The International Journal of Psychosocial Rehabilitation

Integrating Supported Education and Supported Employment for
People with Mental Illness: A Pilot Study


*Abraham Rudnick, BMedSc, MD, MPsych, PhD, CPRP, FRCPC
Department of Psychiatry
University of British Columbia
Vancouver Island Health Authority
Victoria, British Columbia
Canada
Email: Abraham.Rudnick@viha.ca

Robert C. McEwan, PhD
Counselling & Accessibility Services
Fanshawe College
London, ON.
Canada
Email: BMcEwan@fanshawec.ca

Luljeta Pallaveshi, LLB, BA

Department of Psychiatry
Lawson Research Health Institute
Western University
London, ON.
Canada
Email: Luli.Pallaveshi@sjhc.london.on.ca; lpallave@uwo.ca

Lois Wey, BSW, MSW, RSW

Counselling & Accessibility Services
Fanshawe College
London, ON.
Canada
Email: lwey@fanshawec.ca

Wendy Lau, BA hon. MEd RRP
LEADS Employment Services
London, ON.
Canada
Email: wendylau@leadsservices.com

Lueda Alia, BA

Department of Social Science
Western University
London, ON.
Canada
Email: lalia@uwo.ca

Lindsay Van Volkenburg, BSW

Department of Social Science
Western University
London, ON.
           Canada
           Email: lvanvolk@uwo.ca





Citation:
Rudnick A, McEwan RC, Pallaveshi L, Wey L, Lau W, Alia L, & Volkenburg LA (2013).Integrating Supported Education and
Supported Employment for People with 
Mental Illness: A Pilot Study.  International Journal of Psychosocial Rehabilitation. Vol 18(1) 5-25


 *Corresponding Author:
Abraham Rudnick
Email: harudnick@hotmail.com 
Vancouver Island Health Authority
642-2334 Trent Street
Victoria, British Columbia V8R4Z3
Canada


Acknowledgment:
Thanks are due to research staff and others, i.e., Charmaine Leung and Marnie Wedlake, who collaborated in relation to some of the qualitative data analysis. This project was Funded by Ontario’s Ministry of Community & Social Services - Ontario Disability Support Program (Innovation Funds), the Consortium of Applied Research and Evaluation in Mental Health (CAREMH), and Fanshawe College. 

 


Abstract
Background: Supported employment is an evidence based practice for people with mental illness, but it does not typically achieve skilled work. Such achievement may be achieved if supported employment is integrated with supported education.
Objective: This exploratory study evaluated the first year of an innovative program integrating supported employment with supported college education for 37 college students with mental illness.
Method: A phenomenological evaluation methodology was used. A purposive sample of 6 participating students with mental illness (schizoaffective disorder, bipolar disorder, and major depression) and 5 of their significant others, as well as 4 of their counselors from the collaborating organizations, were interviewed at 3 points in time. Thematic analysis was conducted on the qualitative data.
Results: Thematic analysis of interview data indicated satisfaction with the program and other promising outcomes.
Conclusion: Integrating supported postsecondary education and supported employment for individuals with mental illness is promising.
Keywords: Supported education, supported employment, mental illness.



Introduction
People with mental illness are more commonly unemployed and underemployed (working less than they could if enabled) than the general population (WHO, 2000).  This is partly due to some of their impairments, such as cognitive impairments (McGurk & Mueser, 2003), but it is also due to stigma and discrimination toward people with mental illness (Leff & Warner, 2006). This results in social exclusion and disadvantage of people with mental illness, which leads to their poor health, reduced quality of life and impoverished life satisfaction (WHO, 2000). It also results in societal losses and burdens such as loss of work potential and considerable economic burden, e.g., due to provision of income support for many among this population. Indeed, the World Health Organization (WHO) predicts that by the year 2030 unipolar major depression will be the leading cause of disease burden (Lépine & Briley, 2011). For instance, in an Australian study, Waghorn (2005) found an unemployment rate of 83.4% in his sample of young people with mental illness, a rate almost six times higher than for all Australians. Canadian statistics show that among those with disabilities, individuals with mental illness have the second highest level of unemployment (Nandal et al., 2009). Supported employment is the provision of work related services to assist people with mental illness (and/or other health challenges, such as developmental disability) to get and keep work, particularly competitive employment. It focuses largely, but not exclusively, on people with serious mental illness such as major mood disorders and schizophrenia, and it provides and facilitates skills training and supports related to work (Bond, 1998). Supported employment – particularly its most evidence based approach, which is Individual Placement and Support (IPS) – attempts rapid work placement and consists of various components, such as job development, job searching and work-related skills training (job coaching and more). It is effective – both in the US where it originated and elsewhere (Heffernan & Pilkington, 2011) – in helping people with mental illness get and keep jobs, i.e., for up to 80% of people with mental illness who make use of it. Although it is not always successful, employment outcomes are much better with it than without it, including in randomized controlled trials (Bond, 2004; Bond, Drake & Becker, 2008). Unfortunately, its effectiveness holds mostly for unskilled and entry level work, which does not usually require much education. Hence, supported employment by itself is limited by a “ceiling effect” (Rudnick and Gover, 2009), which means that in its current form it does not enable work that is more skilled and hence more lucrative and satisfying; consequently, it is not effective by itself in getting and keeping careers (Anthony, 2011).

Supported postsecondary education aims to help people with mental illness access and graduate from postsecondary education (Unger, 1990). It consists of counselling and supports that are relevant to people with mental illness, such as learning-related skills training (attention enhancement and more) and accommodations (extra time on exams and more), respectively (Mowbray et al, 2005). There is evidence that supported education can increase the educational attainment of persons with mental illness (Mowbray et al, 2005), but that it is not as successful in achieving skilled work (Unger, Pardee & Shafer, 2000), likely because it has not been integrated with supported employment. At best, people with mental illness may access supported employment separately from – and most likely after – supported education, which may not be effective in getting and keeping skilled work.

