Psych Rehab Education

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Current Psychiatry Reviews, 2013, 9, 000-000 1

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Psychiatric/Psychosocial Rehabilitation (PSR) Education: Academic and Professional

Kenneth J. Gill* and Ann A. Murphy

Department of Psychiatric Rehabilitation and Counseling Professions, University of Medicine and Dentistry of New Jersey- School of Health-Related Professions, 1776 Raritan Road, Scotch Plains, NJ USA 07076

Abstract: Introduction: Since the 1980s, it has been asserted in the scholarly literature that education in psychiatric/ psychosocial rehabilitation (PSR) theory and techniques is a necessary component of academic preparation for practitioners providing services to people with serious mental illness (SMI) and, in fact, may be considered an academic discipline in itself. This paper is a systematic review of peer-reviewed publications on the practices, outcomes and predictors of PSR education.

Method: A systematic search of PubMed, PsycINFO, CINAHL, Academic Search Premier, and ERIC databases was conducted using the phrases psychiatric/psychosocial rehabilitation and academic/professional education/training. These terms were then combined with the terms education, higher education, undergraduate education, graduate education, medical education, psychology education, and social work education. Contents of three special issues of peer-reviewed journals devoted to psychiatric rehabilitation education were also included.

Results: Fifty-three non-duplicated articles were identified. Several were non-systematic literature reviews of the subject that often included proposals for curricular changes to specific disciplines including psychiatry, social work, and psychology. Several others were surveys on the issue of PSR content within the rehabilitation counseling field. No controlled studies on the subject were found. Several non-experimental studies have been published, primarily program evaluations of the impact of specific PSR curricula on student career outcomes, their knowledge of PSR practices, and their attitudes. Student proximal outcomes were predicted by the number of completed courses in PSR as well as by demographic and career variables.

Conclusion: Delivering PSR services to persons with SMI is acknowledged as requiring distinct knowledge and skill development. Despite this fact, there is not much research and relatively modest empirical support for specialized academic and professional education on this. More rigorous research on PSR education is required.

Keywords: Academic, education, professional, psychiatric/psychosocial rehabilitation, training.

INTRODUCTION

To provide psychiatric/psychosocial rehabilitation (PSR) competently, practitioners require a specific set of knowledge, skills, attitudes and values that ensure a recovery oriented and person-centered approach [1,2]. With the growing acknowledgment of PSR as both a professional specialty and an academic discipline, one would expect a concurrent growth in educational programs reflecting these developments. Indeed, there are now at least three major textbooks of PSR written in the last decade [3-5]. There is also a test-based PSR certification program based on a comprehensive role delineation study completed in 2000 and revised in 2007 with stakeholder input [6,7]. At least two peer-refereed scholarly journals are completely devoted to Psychiatric Rehabilitation, the American Journal of

*Address correspondence to this author at the Department Psychiatric Rehabilitation and Counseling Professions, University of Medicine and Dentistry of New Jersey- School of Health-Related Professions, 1776 Raritan Road Scotch Plains, NJ USA 07076; Tel: (519) 685-8500 ext. 77034; Fax: (519) 432-7367; E-mail: [email protected]

Psychiatric Rehabilitation and Psychiatric Rehabilitation Journal. In Psychiatric Rehabilitation Journal, a column focused on education and training issues appears quarterly [8]. At least three special issues dedicated to psychiatric rehabilitation education have appeared in Psychiatric Rehabilitation Skills [9], Rehabilitation Education [10], and American Journal of Psychiatric Rehabilitation [11]. In addition, Barrett and her colleagues [12] reported on the development of a Consortium of Psychiatric Rehabilitation Educators established in 2001 and convening twice annually since then. As of 2012, the number of institutions participating in the Consortium is approximately 40 internationally (www.psychrehab.net). Since the1980s, scholarly articles have identified the need for PSR education [13-15]. These papers have described the general lack of preparation within the mental health professions to work with persons with serious mental illness (SMI). Additionally, reports have focused on the lack of preparation for providing PSR services, the relatively small number of PSR counseling programs with relevant content, and the need for education regarding particular

2 Current Psychiatry Reviews, 2013, Vol. 9, No. 3 Gill and Murphy

theoretical frameworks for PSR practice. Weiberger and Greenwald [15] reported that only a few rehabilitation counseling programs had specialties in PSR. Unfortunately, more than 20 years later, these deficits in the preparation of the workforce were reported in the literature once again [16,17].

