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Supported Education in a Swedish Context – Opportunities and Challenges for Developing Career-Oriented Support for Young Adults with Mental Health Problems

Authors:

Veronica Lövgren ,

Umeå University, SE
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Helene Hillborg,

Sundsvall Hospital, Region Västernorrland, SE
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Ulrika Bejerholm,

Lund University, SE
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David Rosenberg

Umeå University, SE
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Abstract

Young adults experiencing mental health problems often need both individual support and educational accommodations to successfully complete their studies. Recent research also points to the need for career-related, educational services in a labor market that increasingly demands formal education or training.

The aim of this study was to investigate the development of supported education services in Sweden, in relation to pursuing educational and vocational goals. Interviews were conducted with a broad sample of stakeholders who are currently developing supported education services, as well as young adults utilizing educational support.

The results suggest a number of key factors for accommodating the needs of these students which include, in addition to basic academic, mental health and individual supports, attention to economic challenges, social contexts and improved mental health literacy for educational actors. The results additionally substantiate the relevance of educational supports to long-term vocational goals when providing employment support services.

How to Cite: Lövgren, V., Hillborg, H., Bejerholm, U. and Rosenberg, D., 2020. Supported Education in a Swedish Context – Opportunities and Challenges for Developing Career-Oriented Support for Young Adults with Mental Health Problems. Scandinavian Journal of Disability Research, 22(1), pp.1–11. DOI: http://doi.org/10.16993/sjdr.648
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  Published on 23 Jan 2020
 Accepted on 20 Dec 2019            Submitted on 06 May 2019

Introduction

Young adults experiencing mental health problems as well as a lack of opportunities to participate in community life as students and employees are more likely to end up in long-term marginalized situations and to require continuing support as adults (Bostedt, Hillborg & Rosenberg 2012; Liljeholm & Bejerholm 2019; Patel et al. 2007). A recent Nordic inquiry into employability of marginalized young adults cited education as the most important factor in improving chances for leaving the NEET (not in education, employment or training) group (Albaek et al. 2015). Studies show that for those who dropped out of school, more than half wanted to return in order to develop skills and to improve their job status, as well as to find opportunities for personal growth (Corrigan et al. 2008; Knis-Matthews et al. 2007). However, while support consisting of a variety of individual and systematic resources is essential for improving academic outcomes among students with mental health problems (Soydan 2010), many post-secondary institutions do not offer services readily available to these students (Knis-Matthews et al. 2007).

Supported Education (SEd) programs have been available since the mid-eighties and can produce increased vocational opportunities as well as build self-esteem among participants (Soydan 2010: 244). SEd is defined as the provision of individualized, practical support to assist people with mental health problems to achieve their educational goals (Rogers et al. 2010). SEd has been seen as ‘a cousin’ to Supported Employment and Individual Placement and Support (IPS). IPS is a manual-based vocational program targeted to individuals with psychiatric disabilities, and there is a large body of empirical evidence for its effectiveness (Bejerholm et al. 2015; Bond, Drake, & Becker 2008).

Recent research, however, questions the ability of IPS to contribute to sustainable participation in the labor market, and whether we must turn our attention to participation in education as an essential aspect of building long-term employability for people experiencing mental health problems (Manthey et al. 2012; Murphy, Mullen & Spagnolo 2005). This coincides with a widespread recognition that the labor market increasingly places higher demands for formal education. It has been suggested that Supported Employment models, such as IPS, may be most effective when linked to services that support young adults with educational goals, as educational achievements can contribute to more sustainable and higher status employment (Manthey et al. 2012; Murphy, Mullen & Spagnolo 2005). There is therefore, a renewed interest in SEd as a critical component in helping young adults to establish themselves in the modern workforce.

This study is the second part of a larger project with the overall aim of developing knowledge of essential supports for young adults with mental health problems in post-secondary education, and to describe how specific components of SEd services are related to and can be feasibly integrated in vocational rehabilitation services in Sweden. Part one consists of a synthesis of research on SEd (Hillborg, Lövgren, Bejerholm & Rosenberg 2019) and part three studies the implementation of integrated SEd/IPS programs in five geographic locations in Sweden. The present study aims to investigate and describe SEd services in Sweden, in relation to the ambition of supporting young people with mental health problems in pursuing educational and vocational goals.