Thus, although supported employment and supported postsecondary education are evidence based interventions for people with mental illness, their common outcome is underemployment. The integration of supported employment and supported postsecondary education across a wide range of occupations may reduce unemployment and underemployment of people with mental illness by helping them get and keep skilled work and hence may also improve their mental health, general wellbeing and independent functioning (Brice, 2011). Indeed, integrating supported employment with other services such as clinical (mental health care) services for people with mental illness is more effective vocationally than using services as usual, i.e., in a non-integrated manner (Cook et al, 2005). 

An integration of supported employment with supported postsecondary education for people with mental illness has not been studied much to date other than some non-controlled pilot research such as one conducted in Israel on a variety of occupations (Rudnick & Gover, 2009) and another conducted in Canada on 2 skilled occupations – cooking and construction (Nandlal et al., 2009). These exploratory studies demonstrated promising findings, such as 61% employment one year after college graduation, with 72% of these working in the industry they were trained in; these numbers decreased only mildly after another year, i.e., 58% and 55%, respectively (Nandlal et al., 2009).

An integration of supported education and supported employment may be beneficial particularly when the demands for skilled workers are on the rise.  According to the Research Council of British Columbia (B.C.) university, a serious skills shortage is predicted to hit B.C. starting in 2016 (Nagel 2013). Due to the lack of skilled workers, the council estimates that 18,800 jobs could go unfilled by 2020 forcing B.C. to look for skilled workers outside of the province (Ibid). Thus, they urge that improving access to all types of post-secondary programs – not just trades but at the university and college level as well is imperative. Hence, in order to obtain skilled occupations for people with SMI, an integration of supported employment with supported postsecondary education may be required. The goal of our project was to implement and evaluate the integration of supported employment with supported community college education for people with mental illness, and to identify enablers and challenges that affect people with mental illness as they attempt to move through the cycle of postsecondary enrollment and classroom study and to transition to the competitive job market and workplace.

Methods
The project consisted of an uncontrolled intervention, using an organizational case study evaluation framework (Yin 2003). The project included 2 components:  (a) implementation of an integration of supported employment with supported college education for people with mental illness (the intervention); (b) evaluation of this implementation using a subsample of intervention participants.

The college participating in this project is a large Canadian community college with more than 15,000 students per year, of which an average of 100 are supported at the college for mental illness at any given moment. The supported employment agency participating in this project is the largest in its region and serves a catchment area of nearly 2 million people in Canada.

Participants with mental illness known to the college were contacted by a college counsellor who explained the project and offered the student the opportunity to learn more about it. During a follow up meeting, the counsellor fully explained the purpose and nature of the project, as well as its anticipated benefits and inconveniences. Students who were interested in participating in the project were also offered the opportunity to participate in the evaluation component of the project, which was fully explained. There were two stages and forms in the consent process. First, all students received information about the project, and those who were interested in participating in the project were required to sign a Consent form for that.  Second, students who were also interested in participating in the evaluation component and met the eligibility criteria were referred to a research staff who explained the nature of the evaluation. Students who provided informed consent were selected for the evaluation. At that stage each student participating in the evaluation was offered the opportunity to have one adult significant other participate in the evaluation as well. If the student consented to that, the significant other was contacted by a research staff, who arranged an individual meeting with him or her, at which time the nature of the research was explained; voluntary informed consent was obtained from participating significant others.

Thirty seven college students with mental illness were interested and participated in the project, of whom 6 who were purposively selected (for variance in sex and mental illness) consented to participate in the evaluation; 5 significant others also participated in the evaluation, as did 2 involved counselors from the College and 2 involved staff from the supported employment agency..  The sample size was determined according to relevant published norms for anticipated saturation of such experiential data (Morse, 2000). 

Participating students were evaluated 3 times: at baseline, at mid-point (which was approximately half a year after the start of the project), and at end-point (which was approximately a year after the start of the project).  The focus of the baseline evaluation was to collect data on relevant demographic content, particularly education, work and clinical information, as well as on the students’ expectations from the project. Using the SCID –I (Steiner et al. 1995), a psychiatric diagnostic assessment was conducted with the 6 participating students at baseline to ascertain their mental health problems. Mid-point and end-point de-novo semi-structured individual interviews were conducted with the 6 participating students to collect data related to the lived experience and impact of being involved with this project. These students’ 5 significant others and the 4 participating staff from the college and the supported employment agency were evaluated with similar de-novo semi-structured individual interviews at midpoint and end-point to obtain data regarding their experiences of the participating students’ journey through the project and any other relevant information regarding the project.  The students participating in the evaluation were financially compensated for each interview, based on local Research Ethics Board standards.  This study was approved by Western University, Health Science Ethics Board and Fanshawe College Ethics Board.

The intervention consisted of supported education and supported employment (using the IPS model); the novelty of it was the introduction of IPS early on, i.e., during the participating students’ college studies, and its structured integration with supported education, which consisted of co-location of supported employment counselling services at the college site and scheduled meetings between involved college counselors and supported employment staff to discuss particular students they were both providing services for, in order to coordinate and thus optimize their services with the joint goal of working toward securing studies-relevant skilled work for the participating students.  Each participating student met both a college counsellor and an employment specialist during their studies in college on a regular basis. The project had a steering committee that met monthly to monitor and guide the project’s progress.