Some programs have been developed to try to address this need. Anthony and his colleagues introduced the framework of PSR curricula as having three levels: exposure, experiential, and expertise [1,14]. Typically, exposure level curricula rely on didactic lectures, exposing the learner to ideas and facts. At the experiential level, the educator introduces a practice component offering the learner the opportunity to apply acquired knowledge and thus develop some relevant skills. To acquire competency, however, an expertise level of education is needed. At this level, students must be afforded multiple opportunities to apply techniques and receive feedback. Gill and his colleagues [18] have built on this conceptualization by breaking down their curricula into didactic level content, skills training courses, and finally supervised “clinical” courses. Exposure takes place in all three types of courses; expertise is developed in the skills and clinical courses; and experiential learning is offered in the clinical courses. Psychosocial Rehabilitation Training Resources [19] summarized a number of academic and in-service training programs that: “Offered topics in their programs that correspond to accepted workforce competencies in psychosocial rehabilitation …these competencies included areas such as: rehabilitation methodology competencies, consumer-centered competencies, practitioner competencies, knowledge base competencies, and system competencies” [19, p. xi]. At that time, 29 college or university level academic programs in the US and 2 in Canada met these criteria [19]. Few were labeled PSR, most were concentrations or specialties within other disciplines such as psychology, social work, and rehabilitation counseling. This paper presents a systematic review of academic and professional PSR and related recovery-oriented education using research, health professions, and education databases, with the aim of identifying current PSR education practices, their outcomes and these outcomes’ predictors; proximal (educational and related vocational) as well as distal (clinical and other) outcomes were searched for. In addition, gaps in such PSR education and its study are discussed.

METHOD

A systematic search was conducted of the PubMed, PsycINFO, Academic Search Premier, CINAHL, and ERIC electronic databases with no year restriction to identify all peer reviewed articles that address the topic of PSR education. A wide set of search terms were used in an effort to capture all relevant literature. The following sets of search terms were used: 1) psychosocial rehabilitation and psychiatric rehabilitation, 2) education, higher education, graduate education, undergraduate education, academic

education, professional education, and professional training, and 3) adult education, career education, continuing education, counselor education, distance education, medical education, nursing education, psychology education, rehabilitation education, social work education, and vocational education. Within each set of terms the Boolean operator OR was used to include articles with any of the terms, while between each set of terms the operator AND was used to narrow the search. A review of the titles and abstracts identified by these searches was conducted to find the relevant articles. The reference lists of all articles were reviewed to further locate appropriate publications. Additionally, all articles from 3 special issues of peer-reviewed journals devoted to PSR education were hand searched and included [9-11]. One author primarily searched the literature, and both authors reviewed and agreed on any publication that the one author was not sure whether to include.

RESULTS

Fifty-three non-duplicated articles on PSR education were identified. No controlled studies were found. Several non-systematic literature reviews of the subject were identified that often included proposals for curricular changes to specific disciplines including psychiatry, rehabilitation counseling, social work, and psychology. The bulk of the articles reported the need for PSR-specific education or offered guidance for the development of such curricula. Several non-experimental studies were also identified in this review.

Academic Disciplines

The academic disciplines offering PSR content included psychiatric rehabilitation itself [1,2], social work [21], nursing [24], rehabilitation counseling [22,23], psychology [25], pharmacy [26], and psychiatry [27-29]. Multidisciplinary or interdisciplinary programs of study were identified [27], as well as peer-specific programs [30,31].

Academic Levels and Structure

PSR education exists at many academic levels. Using the terminology of the United States higher education community, these include post-secondary certificates [32], certificate programs focused on preparing peer providers [30,31], associate’s degrees (diplomas in Canada), bachelor’s degrees [2], master’s degrees in rehabilitation counseling [22,23,34] and in PSR [2] and other fields, graduate certificates [35], and doctoral degrees in psychology [36], PSR and other fields [33]. PSR education also exists as single courses within other degrees in many fields, and is included as content across multiple courses [21,22]. Special workshops and psychiatry rotations are also devoted to PSR [27,28]. In recent years, curricula with recovery-focused content have been developed for insertion into any one of multiple disciplines, but also specifically developed for psychiatric residency rotations and psychology internships [27-29,42]. In addition, a full academic career ladder exists within one academic institution (University of Medicine and Dentistry of New Jersey), as reported in the literature,

PSR Education Current Psychiatry Reviews, 2013, Vol. 9, No. 3 3 providing post-secondary certificates, associate’s, bachelor’s, two master’s degrees, graduate certificates, and doctoral degrees [2]. PSR content has been integrated into educational training programs with a variety of methods: • Single courses, often electives, providing an overview of

PSR or a particular skill or set of skills; • Organized content that can be inserted into one of a

variety of educational formats, disciplines, and levels; • A series of courses, often designed in a sequence, that

provide a specialization within a more general discipline (e.g., psychiatry, psychology, rehabilitating counseling, and social work), providing a foundation for understanding and practice;

• An entire program designed solely for instruction of PSR and providing immersion in the field; and

• A career ladder of programs at different academic degree levels focused on PSR.

