Feasibility Study for Demonstration of Supported Education to Promote Educational Attainment and Employment among Individuals with Serious Mental Illness: Final Report. 2. Background


2.1. Educational Attainment and Employment among Individuals with Serious Mental Illness

Individuals with serious mental illness (SMI) face considerable challenges in educational attainment and employment. SMI is accompanied by a myriad of cognitive, emotional, and social difficulties that negatively affect educational performance (Souma, Rickerson, & Burgstahler, 2006). High school completion rates for youth with SMI are dismal. More than 50% of students with a mental disorder (aged 14 years or older) drop out of high school (Armstrong, Dedrick, & Greenbaum, 2003; Marder, 1992)--the highest dropout rate of any disability group (U.S. Department of Education, 2004). Students with a mental health condition also have the poorest rates of school attendance, lowest grade point averages (GPAs), and highest course failure and expulsion/suspension rates of any students with disabilities. In contrast to students in other disability groups, whose post-secondary employment rates increased significantly since the early 1990s, employment rates of students with psychiatric conditions have not improved (Wagner, 2005). Results from the U.S. Department of Education's most recent National Longitudinal Transition Study indicate that students with psychiatric conditions have a post-high school employment rate of only 50% (Wagner & Newman, 2012).

Individuals with SMI experience educational difficulties that extend to the college setting. Even when they attend college, they experience longer delays in entering college (Newman et al., 2011), and exhibit extremely high dropout rates (Salzer, Wick, & Rogers, 2008). Colleges and universities, including graduate and professional schools, are seeing a dramatic increase in the number of students with psychiatric conditions (Sharpe, Bruininks, Blacklock, Benson, & Johnson, 2004). A survey of five institutions in the Big Ten Conference revealed a 30%-100% increase in student services addressing psychiatric conditions over a 1-year period (Sharpe & Bruininks, 2003). A national survey of more than 95,700 college students across 139 institutions revealed the extent of the problems. The findings were alarming: 75% experienced a traumatic event within the previous 12 months, more than half reported that they had more than average or tremendous amounts of stress, 56% felt very lonely, 61% were very sad, and 46% felt hopeless. Roughly 35,400 students (37%) had been diagnosed with a psychiatric condition in the past year that warranted community mental health services (Collins & Mowbray, 2005).

Educational attainment is strongly linked with critical employment outcomes, such as unemployment and wage earnings (U.S. Department of Labor, 2010) and consistently predicts later employment among adults with mental illness (Burke-Miller et al., 2006; Ellison, Russinova, Lyass, & Rogers, 2008; Rogers, Anthong, Lyass, & Penk, 2006). Supported employment (SE) interventions have a long history of trying to promote the engagement of individuals with SMI in the workforce. These interventions have a strong evidence base and are well suited to provide job placement and employment support to individuals with SMI. However, even studies of SE have found that participants tend to work only part time with relatively low earnings and that job retention rates vary dramatically even after successful job placement (Becker, Whitley, Bailey, & Drake, 2007; Bond, Drake, & Becker, 2008; Campbell, Bond, & Drake, 2011; Mueser et al., 2005; Salyers, Becker, Drake, Torrey, & Wyzik, 2004). Consequently, low levels of education, vocational training, and job skills/readiness may continue to be important factors in increasing sustainable employment and promoting long-term self-sufficiency.

Promising programs to address these educational and employment challenges are emerging; however, despite some strategies with preliminary evidence, evaluation data are extremely limited.

2.2. Supported Education Interventions

Supported education (SEd) interventions focus on individuals with SMI who face challenges in achieving educational goals due to their impairment. SEd has been defined as supports "to assist people with psychiatric disabilities to take advantage of skill, career, educational and inter-personal development opportunities within post-secondary educational environments" (Collins, Bybee, & Mowbray, 1998). The goals of SEd are for individuals with SMI to successfully be able to: (1) set and achieve an educational goal (e.g., training certificate or degree); (2) improve educational competencies (literacy, study skills, time management); (3) navigate the educational environment (e.g., applications, financial assistance); and (4) improve attitude and motivation.

SEd presents a particularly promising approach and is the focus of this report. There is preliminary evidence for the effectiveness of SEd to assist individuals with identifying educational goals, to link to needed resources, and to cope with barriers to educational attainment (e.g., Cook & Solomon, 1993; Hoffmann & Mastrianni, 1993; Mowbray, Collins, & Bybee, 1999; Robson, Waghorn, Sherring, & Morris, 2010; Thompson, 2013; Unger, 1993; Unger, Pardee, & Shafer, 2000). Unfortunately, this general evidence base is limited. Two systematic reviews of SEd approaches have been published relatively recently: Leonard & Bruer (2007) and Rogers, Kash-MacDonald, Bruker, & Maru (2010). Both reviews focused on outcome studies and specifically prioritized studies that operated under controlled situations. In addition, several other articles or reports have been published that more generally summarize the state of the SEd literature (e.g., Chandler, 2008; Ellison, Rogers, & Costa, 2013; Manthey, Goscha, & Rapp, 2014; Mueser & Cook, 2012; Parrish, 2009; Unger, 2011). Generally, these reviews conclude that SEd helps individuals progress toward educational goals and increase their self-esteem and positive self-perceptions and that individuals are satisfied with services. However, across these literature summaries, authors ask for caution in interpreting results. Although many studies of SEd interventions have been published, most do not include rigorous designs and include only minimal evaluation data. Few well-controlled studies exist (Rogers et al., 2010).