Descriptive statistical analysis was performed to depict baseline demographic characteristics of the sample, using SPSS software package 20.0 (SPSS Inc., Chicago, IL). A phenomenological methodology informed the qualitative data collection and analysis. The interview recordings were transcribed verbatim and validated. Comparative thematic analysis (Boyatzis, 1998) was conducted on all the qualitative data. Two researchers independently analyzed the transcripts, and then peer debriefing occurred among them to secure trustworthiness/credibility. A decision trail was established for the analysis by documenting the coding of data, establishing data categories, and emerging themes across categories (Pope, Ziebland & Mays, 2006).

Results
Quantitative results
Demographic characteristics of the total project sample (37 students) are reported in Table 1. 

Table1: Distribution of demographic characteristics of total sample and qualitative sample

Demographics

Total Sample

N =37

N(%)

Qualitative Sample

N= 6 students

N(%)

Age (Yrs)

 

 

         Mean (SD)

         Age range

32.5 ± 12

19-53

33 ± 11.8

19-46

Gender

 

 

        Male

        Female

17(46%)

20(54%)

2(33%)

6(67%)

Diagnosis

 

 

         Major depressive disorder

N/E

2(33.3%)

         Schizoaffective disorder

 

2(33.3%)

         Bipolar disorder

 

2(33.3%)

Geographic Location

 

 

         London

29(78.4%)

6(100%)

         Other

8(21.6%)

 

Employed students

29(78.4%)

6(100%)

Employment areas

 

 

        Sales/services

13(45%)

1(16.7%

        Business/finance

9(30%)

2(33.3%)

        Social science/education/government

4(15%)

2(33.3%)

        Culture/recreation

1(5%)

1(16.7%)

        Management

1(5%)

 

Wage  $/hour

 

 

Mean(range) per hour

$10.89($8.75-$18.17)

$10.89($8.75-$18.17)

Maintained Employment

20(65.5%)

6(100%)

YRS = Years; SD = Standard Deviation; N/E = Not Evaluated

 

Overall, at the end of the project, 272 employers were contacted for 37 students, resulting in 60 interviews and 29 (78.4%) jobs secured, including co-op and/or job trial opportunities (paid and non-paid). Table 1 provides more information about the sectors in which students were employed.  Of 37 employed students who completed the program, 29 (78.4%)  secured skilled employment within one year, with 100% working in the industry that they were trained in;  20 (65.5%) of employed students successfully maintained their job for one year, and of these, 11 (55.2%) received payment with a mean wage of $10.89 per hour (range $8.75 -$18.17 per hour).

 
Qualitative – Results
The qualitative sample consisted of 15 participants: 6 students, 5 significant others of theirs and 4 counselors (2 from the college and 2 from the supported employment agency). Qualitative data were grouped under 6 main categories as elicited from the participants’ responses (see Table 2): (1) Pre-project factors, (2) project’s outcomes and benefits, (3) project’s process, (4) project’s challenges, (5) student related factors, and (6) suggestions for improvement.   

 Twelve primary themes emerged from the narratives that were identified across all the categories. These themes are elaborated on and illustrated below.

1.     Stigma, discrimination and social exclusion
Stigma, discrimination and social exclusion were identified by participants as major barriers by creating a tense environment and preventing them from being successful. They indicated that they face discrimination and prejudice in almost every aspect of their life when obtaining degrees, renting homes, applying for jobs, socializing events, and accessing mental health services. Participants stated that due to social stigma people view them differently and distance themselves. Participants asserted that it may be quite difficult for them to be accepted if they are perceived as different, and/or ignored in the classroom. For example, older students were rejected by younger peers who in their turn were perceived as immature. Participants noted that this is most apparent particularly when there is a lot of group work to be done to receive marks, which can be detrimental to one’s grades. Thus, they felt frustrated due to spending their energy and focusing on being accepted rather than focusing on the school work. Consequently, they felt they are in a tough battle for acceptance and wished to be living as “normal” a life as possible. However, participants stated that this program provided them an opportunity to establish genuine non-judgmental interactions, to feel accepted in classes and be successful in retaining jobs. Participants’ quotes are listed below to illustrate this theme.
Student: “I’m having a very difficult time being accepted, I don’t know why, cause I seem indifferent, or my age or could be that maybe I am not smart so I’m an outcast and I’m finding it really more difficult this term because there’s a lot of group work this term so. I have to be more aggressive and getting accepted…One of our teachers was saying, you know in our field, people with disabilities don’t do really well, they’re usually put in the back room…”

Counselor: “I think there is a lot of stigma; there are negative perceptions or ideas about people with any kind of psychiatric or mental health issues… a lot of misunderstanding… I do not think that the way the media portrayals people with mental health problems is particularly helpful.”

Significant other: “At Fanshawe she felt more alone, even though she was surrounded by people.”

2.     Personal stressors

The most prominent personal stressors identified were the effects of their illness; low finances; being easily affected by stress; juggling family life; attention problems often interfere with tasks; problems with organization and time management; personality conflicts with other students; difficulty with initiative; immaturity; engaging in socially inappropriate behaviours; and problems with medication adherence. Overall, data revealed that  education and employment of students with mental illness seems to be impeded by clinical problems (including severity of illness and symptoms) and social stressors  such as unemployment, lack of education, and lack of social and financial support, which can lead to poor cognitive and physical functioning. Participants asserted that these complex stressors get in the way of education as they interfere and require cognitive energy and concentration, resulting in poor choices and decisions, things that other students sometimes do not have to deal with. Participating students stated that when illness invades one’s life, other tasks can seem very daunting and stressful and extremely difficult to stay organized with, such as school schedules, finding a job or tackling other life obstacles alone. Juggling school work on top of their health care, financial problems, and family complications was often difficult for them. Participating students voiced that the stress that they carry on top of their mental illness is magnified 10 times more when trying to find employment. The mental illness paired with the various areas of stressful external factors, including stressful school environment, often resulted in a cycle of anxiety which was detrimental to their mental health by increasing the severity of their symptoms. Students reported being hospitalized often, falling behind in their school work, dropping out of school or quitting a job. Counselors noted that students can show poor insight into their own disability; they may not wish to disclose their illness to staff; medication side effects/changes are viewed as disruptive; and students may delay asking for help (which can result in failure).  Being aware of stressors and appropriate skills that can be used to avoid these stressful situations was crucial for them. Participants recognized that denial of their stressful situation constituted a barrier that impeded their progress in graduating from college and obtaining a job. Nevertheless, participating students and counselors voiced that this project established a mechanism that substantially reduced external factors and mitigated the burden of complex stressors that students with mental illness deal with beyond of their expectations. Participants’ quotes are listed below to illustrate this theme.
Student: “It’s hard, because I’m allowed with my Canada Pension disability to earn some income, but it’s frustrating because I just get going on a job and think I’m gonna do ok on it and then, I’m at my limit of what I can earn. And that disability pension, right now, is my security. And the job, I start to panic and think, what happens if another month from now I can’t keep the job and whatever and then I’m out in the cold.”
 
