Higher Education and Rehabilitation for People with Psychiatric Disabilities.

In the present day, college attendance is widely considered an economic endeavor (Astin, 1993; Levine & Cureton, 1998). Occupations with greater prestige and status require a college education (Pascarella & Terenzini, 1991; Rodriguez & Ruppert, 1996). Besides contributing to higher socioeconomic status, post-secondary education has also been found to positively impact quality of life (Pascarella & Terenzini, 1991), health outcomes, and mortality rates (Hamburg, 1997; Haveman & Wolfe, 1984; Pincus, Callahan, & Burkhauser, 1987).

No doubt as a result of these obvious and well-publicized benefits, a more diverse and increasingly larger number of adults are attending college. Statistics kept by the U.S. Department of Education show that in 1997, 44% of undergraduates were over the age of 25 and 43% were attending college part-time. Sixty-five percent of all high school graduates now go on to post-secondary education; "the nation has moved from what has been characterized as elite to mass to universal higher education" (Levine & Cureton, 1998, p. 145).

Despite the high volume of individuals who enroll in higher education, most people who matriculate into colleges and universities do not complete a degree (Tinto, 1993). Many factors may account for this attrition, including a lack of fit between students and educational institutions, students' difficulties financing their education, and competing life circumstances (Astin, 1993; Tinto, 1993). An additional factor affecting college completion remains largely unexplored. This factor is mental illness. Evidence suggests that people with mental illness begin college, but are frequently unable to complete their educational goals. Kessler, Foster, Saunders, and, Stang (1995) used nationally representative data to estimate that approximately 4.3 million individuals would have completed college if they had not experienced a serious mental illness. This attrition from college represents a waste of resources by post-secondary educational institutions, financing bodies, and the individuals themselves.

Students who struggle with mental illness may not be finding the specific supports they need to overcome barriers to the completion of their education. Although the symptoms of mental illness present a barrier to higher education, they can often be overcome with medication, psychotherapy, or a combination of these treatments. Aside from the symptoms, there are a number of other barriers to higher education faced by people with mental health problems. Loewen (1993) found that this population of students faced a lack of awareness or understanding of mental illness by faculty and peers. Moreover, institutional discrimination exists on some campuses in the form of mandatory psychiatric withdrawal policies (Hoflman & Mastrianni, 1991). These academic policies require students with mental illness to leave campus until they seek treatment, demonstrate competence through employment or education at another institution, or both.

Campus facilities have only limited mental health services available. Sixty percent of a sample of college administrators surveyed report that increasing numbers of undergraduates are using psychological counseling services and are using them for longer periods of time. One dean wrote, "Students bring more nonacademic related issues [to campus]. We are becoming a secondary social service agency" (Levine & Cureton, 1998, p. 96). Campus mental health professionals responsible for taking care of the psychological needs of students are alarmed by the increasing numbers of students with serious mental illness because they do not have the resources necessary to serve this population (O'Malley, Wheeler, Murphey, O'Connell, & Waldo, 1990; Stone & Archer, 1990). In addition, people with serious mental illnesses who attend college may be falling though the cracks in mental health service systems. While colleges lack the resources to address this population's psychiatric treatment needs, mental health service providers may not be providing these individuals with support for their educational endeavors. That is, in several studies, adults with mental illness have reported that mental health professionals often neglect educational goals (Loewen, 1993; Unger, 1991; Weiner & Wiener, 1996).

The overall value placed on education by people with psychiatric disabilities has not been studied empirically; however, survey research has found that people with disabilities in general and non-disabled people have similar regard for higher education (Bailey, 1994). There is evidence that people with psychiatric disabilities value educational attainment and want to pursue post-secondary education (Moxley, Mowbray, & Brown, 1993; Rogers, Anthony, Toole, & Brown, 1991; Unger, 1993). That individuals who experience mental illness have educational potential is substantiated by repeated findings that their median educational level is over 12 years and that 20% to 50% have some college experience, usually before the onset of their psychiatric problems (Hazel, Herman, & Mowbray, 1991; Tessler & Goldman, 1982; Unger & Anthony, 1984).

The current study presents responses of adults with psychiatric disabilities concerning the barriers they have experienced in pursuing post-secondary educational goals. The information was obtained from a large sample (n=397) of participants in a supported education program for individuals with psychiatric disabilities. The program was located in a major urban area with a high concentration of racial/ethnic minorities.

