Individual Placement & Support Employment and Education Services MISA Cross-Divisional Conference 2010.

Individual Placement & Support Individual Placement & Support Employment and Education Employment and Education

Services Services

MISA Cross-Divisional Conference 2010

Overview of the dayOverview of the day

EBSE & MISA research, principles, practice, org. structure

EBSE & Recovery in consumers voicesIPS/Mot. Intv. & practice skillsVR Ill. & other statesOpportunities for leadership

Why Focus on Why Focus on Employment?Employment?

Viewed by many as an essential part of recovery

Most consumers want to workA typical role for adults in our

societyCost-effective alternative to

day treatment

Positive Outcomes Positive Outcomes from Competitive from Competitive

WorkWorkHigher self-esteemBetter control of psychiatric

symptomsMore satisfaction with

finances and with leisure

(Bond et al., 2001)

Is Is WorkWork Too Stressful? Too Stressful? As compared to what? Joe Marrone, an employment

trainer:

“If you think work is stressful, try unemployment.”

Stresses of work do not translate into higher rates of hospitalization

Negative Effects of Negative Effects of Unemployment in General Unemployment in General

PopulationPopulation Increased substance abuse Increased physical problems Increased psychiatric disorders Reduced self-esteem Loss of social contacts Alienation and apathy

(Warr, 1987)

Competitive Employment for Competitive Employment for People with Severe Mental People with Severe Mental

IllnessIllness

Say they want to work: 70% Are currently working: <15% Current access to supported

employment: <5%

J & J-Dartmouth ProjectJ & J-Dartmouth ProjectmMental health-vocational rehabilitation mMental health-vocational rehabilitation collaboration collaboration iImplement evidence-based SEiImplement evidence-based SELLocal programs selected by statesLLocal programs selected by statesDDartmouth provides training, consultation, DDartmouth provides training, consultation, and evaluationand evaluationFFirst states: CT, DC, KS, MD, OR, SC, VTFFirst states: CT, DC, KS, MD, OR, SC, VTNNew states: DE, IL, MN, OH, Ky, WI. Mo.NNew states: DE, IL, MN, OH, Ky, WI. Mo.

– (Drake, 2006)(Drake, 2006)

J&J Project J&J Project StrategiesStrategiesSStart with “early adopters”: states & SStart with “early adopters”: states &

programsprogramsVVR-MH collaborationVVR-MH collaborationLLongitudinal trainingLLongitudinal trainingOOutcome-based supervisionOOutcome-based supervisionPProblem solving by local expertsPProblem solving by local experts

– (Drake, 2006)(Drake, 2006)

Thresholds/Dartmouth Thresholds/Dartmouth NRTC on Evidence-Based NRTC on Evidence-Based

SESE PPPart of Dartmouth Medical SchoolPart of Dartmouth Medical School PPPhase I: $30 million, ½ Thresholds ½ Phase I: $30 million, ½ Thresholds ½ DartmouthDartmouth EEEndowed Chair, 4 Resource Centers in Ill.Endowed Chair, 4 Resource Centers in Ill. TTTraining of practitioners including VR staffTraining of practitioners including VR staff SSServices to customers including employersServices to customers including employers RRResearch priorities: ex-offenders, improve Research priorities: ex-offenders, improve mental/physical health, less need public mental/physical health, less need public benefits, outcome measurement tools, benefits, outcome measurement tools, public policy re SE & employmentpublic policy re SE & employment

Overview for Overview for NarcolepticsNarcolepticsSSupported employment is an effective SSupported employment is an effective

evidence-based practiceevidence-based practiceLLong-term perspective is even betterLLong-term perspective is even betterIImplementation is criticalIImplementation is criticalAAmplifying effectiveness: more AAmplifying effectiveness: more people and more hourspeople and more hours

EmploymentEmploymentOOnly 10-15% of people with psychiatric OOnly 10-15% of people with psychiatric disabilities are workingdisabilities are working770-80% want to work770-80% want to workWWork improves self-esteem, income, and WWork improves self-esteem, income, and recoveryrecoveryTTraditional programs are ineffectiveTTraditional programs are ineffectiveSSupported employment is effectiveSSupported employment is effective

What Is Evidence-Based What Is Evidence-Based Practice?Practice?