Student: “…And that seems to be one of those, I guess you could say brick walls (psychosis) that I keep running into because, you know, it’s a choice between going to class getting your work done or taking care of your health? What do you do? Because…… if you’re constantly having to make a decision between your health and your education; instinctively, you’re going to choose your health, but a lot of times, if you wanna do anything in life, sometimes your health has to take a back seat to make sure everything else is accounted for. It’s not right by any stretch of the imagination, but it’s a reality. And that can be a real barrier for a lot of people who want to pursue post-secondary education, especially if they have mental disorders.”

Counselor: “The main problem with a lot of them would be their mental issues…they make poor choices and sometimes they are not able to continue on with their employment at that particular time…because it is quite stressful to go to school and do placement and work…and there is always family complications… and then of course the financial area which is big, and then the outside areas that we really don’t address, the human factors, the relationship problems of living issues… the student has to have money to live, a place to live, they have to get their medications updated, they have to visit their psychiatrist. All those kinds of things that are complex get in the way of their education. Because they interfere, they take cognitive energy, concentration, all those things that other students sometimes don’t have to deal with.”

Significant other: “Usually around midterm time or when there are exams, he gets really stressed out and it’s difficult for him to concentrate on his studies… A lot of times he ends up in the hospital, so that definitely makes things difficult for him… definitely the mental illness, his schizophrenia are triggered by stress I’ve noticed.”

3.     Feeling supported and comfortable

Fitting in with people, having a good rapport, having helpful supported education and employment counselors on campus; eliminating negative thinking (negative thoughts and self-talk), building connections and feeling confident led these students towards the feeling of being supported and comfortable. Data also revealed the unique and responsive ways in which both supported education and supported employment established a hopeful and supportive climate reflecting recovery and resilience. For example, many of the participating students identified that by taking steps towards support, a person has the opportunity to grow and become a better person even while facing struggles. According to them, not letting the negative aspects of one’s mental illness take all of one’s energy is critical to succeeding in life. They stated that this is why support plays a huge role in their lives and without this support they felt that it can be easy to be blind to the positive aspects of their life.  Participating counselors stated that it is important and crucial for students with mental illness to have social connections at the college because it makes them feel that they belong in their college, and that there is somebody out there that knows them and looks at and cares about them as a person, be it a counsellor, professor or classmate. Participants felt that the supported employment services implemented appropriate accommodations and provided life support based on needs when assistance was required. According to the participating students, although there are times when they would like to approach challenges unaided, they still want to know that there is an option to seek support or assistance if needed. However, they felt that support can be ineffective without sound knowledge of mental illness and related issues. Participants’ quotes are listed below to illustrate this theme.
Student: “I felt comfortable with her [Leads #1,] I felt she was knowledgeable about the disease and, so that made it easier to explain things and, I was kind of surprised about that… They’ve always been very understanding…”

Counselor: “For a lot of students it’s having a connection to somebody in the college… feeling that you belong here and that, it sounds weird, but thinking like there’s somebody out there in this great big college that actually knows you and cares about you. And whether it’s me as the counsellor, or it’s a professor, or it’s the person at Tim Hortons or somebody that’s out there that actually looks at you as a person and cares about you. I think that’s really important and critical.”

Significant other: “Usually talks to his worker at the college [Fanshawe counselor #1], he gets a hold of his professors and lets them know that he’s been in the hospital, again. And usually makes arrangements to have his exams rescheduled so that, so he can take them. And anything that he’s missed class-wise, he’ll spend extra time with his teachers.”

4.     Self-esteem, self-confidence and empowerment

Supported education and supported employment were found to have considerable positive influence on students with mental illness by creating a comfortable environment, boosting their self-esteem and confidence and providing a feeling of empowerment.  Prior to their participation in the project, participating students felt, depressed, unvalued, worthless, not confident and they easily gave up. They felt that stress and severity of symptoms would always determine the kind of day and ultimately the type of life they will have. However, they stated that this project provided the kind of support that made them develop awareness to their situation and that they learned that facing and overcoming challenges can also build strength and confidence.  Therefore, they indicated that having such support would make their journey more tolerable which could lead to successful completion of challenges. As result of the project, participating students voiced that they learned to cope with their illnesses; desired better understanding and management of their illness; increased self-advocacy and confidence, and wanted to support self. Participants’ quotes are listed below to illustrate this theme.
Student: “At the beginning of the program before I had a job, I felt absolutely worthless, so I was totally depressed. Because I doubt myself and, because I don’t feel it’s perfect then I don’t feel it’s worth handing in and then I go back to the negative self-talk. The self-doubt and just: I can’t do this…and when the FC counsellor asked me a couple months ago what I wanted to do in the future, things were kind of up in the air and I wasn’t sure what I wanted to do.  Because of this project things are a little clearer right now.  I think that I’ll be able to feel my way out, what I want to do, and that’s a lot, college has a lot contributed to that.  It has built my skill to be able to do that… just dealing with counselors, or supports.”