  • What needs are identified concerning developing educational support?
  • Which authorities, actors and professions are involved and what resources and opportunities are available in the Swedish context?
  • How are these services developed in relation to and/or integrated with existing SE/IPS services?

Background

A focus on access to educational environments can be seen as an important step in responding to the recovery-oriented needs of young adults by focusing on natural and age-appropriate roles (Bejerholm & Areberg 2014; Murphy, Mullen & Spagnolo 2005). A life-course approach that analyzes how opportunities and risks during formative or transitional stages may affect both mental health, and participation in employment, is therefore particularly relevant in analyzing the needs of young people attempting to pursue post-secondary education (cf. WHO 2012).

National policies in Sweden have increasingly focused on a relative and situational perspective on disability and impairment, even when it concerns psychiatric disabilities (State Public Reports, SOU, 2006: 100). When using a relative perspective, environmental conditions are in focus, and impairments have to be understood coupled to how the environment (on structural, organizational as well as interactional levels) can be enabling as well as create obstacles, i.e. create disabilities (Shakespeare 2006). Adapted milieus and social support have the potential to bridge obstacles or other ‘collisions’ between non-adapted environments, situational demands and capacity reductions (WHO 2012). While traditional vocational rehabilitation services emphasize skill training, often referred to as train-place models, Supported models, such as IPS, represent an ideological shift to a place-train model. Supported models (education and employment) with roots in psychiatric rehabilitation and a knowledge-based vision of recovery build on the relational perspective by working directly to provide support in natural community environments. They may therefore at the same time, contribute to knowledge regarding the types of environmental adaptation that can prevent impairments from resulting in disability.

IPS has a large body of evidence for its effectiveness (Bejerholm et al. 2015; Bond, Drake & Becker 2008) with rapid job search, a focus on choices and strengths, and ongoing individual support considered as critical components (cf. Hillborg, Svensson & Danermark 2010). It has the highest priority in the Swedish national guidelines for people with severe mental health problems (NBHW 2018). However, several studies have identified the risk that IPS leads to short-term employment, mostly part-time, with low wages, and with few opportunities for mobility in the labor market (Manthey et al. 2012; Murphy, Mullen & Spagnolo 2005). Studies highlighting the long-lasting effects of incomplete education suggest that opportunities for individuals to gain eligibility for more skilled positions might improve job tenure (Murphy, Mullen & Spagnolo 2005).

Supported Education (SEd) services are delivered within a number of models which include on-site support, mobile teams, educational experts based at mental health agencies, and on-site campus-based services (i.e. Mowbray, Megivern & Holter 2003; Unger & Pardee 2002). Although SEd programs differ, most services offer support concerning academic skills and social competences; time/stress management; outreach to educational institutions, financial counseling, and career and educational planning (Mowbray, Megivern & Holter 2003; Unger & Pardee 2002). However, according to Hillborg et al. (2019) SEd programs are typically created, despite a number of previously defined models, ‘from the ground up,’ i.e. the existing programs seem to be formed by local needs, available resources, heterogeneity in stakeholders, and organizations willing to take on the responsibility.

The diversity of models might be one reason that it has been difficult to develop evidence for the effectiveness of SEd, evidence that, according to the national guidelines developed by National Board of Health and Welfare in Sweden (NBHW 2018), is needed if SEd can be prioritized as an effective intervention.

Education and Mental Health Services in Sweden

Supporting young adults with mental health problems includes a range of stakeholders and authorities in the Swedish welfare system located at the municipal, regional (county council) and governmental levels. The Swedish system is considered to be relatively generous and protective of individual’s rights but at the same time highly decentralized, and responsibility is divided among several different authorities (Bejerholm, Larsson & Hofgren 2011; Lundgren et al. 2009).

The education system in Sweden is tax-funded and free of charge from pre-school to university. After the first ten years of compulsory school, most of the pupils continue to (the optional) three-year upper secondary school (gymnasium). Those students who have not completed their compulsory education, or graduated from upper-secondary school, can study for equivalency degrees at Komvux, i.e. adult education offered in each municipality (the Education Act 2010: 800). About 43% of the students who graduate from upper-secondary schools continue in higher education, i.e. University studies or Higher Vocational Education (yrkeshögskola) (Statistics Sweden 2018).

