Community Ment Health J DOI 10.1007/s10597-016-0026-2

Original Paper

Difficulties Experienced by University Students with Severe Mental Illness Who Participate in Supported Education Programs Ron Shor1

Received: 9 December 2015 / Accepted: 27 May 2016 © Springer Science+Business Media New York 2016

Abstract  Knowledge about the difficulties students with severe mental illness (SMI) encounter is essential to helping them meet the challenges of studying in universities. Therefore, a study was conducted in Israel with 80 university students with SMI to ascertain their difficulties and the relationship between these difficulties and their level of recovery. The two subscales of an instrument measuring students’ difficulties that were ranked the highest were “Learning Skills and Management of Academic Tasks” and “Social Inclusion Difficulties.” Inverse relationships were found between the students’ difficulties and their perceived level of recovery. The findings illuminate that one of the major challenges that students with SMI experience is to meet academic requirements while coping with mental illness. They also indicate that students’ difficulties may not be limited to academic functioning. Therefore, there is a need to broaden the view of students’ difficulties to include social and contextual factors in the university environment. Keywords  Supported education programs · Mental illness · Difficulties · Universities

Introduction Since many psychological disorders are first diagnosed between the ages of 18 and 24, the traditional age range for academic studies (Brockelman 2009), students suffering

Ron Shor [email protected] 1



The Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Mt. Scopus, 91905 Jerusalem, Israel

from severe mental illness (SMI) may experience difficulties in their participation in higher education. These difficulties interfere with the possibility of their completing academic studies, and they may be forced to abandon them. (Bybee et al. 2000; Mowbray et al. 2001; Weiner and Weiner 1997). One of the consequences of such disruption is that these individuals are often involved in jobs far below their vocational potential (Frankie et al. 1996). In recent years there has been an increased awareness of the right of persons with SMI to study in institutions of higher education, of the importance of providing them the opportunity to do so and of helping them with the barriers they may experience so that they can maintain and complete formal education courses (Harris et al. 2010). However, limited knowledge exists about the difficulties students with SMI may face when pursuing higher education. Knowledge about this subject could provide both a base for enabling recognition of the nature of their needs for support and for developing the kind of services that could provide an appropriate response for the difficulties they face. Difficulties of Students with SMI in Academic Institutions Studies conducted about the difficulties experienced by students with SMI in academic institutions have been primarily small scale qualitative studies. Structured instruments have been utilized in a limited number of studies examining this subject (e.g., Corrigan et al. 2008; Mowbray et al. 2001). These studies have identified learning skills and management of academic tasks as major difficulties these students experience. These difficulties could stem from psycho-social effects of coping with SMI such as concentration problems because of tiredness and exhaustion from not sleeping, side effects of medications and inability to manage symptoms

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(Martin 2010; Megivern et al. 2003). In addition, there may be memory problems (Corrigan et al. 2008), lack of confidence about their ability to cope with the demands of college (Martin 2010) and difficulties in managing how they complete assignments (Mowbray et al. 2001). The challenges students with SMI may experience are not limited only to learning difficulties but in other areas as well. Studies have identified difficulties with factors creating Barriers to Academic Inclusion affecting their participation in academic activities such as complications in applying for financial aid and having access to educational support services (Mowbray et al. 2001), as well as dilemmas about revealing the SMI within the academic context (Corrigan et al. 2008). The last factor may limit communication with academic staff about their special needs. Social Inclusion Difficulties in the university context, such as avoiding social interactions because they feared that others might find out about the SMI (Storrie et al. 2010; Quinn et al. 2010), were also reported by students with SMI (Martin 2010). Tinto (1993) found that students with SMI who were not able to integrate academically and socially into campus life were more likely to leave the universities. Studies indicate that the extent of difficulties that students with SMI may experience during their studies in institutions of higher education could be related to the way in which they manage and overcome the effects of their mental health situation (Martin 2010; Megivern et al. 2003). A perspective that could reflect the way in which students manage and overcome the effects of their mental health situation is the recovery perspective. This is a perspective that means building a life beyond illness without necessarily achieving clinical recovery (Anthony 1993). The individuals’ psychosocial functioning while coping with the effects of the mental illness could play a key role in achieving the objectives of the recovery perspective (Jacobson and Greenley 2001). Due to the limited knowledge existing about the nature of difficulties experienced by students with SMI, a study has been conducted in Israel about this subject. Two research questions were examined in this study: (1) What are the types and extent of difficulties experienced by students with SMI in meeting the challenges of studying in the university? (2) What are the relationships between the extent of difficulties experienced by the students and their perception of their level of recovery? The underlying assumption of this research is that the students’ way of managing and overcoming the effects of the mental illness could be related to the difficulties they may experience during their studies. The study received the approval of two Institutional Review Boards (IRB). The author knows of no conflict of interest regarding the execution of this study, including the planning, sampling, data gathering, and data analysis performed as part of this research project, and the author certifies responsibility for this report.