Counselor: “This project increases the number of supports they get here in school. But is also gives them access to people who’ve got the skills that we don’t have here… I think it gives them confidence in themselves and I think it really reduces a lot of fear, because I think these kids are scared.”

Significant other: “The employment specialist helped her to find a job and…she feels glad that she has a job. Plus, she’s getting paid a lot more than most of them are getting paid… it’s definitely put her on a more positive track. Oh, she feels pretty excited about the fact that they will allow other departments to borrow her graphic design.”

5.     Motivation and hope

Students were reported to be motivated and determined to succeed; enjoyed the challenge; had strong career and educational goals; enjoyed school and schoolwork; were focused on college; and college involvement put students more ahead than typical clients of the supported employment agency.  Positive reinforcements and encouragement provided by this project were considered the best way of keeping students with mental illness motivated. Participants stated that having goals and working with counselors to achieve these goals is an effective way to keep their motivation high.  According to participating students, having realistic goals such as achieving a grade B could seem attainable. However, they expressed that being unable to reach those goals can be very frustrating and stressful for them. They indicated that those who suffer from mental illness must work much harder than others to complete tasks and reach goals. Otherwise, failure in achieving their goals can result in self-hatred and depression, particularly when knowing that they worked so hard to achieve their goals but were unable to do so. Having hope and adequate support was viewed as important to keep these students motivated in pursuing their dreams, including their education and employment. Participants’ quotes are listed below to illustrate this theme.
Students: “The whole support that’s been here has, has been really good it’s given me a lot of new perspectives… working with LEADS, working on this project has given me an inside experience that will literally allow me to go through the riggers of trying to find a job, …so the experience has actually been quite positive and has shown me the perspective that it is possible to get a job, it’s just a matter of how do I handle it…given me hope that I won’t be stuck on my hind end for the rest of my life on ODSP, that I can actually turn around and work and be a meaningful member of society…. whenever I had a lack of motivation in anything that I needed to do for any reason, I always went to [Fanshawe Counselor] even if it was for like ten minutes, , we’d hammer out a plan and it worked, every time.”

Counselor: “I think there’s a number of things that facilitate student success here while they’re studying at Fanshawe and involved in this project… I think good planning up front allows you to set up accommodations for them that they might need. So things like being able to leave the class if they have to, or a quiet space to write tests. If they know all that’s in place, then it’s, it’s there early. So I think making use of the accommodations”

Significant other: “It helped her with setting goals, achieving the goals despite how she felt,….She’s definitely positive and more motivated and, she thinks highly of herself. She doesn’t do like little things here and there, she does what she wants, that’s kind of what keeps her going.”

6.     Need for skill development

Skill development was perceived as indispensable for students with mental illness to deal with their stressors and challenges when these emerge in the school setting. Feeling overwhelmed with deadlines or things to do piling up; overwhelmed if trusted with more responsibilities; setting goals and working towards them; feeling unprepared for co-op placement; having a hard time in organizing and prioritizing their tasks; and having trouble with an instructor or staff; these factors highlighted the need for skill development. This skill set was found to be particularly useful and important for them during potentially stressful periods, such as at the beginning of a semester and during examinations.  The participating students also reported that due to a large amount of stress, they need constant reminders and emotional support in relation to the progress and goals they have accomplished thus far. Participants stated that for people living with mental illness, it can be difficult to prioritize tasks and time properly. Without supports to assist in organization, tasks can seem excessive and overwhelming, thus increasing the chance that nothing or at least not enough will get done. Participants reported that development of such skills would greatly contribute to their resilience.  Participating counselors focused on challenges that students with mental illness face. According to them, students with mental illness sometimes demonstrate symptoms such as low mood; therefore, they thought it would be helpful if a professional (counselors and faculty) could help the students develop skills to reframe such challenges as positive opportunities, e.g., the transformation of aggressiveness to determination. Participants’ quotes are listed below to illustrate this theme.
Student: “I think sometimes the deadlines were hard for me. I would put so much pressure on myself to make sure that I could try and keep up with everybody else. instead of utilizing the extended deadlines that I could have… when my anxiety would kick into overdrive… the second stage is the panic about making sure that I got all the information that needed to be in there, panic would continue because then I would worry that it’s not gonna be good enough… and I was kind sabotaging myself, and then the next stage would be freezing.”

Counselor: It’s difficult to keeping appointments, difficulty remembering what they were supposed to do, feeling so overwhelmed that you can’t come to class. Then there’s just the issues that all students face, like the workload’s really heavy, and I ‘god, I’m supposed to see somebody, but I’ve got an essay and a test and a project due, maybe I’ll just not go….Often they aren’t good advocates for themselves, and because they don’t fit, the rules have to be examined and applied differently and they need support, – without it, they would drop off, drop out.”

Significant other: “He’s obviously falling behind… He spends two, usually around a week, two weeks in the hospital…. and really try to find something that’s going to work. But if he gets over-stressed, that’s going to trigger him anyway, so he ends up missing exams, falling behind in classes, so he literally has to catch up, and of course that makes things more stressful.”