While upper secondary schools are required to provide the students with access to student health services at no cost (Education Act 2010: 800), these services are not required in municipal adult education. Universities provide two different forms of support: Student Health Services and Disability Services. The University Disability Services are linked to the Discrimination Act (2008: 567), which stipulates targeted efforts to promote equal rights for students with long-term disabilities.

Mental Health Services in Sweden are provided by two main stakeholders, the county councils and the municipalities. The county councils are responsible for the medical dimension via general practitioners at the primary health care center or by specialists at the regional psychiatric department. Support in everyday life, including residential supports, daily activities, and vocational services are provided by the municipal social services.

Method

This study included five sites that provided educational support, and those sites were categorized as follows: two included SEd as an outgrowth of established IPS services (IPS/SEd); one Fountain house-based model (FH), a member-driven organization providing psychosocial support; and two free-standing, SEd services which initially focused on young adults with Neuropsychiatric disorders but were serving many with a variety of mental health problems (SEd). Some of these sites had been active for years and some had more recently incorporated educational support in their services.

Researchers conducted ten group and two individual interviews and included a broad sample of stakeholders who provide educational supports as well as young adults experiencing mental health problems and utilizing educational supports. We additionally conducted five collateral interviews (two individual and three group interviews (Coll) with stakeholders from services that were collaborators in the SEd support network (at municipal, county council as well as national level services). In total, 57 individuals participated in the interviews, Table 1.

Table 1

Chart over sites and respondents.

IPS/SEd FH SEd Coll In total

Education specialists and job coaches 9 3 8 20
Representatives of mental health services at the municipal social services and county medical psychiatry 3 6 9
Representatives of educational services (including guidance counselors and social workers) 4 7 2 13
Representatives of employment services and collaborative projects that focus on the target group 2 4 6
Service users who had experience of studies during periods of mental ill-health 2 4 2 8
Representatives of user groups associations 1 1
17 7 21 12 57

To develop a broad understanding from a variety of relevant and practice-based perspectives, we strategically searched for diversity according to variables such as geographic location (sites from the south, the middle and the north of Sweden) and size (small, middle-sized and large cities). Another criterion concerned where the respondents were situated within the welfare system in terms of responsibilities and organizational settings. It was also critical to involve users of the services in the interviews. While the staff presented their program development strategies and experiences, the users joined the interviews to contribute to the discussion by describing their education-related needs. Therefore, their perspectives are included in the combined results because the aim of the research was to develop a holistic view of needs in relation to the development of these services.

The interviews were conducted by members of the project team in varied constellations, guided by collectively developed semi-structured interview guides, one directed to SEd providers, one to collateral actors and one to service users. While all interviews were recorded, one researcher took notes which were discussed and added directly after the interviews as reflections (cf. Finch & Lewis 2009). The recordings were transcribed verbatim and after project members read the transcriptions multiple times, they conducted an initial coding (cf. Creswell 2009: 183–190) which was then cross-checked and discussed until agreement on themes were reached. A contextual, dialectic and critical approach was applied throughout the process, in order to prove and validate the analyses (Creswell 2009; Silverman 2006).

This project has consulted a ‘user panel,’ consisting of individuals with their own experience of psychiatric illness and care/support. These panel members have undergone training in research methods, and have participated in research and development projects. Their comments and suggestions, before and during the rounds with focus group interviews, gave the research team valuable insights on the interview guide, as well as on everyday life as a student with mental health problems.

Ethics

The research team has extensive clinical and research experience working with people with severe mental health problems, and the project has received approval (dnr 2017-59-31) from the regional ethics committee following the Act concerning the Ethical Review of Research Involving Humans (SFS: 2003: 460). All participants have been informed that participation is voluntary and can be interrupted at any time, that their identity will be protected, that all data will be dealt with according to University guidelines and that their decision to participate would not affect current or continued support.

Results – Supported Education in a Swedish Context

The results are presented in three categories representing the research questions described earlier. The first category describes the specific needs that were reported during the interviews, many familiar from the international literature, and others that illustrate particular challenges in the Swedish welfare system. The next category describes actors and issues related to collaborations and responsibility, and the third attempts to determine the components of educational support considered essential by the respondents.