A practice validated through rigorous research

Has guidelines describing critical ingredients

Ideally, has been successfully implemented in a wide range of settings

Randomized Controlled Trials Randomized Controlled Trials (RCTs) of Supported (RCTs) of Supported

EmploymentEmploymentStrongest scientific design for

evaluating whether a treatment works

Studies include: –4 conducted before evidence-based

principles articulated by IPS model

–9 used full implementation of IPS

Competitive Employment Rates in 12 RCTs of Supported Employment

0%10%20%30%40%50%60%70%80%90%

96 NH (IPS)

94 NY(SE)

04 CA

(IPS)

04 IL

(IPS)

04 CT (IPS)

05 SC

(IPS)

05HK

(IPS)

99 DC (IPS)

95 IN (SE)

00 NY(SE)

05QUE(IPS)

97 CA (SE)

02 MD(IPS)

Supported Employment Control Control 2

Competitive Employment Rates in 11 Randomized Controlled Trials of Individual Placement and Support

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

96 NH 07 IL 04 CT 08 HK 08 AUST 06 SC 99 DC 08 CA 07 EUR 06 QUE 02 MD

IPS Control Control 2

Current Status RCTsCurrent Status RCTs1 1 660% vs. 22% employment 660% vs. 22% employment FFindings very consistentFFindings very consistentRRecent IPS studies over 70% RRecent IPS studies over 70% employmentemployment

Indirect Impact on Indirect Impact on Other OutcomesOther OutcomesRRelated to sustained competitive RRelated to sustained competitive

employmentemploymentIImproved self-esteem, symptom IImproved self-esteem, symptom control, life satisfactioncontrol, life satisfactionNNo changes with sustained sheltered NNo changes with sustained sheltered employmentemployment

(Bond, 2001)(Bond, 2001)

Studies of Long-Term Outcomes Studies of Long-Term Outcomes from Supported Employmentfrom Supported Employment

TTest: 10 yearsTTest: 10 yearsMMcHugo: 3.5 yearsMMcHugo: 3.5 yearsBBond: 3.5 yearsBBond: 3.5 yearsSSalyers: 10 yearsSSalyers: 10 yearsBBecker: 8-12 yearsBBecker: 8-12 yearsDDrake: 10 yearsDDrake: 10 years

10-Year Follow-up of Day 10-Year Follow-up of Day Treatment to SE ConversionTreatment to SE Conversion 992% worked during follow-up 992% worked during follow-up 447% currently working 447% currently working 333% worked at least 5 years333% worked at least 5 yearsMMany reported increases in hope, self-esteem, MMany reported increases in hope, self-esteem, relationshipsrelationships

(Salyers, 2004)(Salyers, 2004)

8-12 Year Follow-up of 8-12 Year Follow-up of SESE771% working at follow-up771% working at follow-up

NNearly all in competitive jobsNNearly all in competitive jobs–77% sheltered, 10% volunteer77% sheltered, 10% volunteer771% worked more than 50% of FU771% worked more than 50% of FUBBut 90% still receiving benefitsBBut 90% still receiving benefits

(Becker, 2006)(Becker, 2006)

Current Status of Current Status of SESE

EEveryone who wants to work should receive EEveryone who wants to work should receive SESEMMost will succeed and difficult to predictMMost will succeed and difficult to predictLLimitations of current SELLimitations of current SECCurrent efforts to improve outcomesCCurrent efforts to improve outcomes

Limitations of SELimitations of SEOOne-fourth do not workOOne-fourth do not workMMost people do not work full-timeMMost people do not work full-timeMMost people stay on benefits MMost people stay on benefits

Amplifying the Effects Amplifying the Effects –SSkills training (Marder)SSkills training (Marder)–EErrorless learning (Kern)EErrorless learning (Kern)–BBenefits counseling (Tremblay)BBenefits counseling (Tremblay)–MMotivational interviewing (Drebing)MMotivational interviewing (Drebing)–CContingency management (Drebing)CContingency management (Drebing)–CCognitive training (McGurk)CCognitive training (McGurk)–CCompensatory mechanisms (Velligan)CCompensatory mechanisms (Velligan)–MMedications (MATRICS)MMedications (MATRICS)

Explaining Variance Explaining Variance 225% local economy225% local economy225% SE fidelity225% SE fidelity550% individual practitioner550% individual practitioner

– (Becker, 2006)(Becker, 2006)

“There are a range of effective treatments for people with mental illness. . . if these effective treatments were more efficiently delivered through our mental health services system ….Millions of Americans would be more successful in school, at work, and in their communities.”