Non-Experimental Studies

Several types of non-experimental studies were identified in this review including: nine program evaluations of planned programs of study in psychiatric rehabilitation [2,l4,18,27-29,31,37,46]; one correlational study, evaluating the association of career ladder steps with the acquisition of PSR beliefs, goals, and practices [38]; a pre-formed groups design of the differences between those who have had PSR education versus those who have not [39]; two program evaluations of the use of educational strategies as part of larger organizational change strategies within hospitals implementing PSR (one of these evaluations reported on the technique of interactive staff training, while the other used an undergraduate certificate program that was offered as part of a long-term, consultative public-academic collaboration [40,41]; three evaluations of specific instructional techniques applied in PSR [24,43,44]; and several surveys on the issue of PSR content within the rehabilitation counseling field [22,23,34,45].

Program Evaluations of PSR Academic Programs

The earliest evaluation of a PSR academic program found in this review appeared in 1988 [14]. It described the on-campus and off-campus programs of the now closed Boston University graduate rehabilitation counseling program, specializing in PSR. The contents of the courses in PSR were briefly described and focused on rehabilitation planning, including overall goal setting, rehabilitation diagnosis, and rehabilitation interventions. At the time, the program was highly selective, with the great majority of students successfully completing the program. Most students were highly satisfied with their experience, and more than half were providing direct services in the rehabilitation of persons with SMI, with an additional quarter employed in leadership, supervisory, and administrative positions [14]. A program to prepare peers, or “consumers as providers”, by a school of social work was reported by McDiarmid and

her colleagues [31]. Its curriculum included basic helping skills, strengths model practice, recovery, wellness, rights, responsibilities, ethics, mental health services, group supervision, and an internship. In a two-year follow-up study, 63 percent of the graduates were employed, and of those up to 75% were employed in social services jobs. At follow-up, 20-25% were enrolled in further higher education, compared to none prior to the certificate program [31]. An evaluation of an Associate in Science (A.S.) degree (2 year, post-secondary) jointly offered by a university and community college was conducted [18]. In this program, students were introduced to an overview of PSR, learned communication and interviewing skills, group facilitation techniques, an overview of psychopathology and its terminology, community resources and case coordination, emerging topics, and almost 500 hours of supervised clinical experience. In this study, the great majority of A.S. degree students (85%) during their first clinical placement performed comparably or better than full-time employees in the same community mental health agencies as rated by their supervisors. In fact, 72% were rated as performing better than regular employees. Prior to graduation, 45% of the students were hired by mental health agencies. Three months after graduation, 76% were working in the field and 16% were pursuing bachelor’s degrees [18]. Today, this program is offered in collaboration with several community colleges and a state university. A Bachelor of Science (B.S.) program offering a dual major in PSR and psychology earned within a traditional four-year Bachelor of Science degree was established [2]. The coursework for the B.S. program includes the courses described in the above A.S. program [18]. Additionally, more in-depth courses in assertive community treatment and case management approaches, supported employment, co-occurring substance abuse and mental illness, and wellness and recovery have been offered. In a post-graduation survey, graduates felt they were “several steps ahead" of their professional colleagues in terms of: a) practical skills, b) knowledge of evidence-based practices, and c) wellness/ recovery principles and practices. They identified communication and counseling skills, group facilitation techniques, knowledge of symptoms and medications, and information on evidence-based practices (EBPs) as specific topics that helped them feel prepared for their jobs. They also said that supervised clinical experiences as students had given them a great advantage for entering the field. They reported opportunities to expose co-workers and even their supervisors to new concepts. Unfortunately, they often experienced resistance to the implementation of the basic principles and values of PSR [2]. Gill and his colleagues reported on the impact of a 36-semester credit master’s (M.S.) PSR degree program on the careers of persons working in the field of PSR [37]. The program taught primarily leadership competencies to be applied in PSR programs and related service organizations [37]. Thirty-seven students and recent graduates of the M.S. program participated in the study. Demographic data, years of experience, work history, and salary were collected. The student body was composed of experienced practitioners who were currently working, with an average of more than 9