Background - What Is Supported Education?

Supported education (SEd) programs have arisen in the past 10 years in response to problems experienced through more traditional vocational rehabilitation approaches (Moxley et al., 1993) and in response to the stated desires of consumers and family members to pursue post-secondary education (Unger, 1993; Unger & Anthony, 1984). Rehabilitation professionals have recognized supported education as a promising method to improve employment rates of those with psychiatric disabilities (Anthony, 1994; Parrish, 1991). Moreover, the Center for Mental Health Services certified supported education as an exemplary program model. As with supported employment and supported housing, SEd takes a rehabilitation approach in providing assistance, preparation, and supports to those with psychiatric disabilities who wish to pursue post-secondary education or training.

Eligibility criteria for supported education programs are fairly minimal. Generally, the criteria focus on adults with severe and persistent mental illness/psychiatric disabilities who themselves want to pursue post-secondary education or training (rather than being referred by providers or family members) and who need ongoing supports in order to be successful in the educational environment. Individuals also need to have some basic academic competencies (e.g., high school diploma, general equivalency diploma) to avoid program heterogeneity so great as to lose participants at either extreme. Experience has also shown that individuals must have access to ongoing mental health services to address crisis, medication, or basic needs because SEd is an educational/rehabilitation intervention (Frankie, et al., 1996; Parten, 1993). It is not designed or staffed to provide mental health treatment. Individuals are recruited into SEd programs from a wide variety of sources, including colleges and universities, rehabilitation agencies, public mental health services, and advocacy and self-help groups.

Across programs, participants have included both men and women, ranging in age from 16 to over 60, although participants are typically in their twenties and thirties. Ethnic diversity varies, reflecting the communities served. Mood disorders, schizophrenia, and anxiety disorders, sometimes co-occurring with substance abuse, are common diagnoses of participants. Frequently, participants have had earlier experiences with higher education (Mowbray & Collins, in press).

The Michigan Supported Education Research Project

To address the higher educational needs of individuals with psychiatric disabilities in metropolitan Detroit, the Michigan Supported Education Research Project (MSERP) was initiated through federal funding from the Substance Abuse and Mental Health Services Administration's Center for Mental Health Services. MSERP made use of the combined efforts and resources of agencies (community mental health, vocational rehabilitation) and institutions (community colleges, universities, and other post-secondary institutions) in the community to provide opportunities for individuals coping with long term mental illness to continue learning and to offer a means to career development in a meaningful vocation of their own choosing. It operated as a research demonstration project from 1992 through 1997, using a true experimental design, with random assignment. It then was continued as an ongoing program, called the Michigan Supported Education Program.

MSERP offered its (non-credit) services at the downtown campus of Wayne County Community College. The goal was to help participants: (a) establish an educational/vocational plan, (b) access supports and resources for the plan, (c) determine career goals, and (d) cope with specific problems presented by mental illness in the academic or vocational environment. MSERP services included career planning and vocational assessments, information on college or training program enrollment, assistance in obtaining financial aid, stress management, time management, rights and resource information, and facilitated contacts with campus special student services and vocational rehabilitation agencies (as a source of financial support for educational and vocational plans).

MSERP services were offered through three models: (a) classroom model, (b) group support model, and (c) individual model. The classroom and group support models were active treatment conditions and the individual model served as a control condition. After applications were received, eligible enrollees were given a baseline interview. They were then invited to attend a 2 hour orientation during which they received an information packet helpful for college enrollment and details about the model to which they had been randomly assigned.

Classroom Model

The classroom model met at the downtown campus of Wayne County Community College, twice a week for 2.5 hour sessions throughout two, 14-week semesters. The classroom model utilized an academic support curriculum, adapted from that developed at Boston University, the original SEd demonstration program (Unger, Danley, Kohn, & Hutchinson, 1987). This model's curriculum was implemented by two instructors in a classroom format, utilizing small group exercises and experiential learning. The curriculum was organized around three major topics: managing the academic environment, stress management, and developing career choices.

Group Support Model

The group support model also met at the downtown campus of Wayne County Community College, twice a week for 2.5 hour sessions throughout two, 14-week semesters. In this model, the aim was to create a supportive learning environment for students' exploration and decision-making on career options. Consumer-driven activities structured the operation of the group, including a needs assessment, prioritized agenda (curriculum) to meet needs, group work to utilize school and community resources, and ongoing evaluation of the group's success in meeting learning goals. Students in the group model developed their priorities through facilitated group exercises at the beginning of each semester; however, the choices of curriculum topics were made from among those covered in the structured classroom model. Two staff, one of whom was self-identified as a consumer, acted as group facilitators.