Michael Hogan, Chairman

Quotes from ConsumersQuotes from Consumers“I feel so much better about myself

now that I have a job.”“Holding down my job is not always

easy but it has helped my self esteem.”“When I go to work I don’t hear the

voices.”“Now that I am working again I can

buy my daughter presents.”

Quotes from Family Quotes from Family MembersMembers

“I worried that if my son got a job he would get stressed. But just the opposite happened. He is doing so much better than before.”

“I feel better that she tries working when she has the support of mental health.”

“I was really glad that my son’s employment counselor asked me about work ideas. He landed a job that I suggested.”

Quotes from EmployersQuotes from Employers“Andre is as good as any worker that I

have.” Automotive parts store manager.“I count on Juanita. If she is feeling

stressed, she sits in the back room for awhile. That’s OK; she gets the job done.” Bakery supervisor.

“The employment counselor helped me understand why Tony paces. It’s okay in the security business.” Security business owner.

Definition ofDefinition of Supported Employment Supported Employment

Mainstream job in communityPays at least minimum wageWork setting includes people who

are not disabledService agency provides ongoing

supportIntended for people with most

severe disabilities

Evidence-Based PrinciplesEvidence-Based Principles

Eligibility is based on consumer choice Supported employment is integrated with

treatment Competitive employment is the goalPersonalized benefits planning is providedJob search starts soon after a consumer

expresses interest in workingFollow-along supports are continuous Consumer preferences are important

Eligibility Is Based on Eligibility Is Based on Consumer ChoiceConsumer Choice

No one is excluded who wants to participate.

Consumers are not excluded because they are not “ready” or because of prior work history, hospitalization history, substance use, symptoms, or other characteristics.

Supported Employment Is Supported Employment Is Integrated with Mental Integrated with Mental

Health TreatmentHealth TreatmentEmployment specialists

coordinate plans with the treatment team, which includes case managers, therapists, and psychiatrists.

Do Client Characteristics Do Client Characteristics Predict Success in Supported Predict Success in Supported

Employment?Employment?Co-occurring substance use does not

lead to lower employment rates.Consumers generally do better in

supported employment than in alternative programs regardless of background characteristics such as: – gender, education, ethnicity, diagnosis,

hospitalization history, cognitive functioning

Valued Gateway Client :

Inserted slide

Valued Gateway Client :

Inserted slide

Competitive Employment Competitive Employment Is the GoalIs the GoalThe agency needs to devote sufficient

resources to supported employment to permit full access to all consumers who seek competitive employment.

Consumers interested in employment are not steered into day treatment or sheltered work.

Personalized Benefits Personalized Benefits Planning Is ProvidedPlanning Is Provided

Benefits planning and guidance help consumers make informed decisions about job starts and changes.

Job Search Starts Soon Job Search Starts Soon After A Consumer After A Consumer

Expresses an Interest in Expresses an Interest in WorkingWorking

Pre-employment assessment, training, and counseling are kept to a minimum.

Follow-Along Supports Follow-Along Supports Are ContinuousAre Continuous

Supported employment staff continue to stay in regular contact with consumer and (when appropriate) the employer without arbitrary time limits.

Consumer Preferences Consumer Preferences Are ImportantAre Important

Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available.

Job Preferences Are ImportantJob Preferences Are Important

S E Unit:S E Unit:Recommended StructureRecommended StructureMinimum of 2 full-time staff Staff devoted exclusively to SEFull-time leader/supervisor who

also provides employment services

Offices physically located in mental health center

Supported Employment Supported Employment UnitUnit

Individual caseloads, but help each other (with job leads, etc.)