7.     Lack of knowledge about mental illness of staff
According to participating students, college staff and faculty may not have enough training and knowledge in aiding students with mental illnesses or they often assume that students may know more than they do; thus, they do not offer assistance or support at all. Students felt that this kind of attitude and lack of understanding/knowledge about mental health illness or learning disabilities prevents them from succeeding and functioning to the best of their abilities in class. They also noted that it can be quite difficult and exhausting for them to repeatedly explain their illness to others without leaving out important details. Conversely, participating students found counselors from both collaborating organizations to be very knowledgeable about mental illnesses, thus making things easier for them to explain. For example, specialty counselors (e.g. in physical and sensory disability, low literacy) asked appropriate questions, know about the rules of game, talked through goals and helped students staying focused by planning and conducting assessment time to time. Students were surprised that employment counselors' knowledge on mental illnesses "goes so far," and that they were teaching students how to balance the things in life rather than simply being there to just help them secure a job. Hence, having adequate knowledge about mental illness was identified by students as an important enabler contributing to a comfortable environment, as it provides them the reassurance that someone will be of help and allows them to cope better knowing that someone else can empathize with them. Participants’ quotes are listed below to illustrate this theme.
Student: “I’ve only had trouble with one or two of the instructors who really didn’t understand my disability… because they couldn’t see it… anxiety and depression,  they don’t really see it as, as far as like a physical disability.  So they weren’t quite as understanding…”

Counselor: “First of all, the counselor should basically understand the rules of the game, even though they change frequently, but the counselor has a tremendous advantage of being able to pick up the phone and ask the appropriate questions.”

Significant other: “It was a lifesaver for her. For one thing, they discovered the uh they discovered what was causing the depression, they discovered one, that she was depressed and, two, that they discovered that she had the prolactoma. It wasn’t them that made the discovery, but if it wasn’t for them, it wouldn’t have been discovered.”

8.     Effective communication (or lack of it)

Lack of effective communication was identified as major barrier to interactions, particularly when the people communicating and /or interacting are not on the same level cognitively.  Many participants felt very frustrated when they were trying to communicate a message and it would not come across clearly. Prior to the project, participants (students and significant others) felt that there was not enough communication happening between them and college counselors. Further, they felt that some counselors were unable to meet at times that were convenient for the students. Participating students indicated that they wanted to have more frequent face-to-face meetings, as it would allow them to voice challenges and deal with problems sooner, thereby preventing hardships and stress while creating space for success in education and employment.  They felt that this kind of communication not only ensures that no messages or concerns are lost in translation over e-mail or phone, but it also shows students that counselors are supportive and committed to helping them succeed. According to participating counselors, time constraints, limited resources and a large number of demands for counselling services constitute major barriers to communicating effectively and efficiently with students with mental illness and to providing support in more creative ways and differently from college faculty and staff. Counselors also noted that students with more serious illness were more difficult to serve and that communication was sometimes difficult between collaborators . However, they noted that these barriers were substantially reduced due to involvement of employment specialists and coordination with them. Participants’ quotes are listed below to illustrate this theme.
Student: Yeah, I had a lot of trouble with getting them to understand what my question really was. Because I have trouble phrasing things to make it sound properly.”

Counselor: “I tried to talk about the difference in perspective and language and difference in mandates of where we come from. That’s always difficult. And then, problems of basic communication….It has become easier because we now know one another better and understand the limitations of their organization versus our organization and that sort of thing, so I suspect our communication and interaction has been facilitated over the course of the project.”

Significant other: “Sometimes she’d write an email and she wouldn’t get an answer back right away if she had a question. Or sometimes, she’d email the question and the person wouldn’t quite understand what she meant and then there’d be back and forth where they’re kind of circling around, where if you meet somebody face to face, and you get feedback right away.”


9.     Lack of support system and navigating information and resources

Navigating resources and information about service accessibility was identified as crucial for students with mental illness, particularly in relation to finding help when it’s not offered. Participants highlighted the importance of having a system in place that is more responsive to the student needs. Participants stated that whether or not you have a disability, it is important to have a support system that can adjust to different learning styles and needs and gives students the feeling of belonging. Due to the fact that college is a stressful environment and has a complex bureaucracy with many regulations and rules that have to be followed, students with mental illness found it hard to navigate resources alone and to access counselor. They wanted a more readily available service system that is more effective in providing the needed resources. For example, participants talked about the importance of having supports like the supported employment agency that establishes necessary community contacts and seeks out and refers students to services that they may benefit from. They asserted that not having such connections would make it very difficult for them to succeed.   Knowing how and where to find extra support, resources and voicing their concerns related to school, work, personal life, health and emotions were all important to making the most out of the time spent with counselor and other service providers. Participants’ quotes are listed below to illustrate this theme.
Student: Improving on the service I guess if anything, it would come down to keeping the options open because 9 times out of 10 people with mental problems who want post-secondary education, as a general rule, they don’t even know where to start. They don’t know who to ask for help, they don’t know any of it, they don’t know how to set up a support network to help them, ah, through post-secondary education and the trials that exist.  So, the services themselves are great, it’s just having –having information available for people with mental problems who wanna pursue education to be able to access this information…. I’d highly recommend the school based on its support system…especially somebody my age you know…it’s really important to have a support system, uh, not only as a mature student, but as a disabled student…I just spent too much of my life without a support system…I spent too much of my life hiding…”

Counselor: “The college system is a very complex bureaucracy in which students must find their way through a whole series of hurdles in order to get into the college, in order to survive in it. So, they have a whole financial aid office that looks after their OSAP and bursary stuff and that’s often very complex, very difficult to get through. The registrar’s office is the same, the departmental rules and regulations are very difficult and inevitably, these students do not fit the normal pathway, they don’t fit the normal process….In my experience, if they do not have connections with another support agency…those things can get in the way and cause huge barriers for success…”

Significant other: “I kind of became the messenger girl which I didn’t mind, because I figure as his wife, that’s my responsibility to make sure that any services that he has while he’s in the hospital, it’s my responsibility to make sure that any communication that needs to get goes where it needs to get to go…


10.  Positive outcomes and benefits of the project

Participants noted positive change due to the project. Overall, the positive outcomes and benefits were mostly related to the improved social skills; attained (self) organizational skills; increased stress management skills; and increased self-esteem. The project was deemed very beneficial to the participating students because they received continuous support for increasing the quality of schoolwork, seeking employment, and they were also taught how to be independent and prepared for the work force.  As noted by participants, the increased quality of schoolwork was mostly reflected in increased socialization; increased confidence and pride such as with student involved in their own plans; good experience for the counselor; and increased employment for some students (hence increased finances). In addition, students found it helpful to have someone to talk to; found project staff knowledgeable about illness; and felt comfortable with counselor.
 