years of experience. The overwhelming majority of students (86%) were already employed in PSR. About half of the employed students were in direct service positions. Other students were already in leadership roles as supervisors, managers, and educators. The program’s curriculum content included the technology, knowledge, and skills of PSR as well as other areas that leaders in the field require in order to be qualified for management, supervision, and teaching positions. These areas included personnel management, supervision skills, program development, organizational factors, statistics, applied research methodology, as well as training and teaching methods. Results of the evaluation indicated that M.S. program completion was associated with salary increases. Multiple regression analysis found that years of experience, grade point average (GPA) and number of credits earned accounted for 59% of the salary variance. Years of experience were the best predictor of salary, uniquely accounting for 27% of the variance. Number of credits earned uniquely accounted for 13%. In a separate analysis, the content and concurrent validity of the curriculum was supported by the significant positive correlation between years of experience and GPA. Experience and GPA were positively correlated (r = 0.50, p < 0.01) [37]. Buckley and colleagues [28] reported on psychiatric resident-led focus groups conducted to understand and enhance psychology and psychiatry trainees’ views of recovery-oriented approaches within mental health care. Twenty psychiatry residents and 6 psychology interns were trained. Three certified peer support specialists (CPS) attended each educational session. The following topics were covered: Recovery-orientation, CPS training curriculum, and developing a Wellness Recovery Action Plan (WRAP). Advantages and disadvantages of a recovery-orientation were discussed. Psychiatric residents expressed cautious optimism regarding implementation of recovery-related principles, but were concerned about the possibility of reduced confidence in more conventional services. All psychiatric residents and psychology interns stated interest in learning more about recovery, the inclusion of WRAP, and the role of CPS staff [28]. Peebles and colleagues [27] reported on the collaboration between a state government and medical college to deliver a curriculum focused on the critical components of recovery as identified by the Substance Abuse and Mental Health Services Administration (SAMHSA). The authors employed a simple pre-post design to study the effects of the curriculum on the recovery-based knowledge and recovery-consistent attitudes of 19 psychiatry residents, 12 psychiatrists and 8 psychology residents and postdoctoral trainees. These outcomes were compared to a similar group of providers at a neighboring medical school who did not receive the training [27]. Psychiatrists, psychiatry and psychology residents and practitioners, along with peer-specialists, participated in a workshop-style intervention focused on teaching principles, knowledge, and skills associated with recovery. The content of the curriculum included: Contrast of recovery-oriented approaches with the more conventional medical model of care, including discussion of the limitations of the medical model; addressing concerns that valuable components of conventional care would be over-looked in a recovery-oriented approach; using language and concepts which

connect conventional care and recovery-oriented care; review of empirical evidence to support recovery; case studies; and skills that can feasibly be learned and implemented within the constraints of real-world practice. Peer specialists were included so they can share their personal accounts to promote interest in the material and develop an appreciation of the ability of people with SMI to articulate their needs and collaborate in their own care. Post-test scores on recovery knowledge, attitudes and skills of the participants, as compared to pre-test scores, showed an improved understanding of the SAMHSA recovery principles. Additionally, less stigmatizing attitudes of trainees were evident when compared to students and practitioners who did not receive the training at the comparison institution [27]. Randall and colleagues [29] studied whether a 3-month rotation in a PSR center changed the competency level of second-year psychiatric residents. Using the Competency Assessment Instrument (CAI), they measured 15 provider competencies critical to recovery, rehabilitation, and empowerment for people with SMI [47]. The 3-month rotation in PSR significantly improved residents' competency in the domains of goal functioning, client preferences, a holistic approach, skills development, and teamwork, as compared to residents who did not participate in the rotation.

Pre-formed Groups Design

The completion of a pre-academic training program was associated with practitioners’ level of PSR knowledge [39]. Casper [39] found that of a sample of 279 practitioners who completed the questionnaire, only 45 (16%) had completed any type of formal training in PSR. Thus the great majority (84%) of the practitioners had not been formally exposed to the basic knowledge of state of the art principles and practices of PSR. The group that had been exposed to university-level training scored significantly higher on measures of adherence to PSR beliefs, goals, and practices.

Correlational Study of a Career Ladder

Using the revised Psychiatric Belief Goals and Practices scale [39], Gill and his colleagues studied 131 undergraduate (certificate, associate’s, and bachelor’s level) students participating in the PSR career ladder offerings of one university [38]. The number of PSR credits earned was positively correlated with the development of knowledge of PSR skills, practices, and attitudes (r = 0.51, p < 0.01). That is, as the number of credits completed by undergraduate students increased, the greater was their agreement with the publicized beliefs, goals, and practices of the field of PSR (e.g., as noted in www.uspra.org). The largest growth in PSR beliefs and practices was apparent after completion of clinical field placements. Significant differences in PSR-related attitudes were found among different levels of credits earned. Students who had completed 6–12 semester credits had stronger PSR-related attitudes than those who completed a single course of 3 credits or less. Those who had completed the clinical field training sequence had the strongest PSR-related attitudes among all students. This suggests that participation in experiential PSR education has the most significant PSR educational impact [38].