Individual and context-dependent needs

Three more or less distinct categories of young adults in need of educational support due to mental health issues were described in the study: young adults with serious mental health problems; young adults with neuropsychiatric disabilities; and immigrants with mental health problems. The first category included diagnoses traditionally associated with serious mental illness, but even including undiagnosed mental health problems, which were seen as major contributors to dropping out of school. Respondents described an interaction between studies and mental health, a need-related mechanism that might fall between the domains of guidance counselors and mental health professionals. Several respondents, as well as users, pointed to the continuing importance of including family when appropriate, as parents are often still involved in a variety of supportive roles of the students. With regard to neuropsychiatric disabilities, mental health problems were described as initially school-related, i.e. as beginning with difficult experiences from a school that was not adapted to individual needs and led to repeated experiences of failure, exclusion, and loneliness. These experiences were described as contributing to the development of depression and anxiety. In one of the collateral interviews, a representative for Psychiatry described a major challenge as the following: ‘It’s difficult to treat exclusion and loneliness with psychiatric tools.’ Respondents described the needs of these students as not primarily related to the actual studies, but to the ‘chaos’ in their social situation and a need for allied supports to ‘build up everything that has collapsed in their lives’ (SEd). In addition to support in everyday life, the need for supportive and inclusive spaces offering participation in educational and other activities and where these students could ‘recover’ was emphasized (cf. Winberg, Bertilsdotter Rosqvist & Rosenberg 2018). For the third category, immigrant students with mental health problems, difficulties were primarily attributed to previous trauma (due to war and/or the flight) and their insecure state as asylum seekers. Guidance counselors connected to integration services were identified as a crucial link between these at-risk students and supported education services.

Although some characteristics were specific to a subgroup, most individual needs were described as common and mirrored descriptions in the international literature (i.e. Knis-Matthews et al. 2007; Manthey et al. 2012; Mowbray, Megivern & Holter 2002). These included difficulties with structuring and organizing studies and everyday life; low self-esteem and confidence due to previous experiences of failure; ups and downs in self-motivation, anxiety related to deadlines, poor familiarity with welfare system supports, loneliness, isolation, and financial obstacles. Stricter rules regarding student financial aid and benefits were seen as creating even more stress for students already struggling with the pressured pace of studies. An additional perspective provided by one user was that ‘It is pretty easy today to become isolated with easy access to online and smartphone communication’ (IPS/SEd), and a study coach added that, the phenomena ‘home sitters’ (socially isolated young adults) is increasing. This type of structural isolation was often framed as an effect of accumulated frustration due to non-adapted schooling and a lack of support, and they emphasized the need to develop knowledge that could be used in schools to prevent long-term social exclusion.

Coordination, collaboration, and responsibilities

One dominant impression while conducting the interviews was the vast number, described in one interview ‘the myriad’ (SEd), of stakeholders and professions involved around individual cases. Domain after domain (i.e. education, finances, mental health care, and support, accommodation), including several stakeholders responsible for various service areas, reflected the highly differentiated and specialized Swedish welfare system, in which needs may be fragmentized in what is referred to as a ‘drainpipe’ effect (Lundgren et al. 2009; Rosenberg 2009). One respondent stated: ‘There are many weak links when there are so many actors’ (IPS/SEd). We have clustered the actors in three particular categories: Educational actors, Municipal and state support actors, and Mental health actors.

Educational actors included a variety of schools (Upper Secondary School, Municipal Adult Education, Swedish for immigrants, Folk High School, Higher Vocational Education, and Universities) and professions (teachers, school social workers, study advisers). The education specialists tried to build networks with teachers, study advisers, and principals in order to influence existing support services in different school settings. Some examples of local initiatives which built on the mental health awareness developed during these contacts included; counseling, extra tutoring, a designated classroom for students who seek a ‘disturbance-free’ or calmer milieu, and various orientation courses students could attend while ‘preparing’ for studies. By preparation, they meant exploring possible courses, developing academic skills, and exploring economic supports.

Formal collaborations between SEd services and Universities had not developed as many had hoped. Their support to university students was therefore of a more consultative nature, for example motivating and encouraging the individual to contact a study adviser and/or Disability Services or to support the individual to obtain a certificate confirming their eligibility for services. The focus on individual support suggested some specific needs related to the nature of Swedish higher education. University programs often consist of an assortment of courses that last for five or ten weeks, are offered in various departments, with varied groupings of students, and taught by teachers who don’t have a chance to get to know the students. According to some respondents, the nature of university studies can therefore lead to students with serious mental health problems not being noticed, and at risk of ‘disappearing’ due to a stigma-related reluctance to seek support. According to some respondents, the nature of university studies can lead to students with serious mental health problems not being noticed, and therefore at risk of ‘disappearing’ due to a stigma-related reluctance to seek support.