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Method A quantitative cross-sectional method was implemented with 80 students with SMI in five universities in Israel. All the students took part in supported education programs financed by the Israeli Ministry of Health. The services included meeting individually with mentors twice a week. The mentors provided the students support and advice aimed at helping them cope with the academic and social difficulties they may experience as they contend with the challenges of studying in institutions of higher education. The criteria for participation in the research were: a determination of a 40 % mental health disability by the Israeli National Insurance Institute or approval of eligibility based on the severity of disability by a committee of the Israeli Mental Health Ministry, and participation in a number of courses equivalent to at least a part time program. Purposive sampling was utilized in which all those in these supported education programs were approached with a request to participate in the study. Seventy percent of those approached agreed to participate. The Instruments The parts of the questionnaire included (a) a background section composed of 20 items, (b) an instrument composed of 22 items created for the purpose of this study to measure the difficulties students’ experience in the university (DSEIN) and, (c) an instrument composed of 24 items measuring the participants’ perceived level of recovery (RAS). The first part, the background section, included questions about the participants’ demographic information, their mental health situation and their studies in the university (e.g., year of study, success in meeting the academic requirements). The second part was the measure of the types and extent of difficulties experienced by students (DSEIN). It had been developed for the purpose of this study and was based on items included in measures by Mowbray et al. (2001) and by Corrigan et al. (2008). The DSEIN was divided into four sections: Lea rning Skills a nd Ma na gement of Aca demic Ta sks Nine items related to difficulties with learning skills (e.g., academic writing) and management of academic tasks needed to achieve the educational objectives (e.g., organization skills, how to complete assignments during mental health relapse). Barriers to Academic Inclusion Six items related to difficulties and barriers that may prevent students from active involvement in the academic studies (e.g., lack of consideration by the professors of the students’ special needs, difficulties requesting adjustments). Social Inclusion Difficulties Four items related to difficulties that may prevent them from feeling socially included

Community Ment Health J

in the university (e.g., communication difficulties with students, difficulties developing social relationships with students). Accessibility Barriers Three items related to barriers that may limit students’ accessibility to studying in the university (e.g., economic difficulties in financing the studies, orientation difficulties in the university). The participants were asked to assess the extent of difficulty they experienced with each item using a Likert Scale with a range of responses from 1 to 5 (1 = not at all, 5 = to a large extent). The content validity of the DSEIN instrument that had been developed for the purpose of this study was examined in a focus group conducted with the five professional staff members of the supported education programs. These staff members were asked about the relevancy of the items drawn from the two instruments already existing and whether, based on their experience, there were other items that should be included in the new instrument. The face validity of the instrument was examined with ten students with SMI who were asked about the clarity of the questions included in the instrument. An exploratory factor analysis indicated that the Learning Skills and Management of Academic Tasks subscale accounted for 30.64 % of the variance with eigenvalue of 4.98. The Barriers to Academic Inclusion subscale accounted for 11.49 % of the variance with eigenvalue of 3.06, the Social Inclusion Difficulties subscale accounted for 12.47 % of the variance with eigenvalue of 3.34. The Accessibility Barriers subscale accounted for 7.14 % of the variance with eigenvalue of 2.16. The cumulative variance of the four factors was 61.61 %. The Chronbach Alpha of the Learning Skills and Management of Academic Tasks subscale was 0.87, of the Barriers to Academic Inclusion subscale 0.71, of the Social Inclusion Difficulties subscale 0.89 and of the Accessibility Barriers subscale 0.66. The third part of the questionnaire was the Recovery Assessment Scale (RAS) and was used to measure the selfperceived level of recovery from SMI (Corrigan et al. 2004). It included the following factors: Personal Confidence and Hope, Willingness to Ask for Help, Goal and Success Orientation, Reliance on Others and No Domination by Symptoms. It also used a Likert Scale of 1–5 and the Chronbach Alpha for each of the subscales ranged from 0.074–0.87. Procedure The initial presentation of the study was done by the coordinators of the supported education programs in each of the academic institutions included in the research. They also explained that refusal to participate will not affect the students’ eligibility for services. The questionnaires were delivered by research assistants in a personal meeting conducted towards the end of the academic year. Students’ who agreed to participate in the study signed a letter of agreement