Individual Model

In contrast, the individual model served as a control group. After the orientation, there were no structured or scheduled interventions for students; they were given a staff person's name and instructed to contact him or her when they desired help. However, if they asked, like students in the active models, they could receive assistance in obtaining vocational rehabilitation (VR) eligibility and services, facilitated contacts with Disabled Student Services offices on campuses, access to contingency funds for school-related expenses (books, transportation--mostly bus tickets, childcare expenses, etc.), and on-site mentorships (from other students or peers). Few of these individuals ever contacted MSERP.

Outcome Evaluation of MSERP

The most significant evidence of the effectiveness of MSERP comes from analyses of quantitative outcome data obtained at the 6 month and 12 month follow ups. These analyses examined the effects of model and participation level on self-perception, social support, and functioning measures (utilizing data from individuals who at least participated to some extent in MSERP). The two active models (group and classroom) differed significantly from the control condition in showing increases on Quality of Life, Self-Esteem, and Social Adjustment measures, as well as in participation in college/vocational training (Collins, Bybee, & Mowbray, 1998; Mowbray, Collins, & Bybee, 1999).

The positive effects of MSERP were also substantiated through analyses using qualitative data. Responses to projective vignettes, based on school situations which were part of the MSERP curriculum, showed that positive coping behaviors differed significantly by participation levels and that the reported use of specific problem-solving strategies (vs. negative or neutral coping behaviors) related positively to 12-month outcomes for MSERP enrollees (Collins, Bybee & Mowbray, in press). Qualitative data were also collected at each interview time-point on educational and vocational goals. For all participants, as expected, the specificity of school-related goals increased over time, as did a measure of optimal goal setting. Furthermore, goal specificity related to model and to participation levels. Stating school as the most important goal at baseline was one of six measures found to predict college enrollment alter the program was completed (Collins, Mowbray & Bybee, 1999).

Methodology

Sample

The research results to be reported here involve the same MSERP sample which provided the previously described outcome evaluation data. These participants came from the 16 catchment areas served by the Detroit/Wayne County Community Mental Health Agency. Over a period of about 15 months, from 19941995, there were 397 individuals who applied, were eligible, and completed a baseline interview. These enrollees were mostly nonwhite and included a slightly higher percentage of female than male participants. The average age was 36.9 years and ranged from 17 to 75 years. On average, participants experienced mental illness for more than 14 years. Most participants received Social Security income (SSI or SSDI). About a quarter had a high school diploma or a general equivalency diploma, and a quarter had not completed high school. Nearly half had some post secondary education. Most participants lived with family or in supervised settings; about one-fifth lived alone and one-tenth with friends. The geographic distribution of the participants encompassed Detroit as well as the outlying areas of the county and generally resembled that of the community mental health agency's overall clientele.

Data collection

Trained staff interviewed at five points: (a) baseline, (b) midway through the intervention (the end of the first semester), (c) program completion, (d) 6-month follow-up, and (e) 12-month follow-up. The interview covered past educational and psychiatric history, functioning, social support, self-perceptions, and behavioral outcomes. Of relevance for this analysis, at baseline, participants who had some previous college attendance were asked a series of questions concerning their prior experiences. First, they were asked the open-ended question, "What were the reasons that you did not complete your college education?" This question was followed by a series of closed-response questions about barriers encountered in the college environment (15 items), personal difficulties in attending college (8 items), and needs -- "would you have continued your education, or would your performance have been improved if the following services were available?" (8 items). Of 397 participants interviewed at baseline, 175 (44.1%) who had some prior college experience answered these questions. The answers to the open-ended question were content-analyzed and coding categories were established. Inter-rater agreement was checked and found to be more than satisfactory (kappa [is greater than] .70). Descriptive statistics were then calculated on the open and closed-ended responses.

Results

Coded responses from the open-ended question are presented in Table 1. The most frequently mentioned problem was symptoms of mental illness, followed by financial need. Both of these responses were spontaneously produced by 45% or more of the respondents. Following these, the most frequently mentioned barriers were lack of resources, competing responsibilities, and academic problems. The other categories were each mentioned by less than 10% of the respondents.