Caseloads of about 20 consumers or less

Weekly team meetings + individual supervision

Roles of an Employment Roles of an Employment SpecialistSpecialist

Problem-solverTeam playerNetworkerEmployment specialist

– Customer-oriented– Community-oriented– Outcome-oriented

Characteristics of Effective Characteristics of Effective Employment SpecialistsEmployment Specialists

High energyOptimisticLikes to meet new peopleGood listenerKnows the communityCreativeProjects confidence and

professionalism

Employment Coordinator Employment Coordinator DutiesDuties

Manages referralsHires and supervises employment

staffEnsures employment specialists are

learning and using effective skills in:Engagement Assessment

Job development Job support

More Employment More Employment Coordinator DutiesCoordinator Duties

Role model good employment practices

Provide supported employment information and training to all staff

Ensure employment services are integrated with treatment teams

ReferralReferralMake referral process simple!Have minimal eligibility criteria

– Unemployed (or working non-competitively) and wants competitive employment, or

– Employed, but not receiving employment supports, and wants such support

Involve multiple stakeholders

Collaboration With Collaboration With Vocational Vocational

RehabilitationRehabilitationVR counselor meets consumers

at mental health agencyVR counselor is part of the

treatment teamVR counselor conveys same

message as rest of team

Valued Gateway Client :

What about the collaboration? This slide is not very informative

Valued Gateway Client :

What about the collaboration? This slide is not very informative

Vocational Rehabilitation

A federally funded program available in all states that assists persons with severe mental, physical, cognitive, or sensory disabilities to return to or enter into employment.

A federal program since 1920. Authorized under the federal Rehabilitation Act.

Persons with mental illness added in 1943.

Vocational Rehabilitation (cont.)

Referral can be from any source.

State VR Counselor determines eligibility based upon a review of the records or new information.

Typical services can be:-VVocational Evaluation-CCareer Counseling-JJob seeking skills trng., job development, job placement- Consultation on job site accommodations

Vocational Rehabilitation (cont.)Medical/psychiatric case management-RReferral to and assistance with medical, psychiatric, etc. services necessary to complete the goals of the IEP-SSponsorship in vocational or academic training-BBenefits planning-SSupported Employment and Supported Education-SSupport services such as transportation, purchase of work clothing/uniforms, van conversions, etc.To locate your state VR program go to: www.nchr.okstate.edu/pages/states-VR.html

Vocational Rehabilitation

-- VR has a corporate culture that values work-first and assumes anyone is capable of employment.

-- VR staff have job placement/development skills & networks.

-- VR staff have expertise in multi-disability work accommodations.

-- VR staff have access to an array of resources.

IPS section of VR IPS section of VR Casework ManualCasework Manual

10 days from referral to IPSUp to 14 days back dating if employed

at referralMandates VR liaison counselor meet

with the rest of the IPS team at least 1x per month

Any LPHA can certify diagnosis

EngagementEngagementBuild trusting, collaborative

relationshipAssume contacts are mostly

outside mental health settingMaintain ongoing contact Involve family, treatment team,

and other supporters

Vocational ProfileVocational ProfileGather comprehensive

information from variety of sources over 1-2 weeks–Consumer–Family, friends–Former employers–Treatment team

Disclosure of Disclosure of Psychiatric StatusPsychiatric Status

Disclosure is the consumer’s choice

Nature of disclosure–When to disclose?–How much to disclose?–Who to disclose to?

A Vignette: GloriaA Vignette: Gloria

Gloria, “I don’t want my boss to know that I have a mental illness. I will be treated differently.”

What would you, the employment specialist, say?

Benefits CounselingBenefits CounselingFear of losing benefits is major barrier to

employmentConcerns of consumers and families

often underestimated by cliniciansRules and regulations are complicatedBenefits counseling provides consumer-

specific information

A Vignette: PaulA Vignette: Paul

Paul, “I don’t know what I want to do. Maintenance work would be okay. I will do anything. I want to make money.”

What would you, the employment specialist, say?

Employment PlanEmployment Plan

Explore jobs by visiting work sites

Develop employment planRevise assessment and

employment plan based on consumer’s experiences

Job SearchJob SearchBegin soon after referral

–Employer contacts within 1 monthPreparatory work

–Resumé–Job application–Two forms of identification–Practice interviewing–Release of information

Individualized Job Individualized Job SearchSearch

Base on consumer’s preferences, strengths, abilities, experiences, and deficits (e.g., substance use)

Seek:– Permanent competitive jobs – Diverse jobs suiting individual

consumers– Different settings

Ways to Find JobsWays to Find JobsIdentify leads primarily through

networking Include family and treatment teamAttend job fairsUse Chamber of Commerce and

community organizations (e.g., Rotary Club)