PSR Education Current Psychiatry Reviews, 2013, Vol. 9, No. 3 5 Organizational Change Strategies

Corrigan and his colleagues [41] reported on interactive staff training as an educational approach to develop and implement PSR in a psychiatric hospital. Over an eight-month period, 35 staff participated in this approach that helped staff to identify, formulate, and choose different approaches to bring about positive change. After this training, staff reported less emotional exhaustion, more optimistic attitudes, and better support among their colleagues [40]. Thus, PSR professional education may result in broader outcomes than just enhancement of PSR practice. Birkmann and his colleagues [40] reported on the use of academic courses as one piece of a larger collaboration between a university and a state psychiatric hospital to promote a more rehabilitation-oriented philosophy of care. The goal was to improve staff competencies, enhance service delivery, improve hospital in-service training, and promote program development, staff mentoring and other organizational change activities. Also included was an undergraduate certificate program offered to direct care staff. Prior to completing these courses, hospital staff scored significantly lower in their understanding of PSR values and practices than other PSR students and community staff. Those hospital staff who completed PSR courses later endorsed a stronger affirmation of PSR beliefs, goals, and practices. In addition, increased exposure to PSR curricula, as measured by the number of PSR credits completed during the course of the project, was related to increased support of PSR beliefs, goal and practices (r = 0.31, p < 0.003) [40].

Pre-Post Study of Continuing Education

Continuing education has been highlighted as potentially the best approach to teach PSR [46,52], although only one study of its impact was found in this review [46]. Casper and his colleagues evaluated the effectiveness of a portable, continuing education orientation PSR course for entry-level workers throughout a state in the US. The standardized course was offered to 367 staff over a one-year period. The trainees’ pre- and post-course scores were compared on an empirically validated measure of PSR principles and practices. A significant robust training effect (Cohen’s d = 0. 99) was observed when the trainees’ pre- and post- course scores were compared. With the same groups of students, in a pre-formed groups design, Casper et al. [46] also found that completers of this continuing education program had a superior understanding of PSR principles compared to a comparison group of practitioners not similarly trained [46].

Evaluating Specific Instructional Techniques

Several articles evaluated specific educational techniques applied to PSR content, including collaborative education [24], inter-professional or multi-disciplinary seminars [43], and structured dialogue [44]. Shorans and Sykes [44] included people with mental illness in a Structured Dialogue with social work students in their classes. The purpose of this approach was to facilitate opportunities for students to interact with persons with mental illnesses in order to develop less stigmatizing and more hopeful attitudes toward working with them. One hundred and eighty five students,

from 15 social work classes, participated in this evaluation. In each of these classes, there were 2 presenters with SMI and/or other mental illness. These individuals had a range of diagnoses, including bipolar disorder, schizophrenia, schizoaffective disorder, dissociative disorder, and borderline personality disorder. All but one had been hospitalized. In 90-minute sessions, they told their personal stories, sharing the difficulties they experienced related to their mental disorder, their interactions with helping professionals, family members or others, and what they had learned about the coping and recovery. The findings showed that Structured Dialogue can reduce the narrow, negative view of people with mental illnesses and modify stereotypes and stigma. Spagnolo and her colleagues reported on a similar technique that successfully reduced stigma among high school students [56]. Clinton [24] reported on an approach he describes as collaborative education in nursing. This technique is rooted in the values of equal opportunity, anti-discrimination and the “mainstreaming” of people with disabilities. Integral to this approach is “status equalization”, reducing the social distance between groups. Theoretically, “status equalization” can be achieved through classroom interactions. In this study, faculty members sought to achieve status equalization both among users of mental health services (persons in recovery from SMI) and undergraduate students. The purpose was to reduce stereotyped beliefs among the students about users of mental health services. This involved the use of first names in the classroom, the setting of norms by collaboration, participation by the facilitators in all classroom exercises and homework, as well as the negotiation of assignments and their scoring. Undergraduate students and service users participated in each class. All assignments were mandatory for undergraduates. Service users completed assignments voluntarily, and those who completed all assignments received credit in the relevant course. Collaborative education was effective in reducing the stigmatization of people with mental illnesses. Stereotypical views of undergraduates declined and negative social stereotypes were reduced through interaction [24]. In contrast to these techniques of intentional integration, other academic programs reported the positive effects of persons in recovery on other students, not by deliberate methods, but by the fact that the programs were able to successfully recruit a large portion of people with mental illness as students for their mainstream classes [2,17]. Steiner et al. [43] reported on the effects of an inter-professional seminar, the “Treatment of Chronic or Recurrent Mental Illness: Recovery, Rehabilitation and Interdisciplinary Collaboration,” developed in an academic community mental health center. Pre- and post- surveys were administered to test the hypothesis that the seminar would have a positive impact on trainees’ attitudes about working in an interdisciplinary team and serving people who have SMI. Seminar members included 24 students from psychiatry, nursing, social work, and psychology, with a wide range of experience. Participants reported valuing the seminar experience. They also reported that the interdisciplinary work was less rewarding than they expected. They described