Table 1 Barriers Encountered in Previous College Attendance Coding of Open-Ended Responses (n= 164)

Coding Category:

Academic problems             0 times = 142 (86.6%)
                              1 or 2 times = 22 (13.4%)

Lack of resources             0 times = 125 (76.2%)
                              1 or 2 times = 39 (23.8%)

Competing responsibilities    0 times = 135 (82.3%)
                              1 or 2 times = 29 (17.7%)

Mental health complications   0 times = 93 (57.4%)
                              1 or 2 times = 69 (42.6%)
                              NA = 2

Interpersonal issues          0 times = 151 (92.1%)
                              1 time = 13 (7.9%)

Physical health problems      0 times = 150 (91.5%)
                              1 time = 14 (8.5%)

Coding Category:              Sample Responses:

Academic problems             "I flunked out."
                              "I felt like a failure, because my
                              grades weren't good enough."
                              "My workload was just too heavy"

Lack of resources             "I needed more money to generally
                              cover my needs."
                              "I experienced problems getting
                              financial aid."

Competing responsibilities    "I had a baby."
                              "I joined the military."
                              "I stopped attending college to go
                              to work."

Mental health complications   "I was depressed."
                              "I was hearing voices."
                              "I was overwhelmed and stressed
                              out."
                              "I needed to be hospitalized."

Interpersonal issues          "My family was experiencing
                              relationship problems."
                              "My family was in the middle of a
                              crisis."

Physical health problems      "I needed to get surgery on my
                              knee."
                              "I was hit by a car."
                              "I was assaulted and received a
                              head injury."

Frequencies of responses to closed-ended questions are presented in Table 2. In terms of barriers, "concentrating in class," "getting low grades," "getting assignments done," and "taking notes" were each endorsed by 30% to 40% of respondents. The next most frequent problems, checked by about 20% to 25% of participants, were "applying for financial aid," "joining in class discussions," "accepting criticism," and "attending classes." The remaining items were indicated as problems by about 15% or less of those responding.

Table 2 Frequencies of Closed-ended Responses on Barriers, Personal Difficulties and Needs (n = 175)

Barriers, % Yes                      Personal Difficulties, % Yes

Concentrating in class, 42.9%        Symptoms of mental illness,
                                     50.9%

Getting low grades, 39.4%            Financial aid, 45.1%

Getting assignments done, 29.7%      Too many classes, 26.3%

Taking notes, 29.7%                  Fear/inability dealing with
                                     college, 25.6%

Applying for financial aid, 25.7%    Family crisis, 25.1%

Joining in class discussions,        Lack of academic skills, 24.0%
22.9%

Accepting criticism, 21.1%           Poor physical health, 17.7%

Attending classes, 18.9%             Stopped taking medication,
                                     14.3%

Commuting to campus, 15.4%

Registering for classes, 15.4%

Meeting with professor/advisor,
11.4%

Getting along with other students,
11.4%

Using the library, 10.9%

Parking, 9.1%

Getting around campus, 8.0%

Barriers, % Yes                      Needs, % Yes

Concentrating in class, 42.9%        Financial support, 58.9%

Getting low grades, 39.4%            Tutoring services, 52.0%

Getting assignments done, 29.7%      Special class instruction,
                                     34.9%

Taking notes, 29.7%                  Transportation to school, 32.0%

Applying for financial aid, 25.7%    Note taker assistance, 31.0%

Joining in class discussions,        Registration assistance, 25.7%
22.9%

Accepting criticism, 21.1%

Attending classes, 18.9%

Commuting to campus, 15.4%

Registering for classes, 15.4%

Meeting with professor/advisor,
11.4%

Getting along with other students,
11.4%

Using the library, 10.9%

Parking, 9.1%

Getting around campus, 8.0%

The middle column of Table 2 lists the personal difficulties that participants were asked about in their baseline interview. As in the open-ended responses, "symptoms of mental illness" and "financial problems" were the barriers most frequently mentioned (endorsed by 40% or more of respondents). Items endorsed by about a quarter of the respondents were: "too many classes," "fear/inability dealing with college," "family crisis," and "lack of academic skills." "Poor physical health" and "stopped taking medication" were personal difficulties identified by only one-fifth to one-sixth of participants.

Finally, as listed in the third column of Table 2, when asked to identify what assistance might have initially helped them stay in school, a majority of participants endorsed "financial support," followed by "tutoring services." Thirty to thirty-five percent said yes to "special class instruction," "transportation," and "having a note-taker." About a quarter said that "help with registration" would have been beneficial.