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to participate in the study. Each participant completed, in about 20 min, the three part questionnaire. They received modest compensation for their participation. The research received the ethics approval of the Institutional Review Board of the university where the researcher is employed and the Institutional Review Board of the Israeli Ministry of Health, the institution responsible for the supported education programs.

Results Background Information Eighty students with SMI participated in the study. Their mean age was 30.34 (SD = 6.48). Forty-nine percent of the participants were male and 51 % were female. Thirty-five percent of the participants were in their first year of study, 27 % in their second year, 25 % in their third year, 9 % in their fourth year and 4 % in their fifth year. A majority of the participants (82 %) were studying for their undergraduate (BA) degree, 15 % for their Master’s degree and 3 % for their Doctorate degree. Most of the participants (73 %) were enrolled in a full time program. The most common areas of studies were humanities subjects (55 %), helping professions such as psychology, social work and education (20 %) and life sciences (20 %). The mean length of participation in the supported education program was 1.93 years (SD = 1.50). The majority of the participants were single (85 %), 10 % were married, and the rest were divorced or separated. The diagnoses of the participants were: 35 % schizophrenia, 40 % mood disorders, 20 % anxiety disorders, 5 % did not agree to reveal their diagnosis. All the participants, except one, reported that they take psychiatric medications. Fortytwo percent had received formal acknowledgement of having learning disabilities and 34 % had been diagnosed as having attention deficit disorder. The Difficulties Students with SMI Experienced in the University As part of the first research question focusing on the types and extent of difficulties experienced by students with SMI, the means of the items included in each of the subscales of the DSEIN Scale (measuring the difficulties experienced by students during their studies in the university) were examined. They indicated that Learning Skills and Management of Academic Tasks (M = 2.87, SD = 0.91) and Social Inclusion Difficulties (M = 2.86, SD = 1.14) were the two subscales with the highest means of the items. Barriers to Academic Inclusion (M = 2.33, SD = 0.90) and Accessibility Barriers (M = 2.17, SD = 1.02) were the two subscales with the lowest means. An examination of the ranking of the

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subscales was conducted utilizing the Paired Sample T test to compare the mean of the items of each of the subscales. A lack of statistically significant differences was found between the two subscales ranked the highest: the Learning Skills and Management of Academic Tasks and the Social Inclusion Difficulties subscales. However, statistically significant differences were found between the means of the items of these two subscales and the means of the items of the Barriers to Academic Inclusion and the Accessibility barriers subscales (p < .001 of the t tests conducted, t ranges between 3.9–4.8), indicating that the participants’ assessment of the difficulties they experienced in the areas examined in the first two subscales was statistically significant higher than their assessment of the difficulties examined in the other two subscales. Correlation analyses utilizing Pearson correlations tests were conducted between the mean level of items of each of the DSEIN subscales and the year of study in the university. Statistically significant relationships were not found in these analyses. The following is a more specific analysis of the items included in each of the DSEIN subscales. Learning Skills and Management of Academic Tasks Within the Learning Skills and Management of Academic Tasks subscale (see Table 1), the mean levels of the three items ranked the highest, indicating a high level of difficulty, were items relating to management of academic tasks: completing assignments during mental health relapse, organizing skills, such as of time division during assignment completion, and coping with stressors during the studies. A level of difficulty equivalent to a medium level of difficulty was found for the items relating to learning skills difficulties (e.g., ‘Difficulties to write academic assignments,’ ‘difficulties with learning skills, how to learn new material,’

