or self-perception was a significant predictor. CONCLUSIONS: 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. Among those with mental illness, social support is a key factor in attaining educational and vocational goals.

Integrating vocational services on case management teams: outcomes from a research demonstration project.

Recent innovations to improve employment rates among persons with psychiatric disabilities include "hybrid case management/employment services." Project WINS was a research/demonstration project which integrated specialized vocational services into case management teams. In this report, client outcomes of WINS involvement are evaluated, using a quasiexperimental, longitudinal design. On almost all the work-related variables, participants in the immediate and delayed treatment conditions displayed better outcomes than those in the control condition, as did individuals receiving moderate or substantial service versus no/ minimal services. To address possible selection bias due to the quasiexperimental nature of the design, further analyses used baseline differences across conditions and participation levels as covariates. Results of multivariate analyses showed some anomalous findings regarding significant positive effects for the delayed, but not the immediate treatment condition versus the no-treatment control group. However, in similar analyses involving participation level as the independent variable, a moderate or substantial amount of service increased the odds of working by almost five times and also positively affected three other work-related variables. While limitations of this quasiexperimental design are noted, the results appear promising enough to support replications of WINS.

Mothers with serious mental illness.

Mental health services have generally ignored the parenting needs of women with serious mental illness. This chapter identifies the parenting risks and strengths that these women display, as well as the opportunities available to psychologists to play a key role in improving mother and child outcomes.

Measuring coping strategies in an educational intervention for individuals with psychiatric disabilities.

Coping is a critical theoretical concept believed to be a mediator for successful outcomes produced through a variety of different social work interventions. This article describes an approach used to measure coping with stressors and was designed specifically for an intervention, the Michigan Supported Education Research Project, aimed at providing support for people with psychiatric disabilities to pursue college or vocational education. Hypothetical scenarios were developed that matched the content of material covered in the program. Open-ended responses were elicited from program participants as part of an in-person interview. Key findings included a participation effect on the number of positive coping strategies of participants and a significant relationship among some coping strategies and later outcomes. Implications for social work practice and research are identified.

Analysis of postdischarge change in a dual diagnosis population.

Many individuals with serious mental illnesses have co-occurring drug and alcohol problems. The research reported in this article examined an integrated inpatient mental illness-chemical dependency program and compared it with standard inpatient psychiatric treatment for two groups: those demonstrating high change from baseline to two-months postdischarge and those with negative or no change. Univariate analyses revealed significant differences in the change groups on baseline personal-clinical characteristics and on aspects of their social and physical environments. The results have implications for improving mental health practice by better predicting patients who will optimally benefit from inpatient treatment.

Mental illness and substance abuse: implications for women's health and health care access.

Individuals with serious mental illness (SMI) and/or alcohol and other drug (AOD) problems often have physical health concerns that are not appropriately treated and that interfere with effective management of SMI and/or AOD problems and contribute to the overall costs to society of these disorders. Although the literature has limitations, available evidence suggests that women with SMI and/or AOD problems have more numerous and severe health concerns than comparable men and that they receive less appropriate health care than men do. These greater problems relate directly to SMI or AOD use, or involve difficulties in complying with medical regimens, side effects of medications, or interactions of AOD use and SMI with other health conditions. Individuals' life situations can also increase their vulnerabilities and health risks. Health problems frequently are not detected by specialty or general practice health professionals, and thus get worse. Women with SMI and AOD disorders have less access to appropriate physical health care services--both within the AOD and SMI treatment systems and within health care settings. Recommendations for improved health care for highly stigmatized groups of women with multiple needs include stronger linkages between systems, increased training of health providers, and policy and program changes.

Effectiveness of supported education for individuals with psychiatric disabilities: results from an experimental study.