More Ways to Find More Ways to Find JobsJobs

Newspaper (However, lots of others seeking same job)

InternetPrevious employersTell everyone you meetTrack contactsStay persistent

Engaging Engaging EmployersEmployers

Present confidently and professionally Help solve employer problem

–Recommend qualified applicantRespect employer’s timeIdentify next step: Meet job

candidate?Be dependable: Do what you say you

will do

Job SupportJob SupportIndividualized and time-unlimited

supportMostly away from work siteInclude consumer’s support

network (treatment team, family, friends, employer, coworkers)

Negotiate accommodations with employer

Common Job Accommodations Common Job Accommodations (MacDonald-Wilson, 2002)(MacDonald-Wilson, 2002)

37%

26%

21%

16%

Cognitive (e.g., learning job, concentrating)

Social (e.g., interacting, reading social cues)

Emotional (e.g., managing symptoms, tolerating stress)

Physical (e.g., stamina)

Job EndingsJob EndingsEach job viewed as learning

experienceJob transitions are considered

normalWith a job loss, consumer and

entire (SE and treatment) team strategize for next step

A Vignette: MargueriteA Vignette: Marguerite

Marguerite worked for three weeks at a dry cleaners. She was let go because of slow work speed.

What would you, the employment specialist, say?

Community-Based Community-Based ServicesServicesEmployment specialists in

community > 50% timeBest way to contact consumers,

families, employersServices do not generalize well to

different settingsPeople reveal more about who they

are outside of the agency

Time ManagementTime ManagementFocus on spending time with a few

consumers nearing employment vs. meeting everyone each week

Take phone book, cell phone, maps, newspapers, address book if possible when job developing

Review daily/weekly schedule with supervisor

Track OutcomesTrack Outcomes

Track employment outcomes monthly

Set goals: 40% rate of competitive employment is achievable

Things that you pay attention to are more likely to be improved

Percent Competitively Employed in 24 month period

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Study Time

Perc

en

t com

peti

tively

em

plo

yed

Standard

IPS

PSR

Track ImplementationTrack ImplementationUse 15-item SE Fidelity Scale to

measure implementation of evidence-based practice

Staff in supported employment program can see if they are on track

Basis for giving objective feedback

Hartford Study: Stable and high Hartford Study: Stable and high fidelity over time after short start-fidelity over time after short start-

upupIPS Fidelity

60

65

70

75

1 2 3 4 5 6 7

Number of Assessment

To

tal S

co

re

Capital Region

What About Supported What About Supported Education?Education?

Consumer choice always a primary consideration

Education and training expand options

SE program should help consumers enroll in community programs (GED classes, colleges, technical schools)

PRJ Article: Neuchterlein et al.PRJ Article: Neuchterlein et al.IIPS effective for assisting youth with IIPS effective for assisting youth with severe mental illness to sustain severe mental illness to sustain employmentemploymentAAlso effective for assisting youth to AAlso effective for assisting youth to complete schooling, including advanced complete schooling, including advanced educationeducationEEvidence of recovery, long-term EEvidence of recovery, long-term studiesstudies

IPS Supported Employment for Clients with First-episode Schizophrenia

0

20

40

60

80

100

Baseline 6 Months 12 Months 18 Months

% o

f Em

ploy

men

t or

scho

ol IPS

SAU

Early Psychosis Study (Nuechterlein, 2005)

Case example:Case example:Transtions, Inc., Rock IslandTranstions, Inc., Rock Island

FFormed partnership with local school FFormed partnership with local school system, spec. ed., social worker, Transitions system, spec. ed., social worker, Transitions SpecialistsSpecialistsAAssist in-school with m.h. issues - part of AAssist in-school with m.h. issues - part of teamteamAAssist with job site issuesAAssist with job site issuesFFollow youth who dropped outFFollow youth who dropped outFFacilitate transition to adult employment & FFacilitate transition to adult employment & treatment services as neededtreatment services as needed

What About Dual What About Dual Diagnosis and Work?Diagnosis and Work?

Work to support sobrietyMoney as a cueSame SE process

Motivation and WorkMotivation and WorkState vs. traitHopelessness as part of illnessWhat has been offered?Program normsWhat ES and practitioners sayWhat does consumer want?Change over time

Peoria D.O.L. grant study

Examined the impact of an Individual Placement and Support enhanced with Motivational Interviewing.