The category Municipal and state support actors includes municipal actors such as Social Services and Social Psychiatry/Community Mental Health Services, and governmental authorities such as the Swedish Public Employment Services, the Social Insurance authority, and collaborations between these actors. The respondents emphasized the necessity of having knowledge of the various actors, their roles and responsibilities and working to support the creation of a shared understanding of how individual needs should drive these collaborations – expressed for example by one representative of Social Psychiatry:

Housing support should not be seen as a support in itself, it should be contextualized. No one strives to get help at home. The strive can be to get into work, have a meeting place or meet others – not learn to wash dishes or clean at home (SEd).

Another respondent expressed a similar challenge: ‘We have to lay a good puzzle for the user’s needs, we have a system in Sweden that demands that we have to work together.’ Working together was achieved through collaborative networks or collaborative support structures. The common goal was to create more efficient support for the individuals’ transition from dependency on benefits to independence, from being unoccupied to beginning work or studies. These networks were often built upon personal contacts as well as formal agreements between organizations and were often described as ‘shortcuts’ between authorities at different levels within the welfare system. Collaborative support structures, often taking the form of co-financed projects, were built upon formal agreements between organizations, and were described as important resources, especially concerning support for returning to work. However, the analysis revealed that such collaborations were sometimes characterized as ‘pop up establishments,’ existing only for as long they were financed with project funds, and not leading to permanent models. For both the staff and the individuals, attendance in such projects might therefore be overshadowed by uncertainties around the future (cf. Germundsson, Hillborg & Danermark 2011). According to the respondents, many exemplary services have been established and then disappeared, at best contributing to the implementation of some of the components of these models in regular organization.

The third category is mental health actors. The county councils (Psychiatry) and municipalities (Community Mental Health Services) are obliged to develop agreements on cooperation. These formal agreements however, may not translate into practice, due to the strong hierarchical structure of the Swedish welfare system (cf. Rosenberg 2009). One IPS/SEd site, a part of Community Mental Health Services, had regularly scheduled meetings with the psychosis unit with a focus on both general questions and the coordination of interventions around individuals. These meetings were seen as compensating for the structural absence of Psychiatry in their organization (IPS principle). The other educational support sites described a more consultative relationship with the Psychiatry department, and these contacts were primarily based on individual need and permission. When such contacts do not exist or work properly, unexpected situations and potential problems may arise for both the individual and the educational support staff.

In study preparation [a previous project], there was little cooperation in the beginning. But one had to work out that cooperation, for suddenly a person was severely ill – and everyone thought that the person could not study. Then it turned out that they [the psychiatric clinic] had changed the medicine because the doctor didn’t know that the person was studying… Then the doctor said: ‘It’s great that this person is studying, but then we shouldn’t have changed the medicine’. It was unusually reckless. So what you are talking about [a name], is that you have to have this genuine conversation where everyone in the professions also knows [about the individuals’ needs] (Coll).

The respondent describes a situation where one of their client’s condition deteriorated, leading to difficulties in the study environment, one that only later was understood as resulting from a change of medication.

In summary, it is fair to say that studies create certain demands on student’s mental health (Public Health Agency of Sweden 2018). Many students, with and without mental health problems, suffer from stress and anxiety when beginning new courses, taking exams, and around the risks of failure and potential financial struggles. The sites offering educational support describe themselves as having a certain responsibility to counteract the risk that individuals ‘fall between the chairs,’ and experience difficulties in accessing resources. One of the IPS sites stated:

We make sure that the individual gets the right support, no matter what kind of support it is. And if we can’t, we will steer the individual further.

As the quote illustrates, educational support service providers see themselves as coordinators, responsible for accessing different actors and resources. Support staff, as well as respondents with experience of mental health problems while studying, stress that sufficient support depends on staff being well-informed of the individual’s current situation as well as of the welfare system; clear boundaries between responsibility areas; and that collaborating actors show respect for each actor’s function, scope, and regulating framework.