Discussion

Congruent with other reports on the educational backgrounds of adults with psychiatric disabilities, a large percentage of individuals from this supported education program had previous college enrollments (Tessler & Goldman, 1982; Unger & Anthony, 1984). Not surprisingly, these individuals reported experiencing multiple barriers in their prior, unsuccessful attempts to pursue post-secondary education and training. Analyses of open-ended responses as well as the items endorsed as "Personal Difficulties" converged in indicating that mental illness symptoms and financial problems were major obstacles to educational attempts. Other issues commonly mentioned were competing demands and family issues, such as working or having a baby.

Attending to Academic Problems

Interestingly, in the open-ended responses, only about 13% of respondents mentioned their academic difficulties. This finding suggests that they did not regard their academic problems as the major reason for their failure to achieve post-secondary educational goals. Indeed, what stood out in their memories were financial problems, their own psychological problems, and barriers due to external circumstances in their personal lives. When asked if they had specific academic problems (in the barriers questions), 30% or more did agree that they had problems concentrating in class, earning low grades, completing assignments, and taking notes. In a supported education model, these are technical problems that can be overcome with skill training activities and with coordination between the SEd staff and the individual's mental health provider. That is, concentration problems are often due to either inadequate symptom control or to the side effects of medication. Therefore, with many more medications from which to choose and with consumer education on the early warning signals of relapse, these academic problems can often be overcome through coordination and communication between the consumer and the provider (for example, medication increases when the consumer is having a stressful period, or decreases when the consumer indicates that medication levels are interfering with concentration).

About a quarter of the participants did indicate that they lacked academic skills. This area of concern is substantiated by the concurrence of more than half of the participants that tutoring services would have helped them continue their education, if they had been available. Also, more than a third said that "special class instruction" would have helped. These identified academic needs may reflect the long standing association between prevalence of mental illness diagnoses and lower socioeconomic strata. Diagnoses of depression and anxiety are 1.5 to 2 times more likely for adults without high school completion, according to data from the National Household Survey on Drug Abuse, 1997 (Mental Health News Alert, 1999). Individuals with adult mental illness may have grown up in poverty, in inner cities, where the academic training they received put them at a disadvantage in college achievement. Supported education programs are able to address many of these deficits. SEd services often provide assistance with academic preparation. The Michigan Supported Education program now has a resource room with self-help, academic skill-building packages available on computers and with tutors able to help in the resource room. The curriculum has exercises and homework to renew reading, writing and speaking skills or to assess skill deficits that need more intensive intervention.

The need for "tutoring" and "special class instruction" in previous college experiences may also reflect participants' needs for social support (as the support networks for individuals with mental illness are typically low; Holmes-Eber & Riger, 1990) or their own fears and sense of inadequacy in trying to compete in the academic environment (more than a quarter admitted fears and an inability to deal with college). Many supported education programs, such as MSERP, emphasize mutual support through service delivery in a group setting that utilizes group members for problem solving and role modeling. A previous article on MSERP analyzed qualitative data collected to demonstrate the personal and group empowerment feelings experienced by MSERP students because of the support that they received from their peers and the staff (Bellamy & Mowbray, 1998).

Addressing Mental Health Problems

Symptoms of mental illness were identified as major obstacles to prior college enrollments. Twelve-month follow up data on participants in MSERP showed that the number of individuals indicating that symptoms were still impediments to their proceeding with their educational plans decreased from 53% to 41% (trend-level difference, see Mowbray, Bybee & Collins, in press). Success in a supported education program and, following its completion, in the academic world, especially for these adults with long-term psychiatric disabilities, is clearly dependent on having adequate mental health treatments available and accessible. The term "adequate" is meant to include treatment which recognizes consumers' goals (such as education) as primary, rather than the convenience of the treatment agency in prescribing just one medication or one medication regime, and which assists consumers to solve challenges they are experiencing in attempting to pursue these life goals. Unfortunately, mental health providers are not immune from stigmatizing conceptions about mental illness (Unger, 1993) and this kind of treatment is not often enough available.

A review of the experiences of consumers pursuing post-secondary education indicates that mental health providers are oftentimes not attuned to the consumers' goals. One client from the Michigan Supported Education program commented. "The Assertive Community Treatment program.... which I belong to [was] supportive. However, my doctor there thought I set my goals too high." One consumer with aspirations for an advanced degree reported that her mental health worker laughed when she told him she wanted to go back to school (Shepherd, 1993). Many mental health providers need more education about rehabilitation and recovery and the importance of client-centered services.