In recent years post-secondary education has been recognized as a viable option in the psychosocial rehabilitation of individuals with mental illness. This study reports the first evidence of effectiveness of a supported education demonstration project which used an experimental design to compare the effects of different model types. A total of 397 participants were assigned to one of three conditions: group, classroom, and individual (control). At graduation from the program significant differences in program participation rates were found; group members participated most, followed by classroom participants, then those assigned to the individual condition. Also, immediate, intermediate, and long term outcomes were examined. On four immediate outcomes (motivation, satisfaction, enjoyment, and learning) significant participation effects were found (high participants scoring highest, followed by moderate participants, and then non-participants). On two intermediate outcome (empowerment and school efficacy) condition differences were found (classroom scoring highest followed by group, then individual). Although no condition differences were found on behavioral outcomes, the percentage of individuals enrolled in school or vocational education was more than twice that reported at baseline. Overall, the results demonstrated success in engaging participants, affecting self-perceptions, and increasing enrollment in post-secondary education.

Methods of ensuring high follow-up rates: lessons from a longitudinal study of dual diagnosed participants.

Despite growing research interest in co-occurring psychiatric and substance misuse disorders, relatively few longitudinal studies have been conducted with dual diagnosis populations. Many of the longitudinal studies that have been done have experienced excessive attrition. Thus, investigators have noted that one of the primary difficulties of conducting longitudinal studies with this population is successfully minimizing attrition during follow-up. This study, conducted in 1991 1993, describes retention and tracking methods employed in a longitudinal study of 485 dual diagnosis participants. Follow-up interview completion rates at the 2-, 6-, 10-, 14-, and 18-month interviews were 86.7, 85.6, 85.1, 84.5, and 88.4%, respectively. Several case studies are provided that document some of the challenges facing project staff and successful strategies for handling them. A notable finding from this study was that participants reported that the relationship established with the interviewer was more important than material incentives in preventing study attrition.

Consumers as mental health providers: first-person accounts of benefits and limitations.

Community support programs are increasingly establishing paid service positions designated exclusively for consumers. Project WINS (Work Incentives and Needs Study), a hybrid case management-vocational program for individuals with severe mental illness, used consumers as peer support specialists (PSSs) to supplement professional roles. Semistructured interviews were conducted with PSSs about 12 months after their employment ended. They identified substantial personal benefits specific to consumer-designated roles (e.g., a "safe" employment setting with accommodations) and general benefits from employment. Problems described were just as numerous, encompassing attitudes toward assigned peers and costs to their own well-being. Critical commentary addressed program operations (structure, supervision, and training needs) and problems in the mental health system. The authors discuss the changed sense of self that service provider roles can create for consumers and suggest that mental health administrators provide anticipatory socialization for this service innovation throughout their agencies and ongoing supports for consumers in their new roles.

Characteristics of dual diagnosis patients admitted to an urban, public psychiatric hospital: an examination of individual, social, and community domains.

The study provides descriptive data on a large, diverse sample of dually diagnosed patients from an urban psychiatric inpatient setting, utilizing a comprehensive array of clinical, social and community functioning measures. The intent is to provide more useful and reliable information, particularly concerning African-Americans with a dual diagnosis in the public sector. Over a one year period, all persons admitted to a public psychiatric hospital with a DSM-III-R psychiatric diagnosis and a positive screen for substance abuse problems using clinical and structured measures (n = 486) were interviewed on the Addiction Severity Index (ASI) and other measures to assess community and social functioning, alcohol and drug use, psychiatric problems, and service histories. The majority of participants were found to have serious economic and employment problems, undesirable living arrangements, limited or conflictive family or social relationships, and some record of arrest. The ASI problem areas most to least in need of treatment were: psychiatric, alcohol and drug abuse, employment, family/social, legal, and medical. Substances most often currently abused were alcohol, cocaine, and cannabis; there was a high rate of polydrug abuse. Participants had experienced a median of 3.0 previous psychiatric hospitalizations, fewer outpatient substance abuse treatments, and limited community mental health contact. Some subgroup differences based on gender, age, and race were found which have implications for community treatment planning. The study results document the extreme heterogeneity in the dually diagnosed as well as their multiple treatment needs. To better inform treatment planning, future research on dual diagnosis should attempt to establish meaningful subgroups relevant to service needs and should utilize diverse clinical and functioning measures.