Educational supports in Swedish vocational services

This theme describes the aspects of educational support considered critical to consider when developing supported education services. These were sometimes related to well-established principles within the field of IPS (Bond, Drake & Becker 2008), and have developed from existing IPS-services or with inspiration from Supported Employment and IPS-practices, for example being person-centered and providing individualized support. However, our analysis suggests that a direct ‘translation’ of IPS-principles into educational support may not be sufficient. Respondents in this study, for example, emphasized factors related to the social context, or the ‘social infrastructures’ where these students find themselves. They describe a web of supporting environments, peers, educational actors and the study environments themselves, more specifically than many of the SEd models described in the literature (Ringeisen et al. 2017).

Education specific contexts

As mentioned above, studies are not as structured as working life and therefore create certain demands and challenges. When beginning at work, the workplace is structured according to time, place, activities and co-workers. For students, the situation is quite different. Schedules with the time and place for lectures are available, but do not offer a structure for the hours where the individual is supposed to independently perform activities, such as reading, writing papers, conducting group projects, etc. – activities critical for success in an educational context. In other words, students might need support to structure their studies, and in many cases, their whole life situation, during such challenging transitions.

Educational support is described as involving both preparatory and maintenance phases. Examples of preparatory activities were; exploring educational pathways, identifying ways to meet eligibility requirements for the desired education, supporting the application process, surveying expected study-related needs and supports and exploring the support provided by student health and/or other available educational resources. These supports were organized differently at different sites, sometimes being connected to a learning center or project (provided by the municipal vocational services agency), or sometimes to an explicit course where generic skills training was provided. A common factor however, was the realization that preparations for education were more complex and time-related than in support to work.

Study spaces, or in other words, places where studies could be conducted, were in one way or another mentioned in all interviews. Some of the sites provided quiet places with separate desks, small rooms for example, while others referred the individual to public spaces such as the school or library, or provided support to developing a designated space/structure at home. One site, specialized in support to people with neuropsychiatric disabilities at a university, provided a “recovery room”, a quiet room where the students could rest and eat. Our analysis demonstrates that study place/space can be seen as a broad concept with varied meanings. For some individuals, a quiet, private place might be adequate, for others, it might feel too lonely. In some cases, a degree of background noise (e.g. music or conversations at cafés, etc.) might even be a better fit for these students. Therefore, both individual and situational aspects influence what may be perceived as a good study environment.

Time and timing

The interviews revealed that in addition to questions of social structure, finance, mental health literacy, and person-centered support, aspects of time and timing were important to consider. Courses and programs are not always available, applications have deadlines and the ‘natural rhythm’ of studies is an important contextual aspect that must be attended to. The respondents describe the need for educational support to ‘grab the moment’ (SEd), to ‘offer immediate support to the individual in their striving’ (IPS/SEd), i.e. a preparedness to respond quickly to an individual’s interest in pursuing educational goals. This resembles the IPS principle of rapid placement, however, it concerns preparations rather than ‘placement.’ Secondly, timing refers to adjustments in the intensity of support –which vary depending on changing demands and/or the pace in the particular course or education, or fluctuations in functioning related to health. Time can also be considered as duration, since the respondents stress that support should continue for as long as needed. At last, as several emphasized, time for rest should be considered when planning for studies, an important aspect of recovery to sustain and promote mental health.

Economic issues

The broad focus on finances was somewhat unexpected, especially since public education in Sweden, compared to most of the world outside the Nordic countries, is tax-funded and free. However, in a highly individualized society such as Sweden, adults are expected to support themselves financially, rather than continuing to rely on family support. Being eligible for student aid provided by the Swedish Student Finance (CSN) was described as a basic condition for studies, as the following quote illustrates: ‘If you want to study at the university and don’t have CSN – it’s a dead-end’ (IPS/SEd). Sometimes students with severe mental health problems or neuropsychiatric disabilities, already receiving social pensions, were offered a six-month trial period. This opportunity however, was only available if the studies were vocationally-oriented, work training. Since higher education is excluded from this important form of financial support, the idea of supporting employability seems to dominate the welfare system. Employment, as the dominant goal for welfare policies (cf. Lillestø & Sandvin 2014), was also identified when respondents described studying Swedish for immigrants. Those who have been granted asylum are eligible for financial assistance from Social Services when studying, however, only for level A to C, and not at the D-level that is a prerequisite for post-secondary education.