Financial Barriers to College Attendance

Financial barriers played nearly as prominent a role as did mental illness issues, according to the adults that were interviewed. Supported education programs do try to address financial problems by giving students information and assistance in applying for college scholarships. Another financial issue which frequently needs to be addressed is clearing up bad educational loans or other debts. Frequently, many adults with psychiatric disabilities attending college have had past withdrawals because of psychiatric crises. However, rather than take a medical withdrawal, because of the shame and stigma associated with psychiatric problems, they dropped out without explanation. Thereby, they accumulated unexcused educational debts. SEd staff can provide information and assist students to negotiate repayments or even have excusal of the debt.

Many SEd participants also need substantial, current financial assistance to further their education. Vocational rehabilitation funders can be critical in this regard. Articles on several other SEd programs have described the partnership and collaboration developed with VR providers, to the students' benefit. Egnew (1993) described a program in northern California which integrates supported education and supported employment. This integration facilitated referrals from CMH to VR and maximized the likelihood that participants would qualify as VR clients and, therefore, receive funding support. Several articles (see Mowbray, Verdejo & Levine, in press; and Parten, 1993) have described similar practices. Such coordination serves the interests of all parties; the VR staff feel that they were more likely to receive eligible clients and CMH staff feel that clients they referred were more likely to be accepted for services.

A highly desirable possibility is for VR to fund SEd services directly. One mechanism is through a fee for service, purchasing a package of services from an SEd program. The purposes of the service may be to prepare or to support a VR client in advanced education or training tied to a vocational goal or both. In Michigan, the state VR agency has paid tuition costs (beyond those of a Pell Grant) for several students. A program to train consumers as case management aides at Houston Community College accessed funding from the Texas Rehabilitation Commission for travel, work clothing, and half the cost of on the job training. The Harris County Private Industry Council provided the other half and also subsidized tuition, books, and travel (Housel & Hickey, 1993).

More commonly, VR funding is accessed to pay for support costs of students attending an SEd program, college, or other post-secondary classes. In Michigan, supported education students receive help from VR district offices for transportation to educational programs (e.g., bus passes, mileage reimbursement, payments for van services, taxis, specially arranged drivers, etc.). Vocational rehabilitation funds have also been used for related expenses, such as car repair when the car was the client's only way to get to the program, car insurance, and even a down payment on a vehicle. VR agencies can provide funds to buy clothing, so that clients can attend classes and "fit in," and to cover expenses for books, notebooks, and other supplies. One student received money for tutorial software and for service on a home computer that had crashed. Another student received lunch money because his required classes met at the noon hour. However, funding availability can be very uneven across VR agencies. For every positive example, MSERP had eight or nine students who had been denied any benefits from VR. For example, one student was working on a technical degree and got a part-time job at Burger King to help with family expenses. His vocational rehabilitation counselor then closed his case because as far as the counselor was concerned, a successful vocational outcome had been achieved.

Conclusions

Despite their academic potential and motivation to get college degrees, individuals with psychiatric disabilities face many barriers. Supported education programs can and do work. However, for optimal success, these programs require support and coordination from other provider agencies. Mental illness symptoms can be addressed with assistance from mental health treatment providers. These professionals can help consumers fulfill academic goals by searching for adequate medications and other therapies to stabilize symptoms and by demonstrating a willingness to adjust medications as needed. Similarly, vocational rehabilitation agencies can help address financial barriers which are also major obstacles to the pursuit of post-secondary education. Community mental health and VR administrators and staff need to be sure that workers are adequately updated on the newest rehabilitation technologies developed for psychiatric disabilities and on research which identifies the kind and combination of supports needed for consumer recovery.

Author's Note

This study was funded by the Community Support Branch of the Center for Mental Health Services, SAMHSA, through a grant to the Michigan Department of Mental Health (Grant# HD5-SM47669). It represents a collaboration between Schools of Social Work at the University of Michigan, Eastern Michigan University, and Wayne State University, and the Detroit-Wayne County Community Mental Health Agency.

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Carol T. Mowbray, Ph.D., University of Michigan School of Social Work, 1080 South University, Ann Arbor, MI 48109-1106.

Deborah Megivern

University of Michigan