several advantages and challenges of inter-professional care-oriented shared learning [43].

Rehabilitation Counseling

As mentioned above, a number of surveys have highlighted the special needs of persons with psychiatric disabilities and thus, the need for a PSR curriculum within Rehabilitation Counseling [22,23,34,45,52]. The surveys concluded that only about 40% of accredited rehabilitation counseling programs adequately cover PSR content. In a 2005 survey, it was found that 91% of 47 programs accredited by the Council on Rehabilitation Education that were surveyed said that their graduates needed to develop the capacity to deliver PSR services [23]. However, only 40% of these programs offered a course in this area, 36% offered portions of a course, and 19% offered no course content in PSR.

Educational Content

The content of PSR education varies markedly. Some of the reports focused primarily on the development of practitioner competencies and the supporting knowledge and skills, taught at both the undergraduate and graduate level [1,2,14,17,18,20,44]. Practice of skills, both in the classroom, or “laboratory”, and in the actual delivery of services is integral to many programs. The Boston University approach, including rehabilitation diagnosis, planning and interventions, is included in a number of programs [2,3,14,18,20]. Some programs discuss other models of PSR, such as the clubhouse model, peer-delivered approaches, the Fairweather approach, social learning, evidence-based practices (EBPs; e.g., ACT, supported employment, and family psycho-education), and promising practices (e.g., supported education and peer operated services) [18]. Increasingly, the evidence-based practices are a focus of education and training [25,29,42]. Some rehabilitation counseling programs have added content on psychopathology, psychopharmacology, SMI, social skills training, community integration strategies, and other mental health care content [45]. Increasingly, recovery, treated as both a process and an outcome, is a focus of curricula, as are related concepts of self-determination and empowerment [27-29]. The primary strategies emphasized in current PSR education efforts include the strengthening of person skills and competencies and environmental supports. Programs that are unable to provide additional PSR coursework support students’ involvement in PSR education by encouraging them to select courses related to understanding SMI, encouraging research papers and projects related to PSR in the basic training curriculum, and encouraging students to take advantage of internship settings that emphasize rehabilitation practices in community PSR facilities [21,45,49,50]. Integral to the content of most programs is contact with persons with SMI as guest lecturers, workshop participants, panel participants, fellow students, and of course, service users [1,2,14,24,27-29,42-44]. This is done for a variety of purposes, including developing an understanding of the

experience of SMI or psychiatric disability, decreasing stigma, reducing social distance, promoting optimism, and enhancing an understanding of recovery of people with SMI. Central to many of the courses of study is the idea of encountering people with SMI as equals and/or experts on the lived experience of SMI.

Complementary Content

Preparing practitioners for the competencies needed to provide evidence-based interventions that are rehabilitation and recovery oriented is a leading priority of the mental health care system [25,29,42]. Graduate programs, particularly doctoral degree programs, have emphasized that additional curricular content complementary to PSR is also necessary [25,36-38]. Those who are educated in PSR principles and practices can also serve as model clinical supervisors, administrators, and innovators who can develop and study new interventions that may become tomorrow’s evidence-based practices [25,33,36]. In the same vein, doctoral programs are critically important for their role in preparing future PSR educators and researchers. Therefore, it is crucial that PSR doctoral candidates become skilled in research methods, statistics, instructional methods, and knowledge of the public mental health sector [25,33].