Immediate outcomes of substance use treatment within a state psychiatric hospital.

Outcomes of an integrated inpatient treatment program for persons with serious mental illness and substance use disorders are examined in relationship to five stages of treatment--stabilization, engagement, persuasion/awareness, active treatment, and relapse prevention. The study used a randomized design with participants assigned to an integrated mental health and substance abuse treatment program or standard psychiatric hospital treatment. At discharge, participants in the integrated treatment program indicated more active engagement in treatment and greater awareness of mental health issues, substance use issues, and the 12-step program than those who received standard hospital treatment. Participants in the integrated treatment program also saw their treatment as being more effective and had more motivation to stay healthy and sober. The integrated treatment program was not equally effective at each treatment stage with all participants. The implications of the program's success overall and at each treatment stage are discussed.

Harbinger. I: The development and evaluation of the first PACT replication.

While Assertive Community Treatment (originally known as the PACT program) is now recognized around the world as an effective model for rehabilitation of persons with severe mental illness, this was not the case 20 years ago. Harbinger of Grand Rapids, in Kent County, Michigan, was the first replication of the PACT model which sought fidelity and included an experimental design for assessing effectiveness. The design and results are presented from an initial 30-month and a follow-up 66-month evaluation of Harbinger. The 30-month evaluation showed significant differences favoring Harbinger vs, the control group on independent living, employment, and client functioning. At 66-months, there were fewer experimental-control group differences. The differences in results are analyzed in terms of design and data collection problems, changes in the treatment environment for the control group, and the longitudinal course of mental illness. The discussion focuses on next steps in ACT research, utilizing program theory to better establish the mechanisms for successful intervention models.

Harbinger. II: Deployment and evolution of assertive community treatment in Michigan.

Assertive Community Treatment (ACT) is now recognized as the model proven to be most successful in working with clients with long-term, severe mental illness. The first documented research replication study of ACT was Harbinger of Grand Rapids, in Kent County, Michigan. The Harbinger program influenced significant programmatic changes throughout the public mental health system in Michigan. This paper describes this evolution in community mental health locally and why these changes came about. The state-level strategy to implement replications of Harbinger is described, as well as funding and monitoring mechanisms that have now resulted in over 100 successful ACT programs in Michigan. For mental health administrators, the implications discussed include the future of ACT promotion and implementation, within the reality of a managed care framework.

Characteristics of participants in a supported education program for adults with psychiatric disabilities.

OBJECTIVE: Supported education programs provide assistance, preparation, and support to individuals with psychiatric disabilities who desire to pursue postsecondary education. To determine the extent to which "typical" clients with severe mental illness can participate in a supported education program, the study examined characteristics of participants in a large supported education program. METHODS: 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. Cluster analysis used five variables (sex, age, educational attainment, work background, and symptoms) to produce a client typology. RESULTS: Five clusters emerged: 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. Although many participants had significant problems with symptoms, social adjustment, and substance abuse, they were able to remain active program participants. CONCLUSIONS: The results indicate that supported education is a feasible alternative for many individuals to meet goals for educational advancement, personal development, and better jobs.

Correlates of functioning in a population with dual diagnoses: an examination of diagnosis and problem history.

This study examines the relationship between diagnosis and life functioning using the Addiction Severity Index (ASI) with 467 hospitalized individuals with mental illness and substance abuse problems. Persons diagnosed with schizophrenia were the best functioning group across most of the ASI domains except employment and psychiatric functioning. More robust relationships were found between problem history (i.e., prior symptomatology or treatment) and current functioning. Respondents with histories of drug treatment, prior experience of anxiety and depression, self-injurious behavior, or violence control problems experienced more severe medical, drug, alcohol, psychiatric, legal, and family/social problems at the time of hospitalization. Violence control problems were related to drug use and criminal involvement, whereas self-injurious behavior was more often related to alcohol use and psychiatric distress. These findings suggest that problem history may be a stronger predictor of treatment need at the time of hospital entry than are more commonly used indexes, such as diagnosis.