Increase stages of change to increase jobs offered, jobs obtained, and hourly wage.

Increase job leads from employment specialists to increase job interviews and job offers.

Increase clients telephoning potential employers to increase job interviews and job offers.

Stages of ChangeStages of Change

Pre-contemplationPre-contemplationContemplationContemplationDeterminationDetermination

ActionActionMaintenanceMaintenance

RelapseRelapse

Motivational InterviewingMotivational InterviewingFive Early StrategiesFive Early Strategies

Aask open-ended questionsAask open-ended questionsLlisten reflectivelyLlisten reflectivelyAaffirmAaffirmSsummarizeSsummarizeEsolicit self-motivational statementsEsolicit self-motivational statementsWhat are these?: problem recognition, What are these?: problem recognition, expression of concern, intention to change, expression of concern, intention to change, optimism about changeoptimism about change

Five Basic Principles of Five Basic Principles of Motivational InterviewingMotivational InterviewingEexpress empathyEexpress empathyDdevelop discrepancyDdevelop discrepancyAavoid argumentationAavoid argumentationRroll with resistanceRroll with resistanceSsupport self-efficacySsupport self-efficacy

Motivational Interviewing Enhancement technique for behavioral change

through identifying and resolving ambivalence and discrepancies between verbal and behavioral actions.

costs/benefits analysis

discuss the readiness ruler

engage with active listening

promote change talk

avoid arguments

IPSMI Intervention FrameworkReview Handout (Appendix N)

Stage of Change Intervention Outcome

Pre-contemplation Motivational Int. Move to contemplation

Contemplation Motivational Int. Move to determination

Determination IPS Set job goals

Action IPS Locate job

Maintenance IPS Maintain job

Relapse Motivational Int. Problem-solve

Move to earlier stage

IPSMI TipsContinually assess stages of change

Contextually based application

Modify

Problem-solve

Practice

Role-play

What Does Supported What Does Supported Employment Cost?Employment Cost?

Some programs, $2,000-$4,000 per client per year (Clark, 1998).

Latimer (2004) $2,449 per full-year equivalent

Figures vary according to severity of disability, local wages of employment specialists, and how much indirect costs and costs of clinical services are included

Examples of other Examples of other funding optionsfunding options

PASS & PESS PlansEnhanced Medicaid supportIndividual Development

AccountsSchool & education systems ?

Identify LeadershipIdentify LeadershipYou need a champion!

– Identify committed leader with sufficient authority to oversee and ensure implementation

Leaders at all levels visibly show support for supported employment

Center director buy-in is criticalLeadership from Vocational

Rehabilitation augments collaboration

Leadership RolesLeadership RolesProvide necessary resourcesSeek buy-in from consumers,

families, and practitionersGive recognition to staff and

consumer for successes Rapp’s finding – Critical role of

supervisor in program success

Provide Ongoing Provide Ongoing TrainingTraining

Initial training for all team members, including medical staff

Continuing access to expert consultation

Ongoing supervision that is outcomes-oriented

Make Time Make Time CommitmentCommitment

Typically, 6 - 12 months needed to develop skills, interest, and confidence for implementing evidence-based supported employment

SummarySummaryPrograms following evidence-

based principles of supported employment have better outcomes

Effective employment coordinators are key to good implementation

Resource materials complement training and supervision

Dog ear books

Becker, D.R., & Drake, R.E. (2003). A working life: The individual placementand support program. Oxford, England: Oxford University Press.

Miller, W.R., & Rollnick, S. (2002). MI : Preparing people for change. New York: Guilford Press.

Dog ear books

Bissonnette, D. (1994). Beyond traditional job development.

Substance Abuse and Mental Health Services Administration Supported Employment Tool Kit. Found at:http: / /mentalhealth.samhsa.gov/cmhs/http: / /mentalhealth.samhsa.gov/cmhs/

communitysupport/ toolkits/employment/communitysupport/ toolkits/employment/

Information: books, Information: books, videos, research articlesvideos, research articles

KKaren DunnKKaren DunnKKaren.Dunn@Dartmouth.edu6603-448-02636603-448-0263www.mentalhealth.samhsa.govwww.mentalhealth.samhsa.gov