2.3. Current Project and Research Questions

The current project was designed to characterize the current state of knowledge about SEd as a way to assess the feasibility of conducting a demonstration of SEd for individuals with SMI. This project sought to identify key considerations in planning and preparing for a larger-scale demonstration of SEd by compiling evidence on SEd programs, identifying gaps in the knowledge base about SEd and describing possible approaches for addressing unanswered questions about SEd.

There were three key tasks associated with this project: (1) a literature review (summarized in Chapter 3); (2) an environmental scan of SEd researchers, program managers and other key informants (described in Chapter 4); and (3) site visits to three programs implementing SEd service delivery models (summarized in Chapter 5). Findings from across these tasks, as well as the identification of future needs and opportunities for SEd programs and research are described in Chapter 6.

The project focused on answering a series of research questions about SEd program composition, implementation, service context, the experiences of individuals involved in SEd programs, available SEd data sources and ongoing evaluations, SEd policies, financing, and gaps in the SEd knowledge base. Specific research questions are described in Table 2-1 along with the approach (literature review, environmental scan, or case study) used to address each question.

TABLE 2-1. Research Questions and Proposed Analytic Approach
Research Questions Analytic Approaches to Address
SEd Program Composition
What services/supports are included in typical SEd interventions and related programs, and how are they combined? X X X
How do SEd and related programs recruit participants? How do SEd programs continue to keep participants engaged in SEd interventions?   X X
What are the demographic characteristics of clients served by SEd programs? What are client needs and goals regarding educational attainment? X X X
How are SEd and related programs staffed and managed?   X X
What are key challenges for individuals' accessing SEd, attaining educational goals, and transitioning to employment?   X X
SEd Program Implementation
Who are the primary partners involved with the SEd program implementation process? Which partners are most critical to running SEd programs? Are certain partners missing in SEd program implementation processes that would be helpful?   X X
Do SEd programs engage service users in planning and developing programming?   X X
What are the main challenges in implementing SEd and related programs? How have these challenges been overcome?   X X
How do SEd programs measure implementation success? What metrics are important to SEd program funders?   X X
SEd Program Service Setting and Context
How do SEd approaches differ depending on the service setting (mental health agency, VR, VA system, community college), and what are the policy implications of these differences? X X X
Can SEd and related programs be disseminated through integration with SE programs available for people with SMI?   X X
Can SEd and related programs be disseminated through integration with other interventions for people with SMI (medical homes, substance abuse treatment, state VR programs, etc.)?   X X
What plans have been made across SEd programs to maximize the potential for program sustainability?   X X
Experiences of Individuals Involved in SEd Programs
How did participants in SEd programs learn about the program? What do participants say keep them engaged in the program?     X
What services do participants receive through the SEd program? Are these different from education services that these individuals have received before? If yes, how?     X
Do individuals who receive SEd program services identify specific goals? Who from the SEd program supports individuals served by SEd programs? What do these individuals do?     X
Do individuals who are receiving SEd program services feel that something has changed (improved or gotten worse) since they've been in the program? What do they think facilitated this change?     X
What do individuals served by SEd programs feel has been most useful? What do they think would make things even better? What is missing?     X
Available SEd Data Sources and Ongoing Evaluations
What data sources are available to assess the impact of SEd and related programs (education, employment, program participation, health--service use and outcomes, influence of contextual factors on program impact)? X X X
Can current studies be modified to address unanswered questions, or is a new demonstration recommended? X X  
What specific outcome measures should SEd studies examine (program implementation and educational, employment, and health outcomes)?   X X
What evaluations are ongoing and when will they end?   X  
What are the key challenges to evaluating SEd and related programs?   X X
Current SEd Evidence Base
What is the evidence on SEd program design implementation and financing? X   X
What is the impact of SEd on client educational attainment, employment and health? X   X
What other programs described in the literature (but not formally called "supported education") have similar objectives and designs to SEd programs? X    
Does the SEd literature identify different program impacts by psychiatric, demographic, or socioeconomic characteristics? X    
SEd Policies
What state/federal policies inform and guide SEd programs? Are there particular policies that support SEd program growth? Are there specific policies that restrict SEd program growth?   X X
What state/federal agencies are engaged in SEd policies?   X X
SEd Financing
How are SEd and related programs financed?   X X
What existing and potential financing streams could be leveraged to fund expansion of SEd/related programs?   X X
How can various funding sources be used to meet the needs of individuals, including needs for SEd services?   X X
What are main challenges in financing SEd and related programs?   X X
Gaps in the SEd Knowledge Base
What are gaps in the literature on SEd programs that are relevant to further program dissemination and scale-up? X X  
What are gaps in the evidence base on SEd programs that prevent SEd from being considered an evidence-based practice? X X  
What are important unanswered questions that are relevant to planning a SEd demonstration? X X  
What are potential study designs to address important gaps in knowledge of SEd and related programs? X X  

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