Recovery Content Insertion

Several reports have focused on curricular transformation initiatives. One of these, the Recovery Education in the Academy Program (REAP) is designed to integrate principles of recovery, such as self-determination, and related EBPs, into medical, social, and behavioral sciences curricula [42]. REAP draws on a theoretical framework derived from the evidence-based literature, the reports of the Annapolis Coalition for Behavioral Workforce Development, and the Final Report of the President’s New Freedom Commission on Mental Health [16,42]. REAP has been used to deliver education to over 1,000 trainees: medical students, psychiatry residents, psychology interns, social work interns, rehabilitation counselors, pre/post-doctoral students and professionals within a variety of academic settings. It includes a wide range of approaches and activities depending upon the setting and serves as a structure to successfully integrate recovery-related education into existing accredited academic programs and curricula [42]. Evaluation data of this program have not yet been published.

Academic Accreditation

Some educators report that professional accreditation bodies, such as the Council on Social Work Education, the American Psychological Association, and the Council on Rehabilitation Education, have so many existing standards that there is no room in their curriculum for PSR content. Contrary to this assertion, several authors have demonstrated that such content is consistent with these accreditation standards [21,44,51]. Sands and Solomon [21] state that PSR is consistent with the standards of the Council on Social Work Education and describe two methods by which PSR content can be integrated into related curricula. One of these

PSR Education Current Psychiatry Reviews, 2013, Vol. 9, No. 3 7 methods involved the use of an elective, which is a popular option in many fields. The standards of the Council on Social Work Education, the Council on Rehabilitation Education and the American Psychological Association have areas of congruence with PSR [21,44,51]. Nevertheless, adults with SMI tend to be overlooked in these professional education programs. Clinical curricula tend to exclude interventions that are developed for persons with SMI [12]. When PSR content is included within curricula, it tends to support an emphasis on community-based treatment, the use of individual skills and competencies, and the integral nature of environmental supports [14,20,45].

Collaboration with the Public Mental Health System

A number of authors have made the point that collaboration with the public mental health system, state and local mental health agencies, is a helpful strategy [25,49,50,53]. Knowledge of the public mental health system is considered an important objective for mental health care training. Schools of social work have collaborated with state mental health departments to encourage graduate students to enter the public mental health system. Two articles address a statewide initiative that teaches Master of Social Work (M.S.W.) students the skills and knowledge to support resiliency, recovery, EBPs, and PSR principles [49,50].

Web-based Education

At 3 least articles have addressed the subject of web-based, or internet-based PSR education [35,54,59]. One focused primarily on the content of a certificate program [35]; the second offered a theoretical overview of the issues surrounding internet-based PSR education [54]; the third focused on a distance learning model including both web-based and internet-based video teleconferencing by Skype and similar services [59]. A summary of the practical experience of one university’s efforts to offer this educational opportunity over a two-year period at both the undergraduate and graduate levels is described there. Strengths, limitations, opportunities, and threats of web-based education are discussed, including a discussion of a completely web-based Master of Science curriculum in PSR [54]. This program, offered on the Moodle platform now, has not been evaluated nor compared to similar classroom based education. A non-credit program developed by Pratt and Smith [59] was designed to improve the competencies of staff and volunteers in a human services agency in Pakistan. The program is primarily internet-based with video teleconferencing and some on-site visits in Pakistan by faculty from the United States [59].

Relationship of Education to Certification

Nemec and Legere [55] provided an overview of different types of PSR credentials, including academic degrees, as discussed above, as well as certifications provided by independent non-academic bodies, including the Certified Peer Specialist and the Certified Psychiatric Rehabilitation Practitioner (CPRP) hosted by USPRA (www.uspra.org). One article reported on the impact of

related PSR education and level of education on CPRP certification exam scores, showing the somewhat surprising finding that level and type of education was a better predictor of certification scores and pass rates than related professional experience [56]. The first 1,054 applicants for this test-based credential were included in the study. Level of education and mental health-related education were found to be positively correlated with test score and predicted who passed the examination. Objectively scored letters of reference contributed a small but significant percentage of the explained variance. Years of PSR experience were not correlated with test outcomes. The findings highlight the importance of relevant educational experience for the certification of PSR staff. Implications for test validity and the preparation of CPRPs are also discussed there [56].

CONCLUSION

Delivering PSR services to persons with SMI has long been acknowledged as requiring distinct knowledge and skill development. Indeed the need for specialized expertise to serve persons with SMI has been included in the US’s national plan for behavioral healthcare workforce development, but this plan has yet to be implemented [57]. As the rest of this theme issue illustrates, there is a considerably expanding evidence base to both the promising and established practices of PSR. Yet, despite this fact, there is not much research and relatively modest empirical support for specialized academic and professional PSR education. Our review shows that PSR education exists within a variety of disciplines, at a diversity of academic levels, and is delivered through a variety of formats. However, this relatively scant literature highlights the fact that many of these programs are either exceptions or exemplars. Early empirical evaluations were done by Boston University on its now defunct program (which admittedly may yet be revived). More recently, the bulk of the evaluation data on PSR academic programs reported in the peer-reviewed literature comes from one institution, the University of Medicine and Dentistry of New Jersey (UMDNJ), which has published the only reports of a PSR academic career ladder within a higher education institution [2,58]. Some recent evaluations of PSR and recovery related content have come from the Medical College of Georgia.