Using natural supports

To support students in maintaining themselves in studies, several strategies were described. One common example involved encouraging individuals to better utilize existing service structures, such as Student Disability Services, to reach resources such as academic accommodations, i.e. extra tutoring; a mentor; extended time; computer and/or private room at exams. However, these types of support require a certificate detailing a specific diagnosis-related need, a demand that many of the students were reluctant to or found difficult to fulfill. Other activities described included arranging or providing lectures/information on academic skills, on promoting mental health, and supporting the individual to find and engage in social activities – to connect with peers:

Just to find someone who can help out with the studies can be so helpful, in my case I found someone who was really involved in helping me. Then you can do it even if you get caught up. My mate tried to save me into the last. She said, ‘Now have you missed this and this, but if you read those pages there and those pages there, you can manage the lab’ (IPS/SEd).

This quote is from one of the interviewed students who was studying with SEd support, as an answer to the question of whether they would recommend that others seek support from peers. The student meant that developing social contacts, even if these aren’t close friends, might be the difference between success and ‘failure’ – in this case an inability to study.

Mental health literacy

Many obstacles the respondents described were framed to some extent, as resulting from stigma connected to mental health problems rather than individual difficulties. Several of the respondents, both staff and users, describe that in the past, people in supportive functions (teachers, guidance counselors, caseworkers at the Social-, Employment- and Social Insurance Services), had avoided talking or asking about mental health issues. This avoidance was most often described as reflecting a lack of awareness of mental health issues, prejudices regarding mental illness, and a common conclusion was the suggestion that increased knowledge might therefore be seen as a means for normalizing mental health issues and counteracting stigma. All of the sites described efforts to increase mental health literacy among individuals as well as collaborating actors, and a goal of supporting their understanding that individuals with mental health issues can participate in post-secondary education with appropriate support and accommodations. They also describe questions of disclosure; i.e. supporting the individual to determine when, how and with whom they want to talk about mental health needs. Other ways of working with mental health literacy included (open) lectures about overall health, stress and coping, and outreach to study counselors and teachers.

Discussion

In attempting to consider the results with reference to the overall aim of the project, three themes have emerged during the analysis of the more concrete aspects of needs, collaborations, and social/contextual issues that have been presented in the results chapter. These describe critical perspectives that can shed light on strategizing and developing appropriate supports for young adults with mental health problems, with the Swedish social welfare state as an example. The results, which differ in some significant ways from the majority of the international literature (Ringeisen et al. 2017; Rogers et al. 2010), suggest that the development of SEd in Sweden might proceed from the basic principles, but in a manner that is much more context-dependent and in collaborative forms with natural welfare system resources. The results also suggest that we might begin to consider needs related to educational and vocational goals, from a holistic and long-term perspective that reflects the manner in which all young adults struggle to establish themselves as participatory adults.

Keeping the individual in the center in a complex and rich welfare system

Public education opportunities and supports related to labor market participation are quite rich in the Swedish welfare system. However, the issue of responsibility for educational and mental health needs is complicated. Despite the premise that services and supports should be offered on equal terms (The Discrimination Act 2008: 567), it is still important to advocate for the individual’s specific challenges and capabilities, in order to support the adaptation of available resources to their needs and to work through the fragmentation that seems to be an inherent part of these systems (Lundgren et al. 2009). Some respondents suggest that individual goals should be prioritized as “something bigger than the particular service or organization” (SEd) that meets them, and support services should strive to work beyond the ‘drainpipe’ effects that might otherwise create obstacles rather than individualized opportunities. The respondents described the importance of advocating for rights for their clients in such a complex and stressed system, especially when the individual has a clear and, in their assessment, appropriate goal. When helping the individual to navigate the complexity of the educational and financial rules and regulations various challenges were described. Gaining access to opportunities and resources was one aspect of this process, but advocating with these actors to assume their responsibility to accommodate to the needs of these students was important as well. They described the need to find ‘shortcuts’ to access the available supports as the student needed them, since, as discussed above, timing is an important aspect of providing these supports.

The nature of stated goals also seemed to influence the responsibility that might be assigned or assumed by various actors. Are the goals short term or long term? Is the financing considered as an investment or an intervention? As opposed to funding employment services, which lead to both short term outcomes and an immediate reduction in the need for economic supports, funding education services may be seen as more of an investment in a possible future. The fact that short term gains may be incremental and primarily contribute to a complex pathway to future success in the labor market, seems to challenge these services in a politically steered public sector which demands immediate outcomes. Outcomes in SEd may, therefore, be more understandable when integrated into IPS services that can connect them to both short- and long-term employment success. On the other hand, funding which is too closely connected to direct employment may not offer these programs the chance to explore and develop networks with responsible actors in the field of education, training and career development. The results suggest that a coordinated public sector responsibility is a condition for, but also a result of, the confidence and connection that these services might establish in the community as they support these young adults in a transition to adulthood.