In terms of seeking employment and being prepared for the workforce, students liked the hands-on supported employment coaching; they also liked the help with job search, being able to gain employment, and they felt good about finding and getting work. According to participating students and significant others, finding employment can serve as a positive aspect in the student’s life and can greatly contribute to self-confidence, self-esteem and happiness. Participants stated that supported employment helps create positive environments for students with mental illness to thrive in and make positive decisions, and it gives them hope as well as reassures others that living an active and prosperous life are possible even when diagnosed with a mental illness. Participants believed that a job could provide support and positive energy for someone with a mental illness, giving them hope for a better future. Participating counselor and significant others stated that throughout the project, students received more attention to their needs because the project was tailored based on their individual needs. Moreover, they indicated that the project was very rewarding for the majority of students who came quite far and “got a new lease” in life by exceeding their counselor’ expectations. In addition, their participation in either competitive or non-competitive employment was associated with having less severe symptoms, better neurocognitive functioning, higher motivation, empathy, and other psychological benefits. However, besides the support provided by counselor, students claimed that they still needed other daily support from parents, siblings, children and friends, as they are in a better position than counselor to understand and help them in scheduling their time more effectively; moreover, these supports would also assist them in setting task reminders, such as for taking medication, going to their appointments or completing school work on time.  Participants’ quotes are listed below to illustrate this theme.
 Student: I learned how to take on projects and how to, deal with teachers.  I ended up learning how to communicate on my own with the teachers rather than having them do it for me. Which made me built my self-esteem … my self-confidence more, being able to deal with teachers…and how to take college in a positive way... I guess if I had to put anything on it that this project has helped with has helped put a brighter future… Without them I would have been screwed…”

Counselor: “They get far more attention if they are in this project and it is really personalized to them where going through the regular career services, they will get help with making a god resume, they will be told go and look at the job listings and apply on your own…if they need help with an interview, they might do a mock interview…I was seeing is that for a lot of them, the referral to [Leads staff ], seeing her on a regular basis, talking about some of the issues that they’re facing, I think, um, lessened the need for them to see me, that they felt really supported by her…The project for me was very rewarding. A lot of people have come quite far; they have exceeded their expectations so that makes me feel good. Some of them have got a new lease on life…”

Significant other: “She found out how she could use her graphic design talents to make a rather mundane job so much better. And she just wowed everybody out of the water, they were just flabbergasted by what she could do and she’s getting all kinds of praise and everyone was so happy with her, it just made her feel so good.  And then the fact that they were quite willing to keep her on during the year so she could be earning extra money, was just wonderful. And then they offered her a full time job. They’ve actually made up a job for her because they don’t have a job description that fits her really well.”

11.  Suggestions for improvement

Suggestions for improvement were mostly related to: addressing the need for increased social support; improved coordination with other mental health care services; making the college system a better fit for student needs; locating the supported employment agency in the college for longer and in a dedicated private space; and expanding the program to apply to people with other types of disabilities. Participants reported that there are various system barriers that prevent them from succeeding, including the college not being sufficiently responsible to learning disabilities, or students struggling with class scheduling.  Therefore, they suggested that it is necessary to create a mechanism that can be responsive and accommodating to specific needs for students with mental illness, starting with an assessment of the system as a whole, including its organization and structures. They suggested that arrangements for academic accommodations and adjustments should be ongoing throughout the academic year. They also noted that Faculty, counselor and administration should learn and provide concrete information and guidance about how these academic adjustments can enhance a student’s chances for success. Participating counselor stated that having a collaborative team approach, similar to the one offered by this project, will contribute to a better understanding of students’ perspectives and will address their specific needs better. Participants’ quotes are listed below to illustrate this theme.
Student: “If more of that information was available to me, where I could go, what I could do, what services are available, and also making the services more available…well, I guess a way to improve it would be to make these services more available to people who need them.”

Counselor: “I think that students need a team approach or a multi-faceted approach of support…so they will be able to have the educational support (Fanshawe) and employment support (LEADS) that I thought it was a really nice team approach.”

Significant other: “Possibly, the one advantage would be if they had teachers that were at campus for certain times so that they could go for, to talk to the teacher. I think a lot of the teachers have a tendency to come in from business and so they’re only there during class time. There’s been a couple of times where it would have been really nice, even if they were given an extra hour a day, maybe in an office, they have an office they could go to, that would probably have useful.”

12.  Similarities and differences among the 3 groups of participants:

In general, there were more similarities than differences across the 3 groups of participants – students, their significant others and counselor. Overall, participants from all groups stated that the project was beneficial to them, although partly in different ways.  

The main similarities were found to be in almost all the areas reflecting challenges, barriers and enablers. For example, both students with mental illness and counselor stressed the importance of an ongoing support system for establishing a positive environment that promotes learning, a positive emotional state, effective communication, reduction of severity of symptoms, reduction of stigma and discrimination, increased social inclusion and enhanced social network connections. The only important difference was in relation to knowledge about mental health. For example, participating students were very concerned about the lack of knowledge about mental illness that some of the instructors show; because mental illness is invisible, they argued that they do not view mental illness similarly to how they view physical illness. Participating counselor did not address their colleagues’ lack of relevant knowledge, apparently presuming that their colleagues know about mental illnesses; however, they agreed with the students’ comments regarding their knowledge being beneficial resources to help students with mental illness learn how to use coping strategies effectively when struggling with education and employment.  
Discussion
The integration of supported education and supported employment was helpful in mitigating challenges and severity of symptoms faced by students with mental illness. This study demonstrated that engaging in supported education and supported employment together provided assistance to students academically, emotionally and otherwise.
 