Despite the limits of the research on PSR education, based on this literature review several conclusions and recommendations can reasonably be made. Education and training focused on PSR does, in fact, improve endorsement of and adherence to PSR goals, values, and practices [27,29,38-40,56]. The beneficial effect of education and training is seen with higher education coursework, workshop style training, and continuing education courses [27,38-40,46,56]. It also positively impacts professionals in a variety of mental health related fields [27,29,38-40,46,56]. The content of the education and training curricula should focus upon recovery as a process and an outcome; with techniques building upon the skills and interests of persons with serious mental illnesses. Psychiatric diagnosis and symptomatology may be presented as important to know, but not as limiting factors in terms of recovery and community


integration. Functional deficits are seen as specific to environments and related tasks; further these deficits are approached as potentially remediable through skill development and the use of supportive resources [1-3,14,17, 18,20,25,27-29,42,44]. In order to impact practitioners’ skill development, education at the expertise level needs to be included in all curricula [2,18,38]. Clinical fieldwork provides an opportunity to hone and refine a practitioner’s skills through supervision in way that didactic teaching and classroom practice cannot. Most experts agree that the experiential component of the delivery of psychiatric rehabilitation services under planned mentorship or supervision is critical to becoming a competent practitioner. A critical component of all PSR education and training needs to be the integration of people with serious mental illnesses in expert or equal roles. The inclusion of people with mental illnesses in education and training via a variety of instructional techniques, and as fellow students, has demonstrated reductions in negative stereotypes and stigma [2.17,24,44]. Despite significant changes in the delivery of mental health services, the curricula of undergraduate and graduate programs in traditional helping fields have been slow to evolve. Relatively few graduate and undergraduate programs are emphasizing important trends in service provision such as established evidence-based practices, recovery-oriented services, or promising practices such as supported housing, supported education and peer provided services. The inclusion of this content is still considered novel and innovative. Anecdotally, accreditation issues persist in higher education with existing standards viewed as a barrier, despite the fact that several articles have addressed that the content of psychiatric rehabilitation education is complementary to that required of the major professional accreditation bodies, and indeed helps to meet those standards [21,44,51]. In order to influence the inclusion of PSR focused education in related academic fields, PSR professionals should advocate and involve themselves in the higher education accrediting bodies.

A greater emphasis on the development and evaluation of a career ladder in PSR needs to be made. At present there is only one career ladder that can educate an individual from the certificate or associate’s level on to the doctoral level. With the exception of this program, it is impossible for an individual to pursue degrees in PSR at all academic levels. It is important for the field of PSR to be able to provide both intrinsic and extrinsic rewards to individuals pursuing education in the field via a full career ladder offered by more than one institution. There is no question more rigorous research on PSR education would be helpful, however, its absence is not at all unusual, with many professions lacking an evidence base for their professional preparation. One exception is rehabilitation counseling. This field has shown that practitioners who have graduated from accredited programs and earned the certification (CRC) have a higher proportion of successful outcomes for service participants of public vocational rehabilitation programs. These outcomes include competitive employment, at lower cost to the public, and with a greater

benefit, including higher income, to their service participants compared to vocational counselors prepared by other approaches (59). This sort of cost-benefit analysis would be helpful across the related disciplines involved in psychiatric rehabilitation. The impact of education and training in PSR is most accurately measured by the outcomes experienced by service participants. Evaluations of this kind will be important to the further development of the PSR field. In the challenging world of public psychiatry and mental health services, today’s faculty need to be sufficiently versed in the principles of psychiatric rehabilitation to be effective educators and developers of PSR practitioners. Both persons with serious mental illnesses and the general public deserve practitioners who are competent to implement well-established practices that achieve the best outcomes. This review has demonstrated that there is enough evidence to suggest promising practices in curricula content and education delivery of PSR practices in a variety of professional fields. It is also clear, however, that more comprehensive and controlled evaluations of PSR education need to be conducted.

CONFLICT OF INTEREST

The author(s) confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

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Received: May 21, 2012 Revised: May 21, 2012 Accepted: June 27, 2012

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