Education from a disability perspective – Partnership and accommodation

During most of the interviews, educational support for young adults with mental health problems was framed as an answer to a growing population of young people at risk of long-term marginalized positions in society. These risks were ascribed to individual needs as well as to a society that has ‘narrowed the concept of normality’ (SEd) and a welfare system organized as ‘boxes,’ increasingly difficult to access. Educational support is therefore considered an attempt to equalize a societal discrepancy that affects persons with various mental health problems.

Functional impairments, including those attributable to mental health problems, do not necessarily need to lead to reduced participation in the educational arena – if sufficient accommodations and supports are available (Shakespeare 2006; WHO 2012). The experience of working with supported education models in Sweden reported here would suggest that this may be an achievable vision if the individual’s goals (short- and long term) and needs for accommodation and support can be prioritized in relation to their study interests. The Scandinavian countries, and Sweden in particular, have a rich tradition of ‘folkbildning’ (public education in a broad meaning) and include a variety of resources in the Swedish social welfare system that can become available for these young adults. However, respondents described difficulties connected to a lack of health literacy regarding mental health challenges, and it seems that ‘naturally’ occurring services were less ready when it came to young adults experiencing mental health challenges than those with other impairments. The need to become knowledgeable regarding mental health issues and how to help is one aspect of this challenge. Awareness of possibilities for accommodating existing services to the long-term needs of these young adults is another.

Career as a link to a life cycle perspective

The notion of career development as a long-term focus for these individuals helps to illustrate the limitations of an exclusively problem-focused perspective. The study that preceded this one (Hillborg et al. 2019), explored the literature on Supported Education, with a specific focus on the relationship between education and vocational development. It broadly concluded that SEd models were extremely context-dependent, based on the targeted population and societal resources. For young adults in a transition to adulthood, the interdependency of educational and vocational needs and resources, emerged as well:

It’s not just about being a dishwasher anywhere and getting paid. For some, it may be a great start – to get an income for the first time in your life. But the second step may be to start thinking about a career, to think about how you will develop (IPS/SEd).

This quote shifts the focus to a more long-term view, a life course perspective. It might also be seen as describing the need to develop a long-term and integrative planning process as a ‘drive’ in these types of support services. A holistic focus on career may be seen as a next step in seeing people who experience mental health problems as not only having a right to work but the capability (Mitra 2006) to develop careers, if they have opportunities to participate while receiving supports and accommodations that minimize the disabling effects of their mental health problems.

While SE/IPS and SEd are central and effective tools from a rehabilitation perspective, they may not achieve their potential when provided in an individualized impairment-related context. There remains a need to develop planning tools and processes that can support the individual in normalized life transitions. The results point to the importance of developing an understanding of individual needs in relation to societal opportunities and supports when working in well-developed social welfare systems.

Conclusions

In working with young adults, the notion of career is suggested as a unifying focus for developing models and services that integrate educational and employment supports. It emerged in the study as a theme that can encompass the integration of education and employment as a long-term investment, as opposed to short term measures that address just one issue, such as unemployment. This suggests a logic of integration of supports that build on a life cycle perspective reflecting the challenges these young adults face, and points to the need for further research that develops knowledge of the various mechanisms that operate in this complex transition from youth to adulthood and from education to employment.

The results of the study suggest that a number of key factors should be attended to however in developing vocationally-oriented educational supports. These include, in addition to basic academic, mental health and individual supports, a focus on economic challenges and attention to the social contexts in which these students experience challenges. The knowledge-based needs of educational actors who meet these students in various arenas is suggested as an important focus as well, so that they might receive support in accommodating to the needs of young adults with mental health problems. Finally, further research is suggested in understanding the timing of interventions and of time frames related to societal expectations for results produced when supporting educational opportunities.

Acknowledgements

This article is based on one study in the project, A working life on the horizon – Supported education for young adults with mental health problems, with dnr: 2016-00946. The project has received funding from FORTE: Swedish Research Council for Health, Working Life and Welfare.

Competing Interests

The authors have no competing interests to declare.

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