The results of this study were similar to the previous pilot research (Rudnick and Gover, 2009; Nandal et al., 2009) on integrating supported employment with supported postsecondary education, which was conducted in other settings and geographic locations.  Similar to the findings of Rudnick and Gover (2009), our pilot study demonstrated that students who completed the program were able to successfully maintain their job within one year with an earning mean wage above minimal wage in the studied jurisdiction.

One of the important aspects of this project is that its program established a structured way of enabling enhanced support, connections and a collaborative environment. Being connected and having ongoing supports boosted students’ self-efficacy and confidence.  Due to the fact that college is a very stressful environment with many regulations and rules that need to be followed, individuals with mental illness may find it hard to navigate the system alone, and to transition from postsecondary education to work successfully. They may need more guidance and support to accomplish this. According to Bond et al. (2001), programs that remain engaged with their clients over time, respond to clients’ expressed wishes, and sustain an approach that integrates clinical and rehabilitation services, are those that have the best outcomes over time. By being connected to supported employment early on, before college graduation, individuals with mental illness may achieve more vocational and other success and satisfaction. At the college, the counselors, Faculty and staff should have knowledge about mental illness and an understanding of individuals’ situation.
 
Nevertheless, several barriers, enablers and challenges were identified throughout the life course of the project.  The identified barriers were mostly related to history of personal and academic struggles (the variance in educational background of the participants notwithstanding); students’ low income; employers’ stigma; low self-confidence; low social support and lack of job stability and security; need for more support (more severe illnesses or multiple problems); students’ poor program choices; and the fact that college procedures and schedule can conflict with students’ illness cycle. The identified enablers were motivation to succeed in school/employment; family support; hopefulness; and supported education providing accommodations. Others identified enablers were supportive professors; good liaison between project staff and family or other services in the community; support during hard times, as well as support by family, some peers, and some professors. Throughout the stages of the project, students’ personal goals for their future were prominent.  The personal goals that stand out were an increased desire for independence and a desire for more personal success.
 
The major challenges there were noticed during the life course of the project were found in both the education and employment areas. For example, challenges in education were mostly related to: scheduling issues making it difficult for students to meet with program staff; schoolwork and work were overwhelming; there was a need to take time off for physical and mental health issues; and work placements were challenging. In the employment area, challenges were mostly related to work not being attained for all; college as well as employment environments were difficult for older students; and there was employer stigma.

Similar to previous research, this study showed that stigma, discrimination and inequality associated with mental illness were barriers that prevented students from successfully attaining their academic goals and work placements.  Social exclusion placed students with mental illness in a tough battle for acceptance. Similarly, Soydan, (2004) noted that students with psychiatric disabilities face fear, prejudice, and stigma that interfere with their access to and use of available services. Weiss et al. (2004) asserted that stigmatizing attitudes among providers and administrators not only block access to existing services, but they also hinder the planning and development of new ones needed. Moreover, if people with mental illness want to be successful in postsecondary education, they must overcome anxiety about higher education based on concerns about past difficulties in school, the stigma of mental illness and present interfering symptoms. Feeling stigmatized in schools as well as in employment settings forced these students to spend extra energy on being accepted rather than focusing on what’s most important, which is accomplishing their academic and vocational goals. To be excluded from the workforce creates material deprivation, erodes self-confidence, creates a sense of isolation and marginalization and is a key risk factor for psychiatric disability (Stuart, 2006).  Indeed, research has shown that successful participation in education is closely linked to sustainability, improved employment outcomes and maintaining employment (Best, Still, Cameron, 2008).

This study showed that stress was a major factor for people with mental illness when trying to obtain an educational degree and find employment. There are many stressors that individuals with mental illness have to deal with that is not typically an issue for other students. Balancing school work on top of their health care, financial problems, and family complications is often difficult. The stressful school environment results in a detrimental effect on an individual’s mental health and the stressful external factors results in the individual falling behind in school work.  Challenges and obstacles that they experience while searching for employment can lead to feelings of frustration and hopelessness and consequently a lack of confidence in one’s ability to meet one’s vocational goals (Corbiere, 2011). Integrating supported employment with supported education made the process of finding employment less stressful, and it promoted self-efficacy and self-esteem for students with mental illness in relation to overcoming potential barriers to employment.  This kind of support provided systematic guidance, created clearer goals and prevented the students from feeling overwhelmed by barriers that are present during the search for employment. Consequently, this supportive project significantly improved their career prospects and resulted in concrete actions toward obtaining a job.

This study has limitations such as not being controlled, its very small sample size for evaluation, and its location in one particular setting in Canada. Hence the findings may not be transferrable to other samples and locations. Yet the study elicited rich data from various stakeholders, yielding mainly common themes. Still, further research is required with larger samples and more rigorous study designs, such as multi-site randomized controlled trials.

Conclusion
The results of this project are promising.  This study showed that an integration of supported education and supported employment may be beneficial to individuals with mental illnesses as well as to society (due to the need for more skilled workers). There is still much to be understood about individuals with mental illness and how they can be supported to be successful and satisfied in relation to postsecondary education and employment. Developing a better understanding of interventions and the processes involved in supported education and employment and their integration will allow educators, employers, providers and policy makers to be better prepared to aid individuals with mental illness.

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