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A Program of Supported Education for Adult Israeli Students With Schizophrenia

Posted on: Friday, 11 November 2005, 03:03 CST

By Sasson, Rachel; Grinshpoon, Alexander; Lachman, Max; Ponizovsky, Alexander

This report describes a supported education program (SEP), a novel community-based program of rehabilitation for psychiatric patients, started in Israel in 1999. Objectives, target population and activities are described. In addition, initial findings of two program-related studies are presented. One study explored the relationship of psychological distress with students' coping strategies and perceived social support. The second study is a survey of mental health literacy and attitudes of heads of schools for adult education where the SEP was implemented. Studies' findings suggested a "case for action" with the following objectives: to develop interventions to prevent distress among SEP users, and to enhance mental health knowledge and foster positive attitudes among school personnel aimed at decreasing dropout rates and encourage the utilization of the opportunities provided by SEP.

Supported Education in Israel

The Rehabilitation Law for people with psychiatric disabilities, introduced of late in Israel, addresses the right to financial support for persons with mental disorders in need to complete their education including: i) Hebrew classes (for recent immigrants); 2) basic education; 3) high school education; and 4) computer learning courses.

The supported education project includes three components: formulation of policy, definition of the needs of the population, and design and implementation of the intervention program.

Policy. The Government is currently drafting a set of policies aimed at the development of supported education services for persons with severe mental disorders (Lachman, 1998; Sasson, Grinshpoon, Lachman, & Boni, 2003). Programs for this population include: identification of their specific educational needs and of suitable educational settings; formulation of a comprehensive program integrating health, education and immigration (when relevant) services; training of the teaching staff; and establishment of a service-pricing mechanism.

The target population. Our database system (Lichtenberg, Kaplan, Grinshpoon, Feldman, & Nahon, 1999) provided the number of years of education for 6.016 out of the 12,224 persons aged 21-55 who had been admitted to inpatient psychiatric units during at least one day in 1998. Of them, 4,500 were recent immigrants. Over half of the population (56.1%) had more than 12 years of education. The SEP was programmed according to the differential educational needs of our candidates, including their learning capacity as reported by his/ her personal carer.

Implementation of the program. Community mental health agencies, vocational rehabilitation services, service-user groups, clubhouses, hospitals, and other agencies for persons with mental disorders were informed about the SEP. The inclusion criteria for enrollment were i) ICD-io diagnosis of schizophrenia; 2) between the ages of 18 and 65; 3) free of substance dependence disorder; 4) without a known history of violence in the community; 5) with at least 8 years school education; and 6) candidate's desire to obtain high school matriculation in one of the following subjects: computers, reading comprehension, Bible interpretation, or citizenship. Of the 440 candidates, 180 met the above criteria and were enrolled.

The courses were conducted in community high schools for adult education in eight cities. The topics covered are part of the formal high school education program of the Ministry of Education. The duration of the course was 3 to 6 months; 72 classroom hours were spread through 3- to 4-hour sessions conducted once to twice weekly. Homogeneous groups of 15 to 25 students were guided by a social worker or an occupational therapist in order to achieve group cohesion and facilitate the students' integration in the educational setting.

Based on a review of the literature on the subject, we conducted pre-intervention meetings with school principals and teaching supervisors. In these meetings we attempted to dispel unjustified fears and stigma.

Research Activities

Psychological distress among students. To better use the opportunities provided by the SEP. we wanted to know what factors might hamper the educational efforts of our students. We conducted pre-SEP assessments of psychological distress as well as coping and social support resources. We compared these measures between students with and without psychiatric disorders (Ponizovsky, Grinshpoon. Sasson, & Levav, 2004) relying on standardized self- administrated questionnaires: the Talbieh Brief Distress Inventory (TBDI; Ritsner, Modai, & Ponizovsky, 2002), the Coping Inventory for Stressful Situations (CISS; Endler & Parker, i993), and the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Parley, 1988).

Preliminary findings of this enquiry showed that the students with schizophrenia reported emotional distress and the use of emotion-oriented and avoidance-oriented (diversion) strategies to cope with stressful situations at school more often than students without psychiatric disorders. In addition, they perceived less social support from friends. In a regression model, the best predictors of experienced distress in the students with psychiatric disorder were emotional-oriented coping and social support from friends and family, which accounted for 46.3%, 24.5%, and 22.5%, respectively, of the total variance in emotional distress scores. We concluded that the potentially beneficial effect from social support as a buffer of distress was likely to be reduced by using emotion- oriented coping styles (Ponizovsky et al.. 2004).

These findings may have important implications for practice. Published reports of supported education evaluations show that nearly a third of students with psychiatric disorder drop out of the program due to increased stress and symptomatology (lieberman, Goldberg, & Jed, 1993). Our findings suggest targets for specific interventions that include: increasing the perception of availability of social support from family and friends, and utilization of more adaptive coping strategies, such as task- and avoidance- (social distraction) oriented coping devices.

School principals' mental health attitudes. Since stigma and discrimination at school may lead to failure of the SEP, we undertook a brief survey of mental health knowledge and attitudes (Ponizovsky et al., 2003). Almost allcountrywide heads of schools for adult education (93.8%. 0=76) were interviewed by telephone using a short questionnaire. The study results showed that the school principals know a fewer number of mental disorders in contrast to general medical conditions (taken as reference criteria). They recognized psychosis but not depression as a mental disorder. Their attitudes revealed an ambivalent approach to the person with a psychiatric disorder, including those that are students. A large majority of respondents claimed that a person who has a mental illness would be accepted as a friend or a neighbor by their social network (72% and 67%. respectively) and almost the same proportion (75%) would oppose letting a teacher affected by a mental disorder teach a young child. Of concern was the fact that 42% of school principals regarded a student with a mental disorder as being potentially more dangerous than other students. Respondents with relative higher level of education had more positive attitudes, while personal familiarity with a person with mental disorder was associated with slightly more positive school-related attitudes.

These findings suggest that psychoeducation programs improving mental health literacy and fostering more positive attitudes among school personnel and students without psychiatric disorder would better assure the integration of the SEP users into the adult education system.

Preliminary evidence of effectiveness

Post-course meetings were conducted with the school principals, teachers, psychiatric staff, representatives of the Mental Health Services and the National Insurance Institute (where the Institute had helped in funding). The purpose of the meeting was to assess the educational and rehabilitation achievements of each student and to draw conclusions for future interventions.

It was noted that those who completed the computer utilization course are now employed. In addition to their educational achievements, a marked improvement in self-respect and self- confidence were reported by carers. Family members reported an improvement in family relationships, students' satisfaction with their learning, and less preoccupation with their symptomatology. Teachers reported substantial changes in their previous negative attitudes and greater ability to build positive relationships with the students.

Conclusions

We noted that our target population has the basic ability to function in educational settings and reach a reasonable level of achievement, as long as they are provided with an appropriate support system. From the responses of our students, psychiatric staff and family members we gathered that the intervention improves self-respect, general functioning, coping with stress and perception of social support. The overall distress level drops and students reported greater satisfaction with different l\ife domains. Much remains to be done, e.g., to raise awareness, to design and fully evaluate the program. However, given our initial experience, the contribution of supported education to the overall success of psychosocial rehabilitation makes these efforts warranted.

References

Endler, N. S. & Parker, J. D. (1990). Multidimensional assessment of coping: A critical evaluation. Journal Personality Social Psychology, 58, 844-854.

Lachman, M. (1998). Psychosocial rehabilitations in Israel: A turning point? Society and Welfare, 18, 45-63.

Lichtenberg, P., Kaplan, Z., Grinshpoon, A., Feldman, D. & Nahon, D. (1999). The goals and limitations of Israel's Psychiatric case Register. Psychiatric Services, 50, 1043-1048.

Lieberman, H. J., Goldberg, F. R. & Jed, J. (1993). Helping seriously mentally ill patients to become students. Psychosocial Rehabilitation journal, 27(1), 99-107.

Ponizovsky, A., Grinshpoon, A., Sasson, R., Baidani-Auerbach, A., Ben-Eliezer, D. & Shershevsky, Y. (2003). Knowledge and attitudes about mental disorders among principals of adult education schools. Israel loumal of Psychiatry, 40, 283-289.

Ponizovsky, A., Grinshpoon, A., Sasson, & R., Levav, I. (2004). Stress in adult students with schizophrenia in a supported education program. Comprehensive Psychiatry, 45. 399-405.

Rehabilitation of the Mentally Disabled in the Community Act, 2000 Version no. 2782, pp. 1 (in Hebrew).

Ritsner, M., Modai, L, & Ponizovsky, A. (2002). Assessing psychological distress in psychiatric patients: Validation of theTalbieh Brief Distress Inventory. Comprehensive Psychiatry, 43, 229-324.

Ritsner, M., Modai, I., Endicott, J., Rivkin, 0., Nechamkin, Y., Barak, P., Goldin, V. & Ponizovsky, A. (2000). Differences in quality of life domains, psychopathological and psychological factors in psychiatric patients. Journal of Clinical Psychiatry, 61, 880-889.

Sasson, R., Grinshpoon, A., Lachman, M. & Boni, O. (2003). Supported education for persons with mental health disabilities: Programs and objectives. Israel journal of Occupation Therapy, 12,135-149.

Zimet, G. D., Dahlem, N. W., Zimet, S. G. & Parley, G. K. (1998). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52, 30-41.

RACHEL SASSON, BA, IS THE DIRECTOR OF THE SUPPORTED EDUCATION PROJECT OF THE MENTAL HEALTH SERVICES AT THE MINISTRY OF HEALTH, IERUSALEM, ISRAEL.

ALEXANDER GRINSHPOON, MD, MHA, IS HEAD OF THE DEPARTMENT OF MENTAL HEALTH SERVICES ATTHE MINISTRY OF HEALTH, JERUSALEM, ISRAEL.

MAX LACHMAN, PHD, IS IN THE SOCIAL REHABILITATION UNIT OF MENTAL HEALTH SERVICES OFTHE MINISTRYOF HEALTH AND BAERWALD SCHOOL OF SOCIALWORK, HEBREW UNIVERSITY, JERUSALEM, ISRAEL.

ALEXANDER PONIZOVSKY, MD, PHD, IS SCIENTIFIC ADVISOR IN THE DEPARTMENT OF MENTAL HEALTH SERVICES ATTHE MINISTRY OF HEALTH, JERUSALEM, ISRAEL.

CORRESPONDING AUTHOR:

ALEXANDER PONIZOVSKY, MD, PHD

MENTAL HEALTH SERVICES

DEPARTMENT OF RESEARCH AND PLANNING MINISTRY OF HEALTH

2 BEN TABAI ST.

JERUSALEM, 93591, ISRAEL

TEL: +972-2-6725835

FAX: +972-2-6719007

E-MAIL: alexander.ponizovsky@moh.health.gov.il

Copyright Psychosocial Rehabilitation Journal Fall 2005

Source: Psychiatric Rehabilitation Journal

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