and ‘difficulties to read academic texts’). The lowest mean levels of difficulty were found for the students’ difficulty to maintain consistency in their studies and difficulty with listening to lectures. Barriers to Academic Inclusion Within the Barriers to Academic Inclusion subscale (see Table 2), a high level of difficulty was found for the item ‘dilemmas about whether or not to reveal mental health difficulties in the academic context,’ and a medium level of difficulty was found for the item ‘difficulties requesting accommodation in the academic studies.’ A lower mean level of difficulty was found for the items relating to communication difficulties with the academic staff regarding the students’ needs (e.g., ‘lack of the professors’ understanding of difficulties encountered by students with SMI’) and to the ‘implications of stigma and prejudice about their involvement in academic studies.’ Social Inclusion Difficulties Within the Social Inclusion Difficulties subscale (see Table  3), a medium to high mean level of difficulty was found for each of the items in this subscale (e.g., ‘difficulties developing social relationships with students,’ ‘social isolation,’ ‘communication difficulties with students’). The frequency distribution of the items indicated that almost two thirds of the participants (at least 68 %) felt, at least to a little extent, social difficulties for each item. Accessibility Barriers Within the Accessibility Barriers subscale (see Table 4), a medium level of difficulty was found for economic difficulties relating to financing the studies. A lower mean level was found for the other two items: ‘difficulties to finance

Table 1  Difficulties with Learning Skills and Management of Academic Tasks subscale

Table 2  Barriers to Academic Inclusion subscale

Difficulty

M (SD)

95 % CI

Difficulty

M (SD)

95 % CI

Completing assignments during mental health relapse

3.61 (1.43)

[3.36, 4.07]

Dilemmas about whether or not to reveal the mental health difficulties

3.40 (1.55)

[2.95, 3.75]

Organization (time, assignments) Coping with stressors Assignment completion Skills: writing Skills: reading academic texts Skills: learning Maintaining consistency in studies Skills: listening to lectures

3.36 (1.20) 3.26 (1.19) 2.82 (1.25) 2.77 (1.35) 2.73 (1.18) 2.69 (1.14) 2.48 (1.37) 2.42 (1.25)

[3.09, 3.71] [2.99, 3.61] [2.53, 3.18] [2.48, 3.17] [2.52, 3.13] [2.41, 3.02] [2.13, 2.82] [2.19, 2.82]

Requesting accommodation Lack of professors’ understanding the difficulty the students face

2.53 (1.37) 2.11 (1.30)

[2.16, 2.89] [1.87, 2.54]

Communication difficulties with academic staff

2.18 (1.15)

[1.90, 2.48]

The implications of stigma and 1.97 (1.58) prejudice about their studies Lack of professors’ consideration of the 1.86 (0.99) students’ special needs

[1.16, 2.26]

CI confidence interval; scale of 1–5; 1 = not at all, 5 = to a large extent

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[1.65, 2.16]

CI confidence Interval; scale of 1–5; 1 = not at all, 5 = to a large extent

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Table 3  Social Inclusion Difficulties subscale Difficulty

M (SD)

95 % CI

Developing social relationships with students

3.07 (1.30)

[2.71, 3.38]

Social isolation Communication difficulties with students Lack of support from students

3.01 (1.37) 2.82 (1.27)

[2.71, 3.38] [2.51, 3.17]

2.54 (1.39)

[2.21, 2.91]

CI confidence interval; scale of 1–5; 1 = not at all, 5 = to a large extent Table 4 Accessibility Barriers subscale Difficulty

M (SD)

95 % CI

Economic difficulties in financing the studies

2.57 (1.50)

[2.21, 2.96]

Difficulties to finance travelling to the university Orientation difficulties—finding their way within the academic institution

2.17 (1.32)

[1.84, 2.51]

1.87 (1.15)

[1.58, 2.16]

CI confidence interval; scale of 1–5; 1 = not at all, 5 = to a large extent

travelling to the university,’ and ‘orientation difficulties within the university.’ It should be noted, however, that despite the low mean level of difficulty for these items, at least 43 % of the students experienced, at least to a little extent, Accessibility Barriers for each item. The Relationships Between the Extent of Difficulties (DSEIN) and the Students’ Perception of Their Level of Recovery (RAS) Correlation analyses were conducted between each of the DSEIN subscales and the RAS subscales in order to examine the second research question: the relationships between the extent of difficulties experienced by students with SMI and their perceived level recovery according to each of the RAS subscales (see Table 5). Statistically significant

inverse relationships were found between the means of the items of the difficulty with Learning Skills and Management of Academic Tasks subscale and three of the factors of the RAS: Personal Confidence and Hope (r = −0.245, p =  .035), Goal and Success Orientation (r  = −0.234, p = .045) and No Domination by Symptoms (r = −0.351, p = .002). Statistically significant inverse relationships were also found between the means of the items of Barriers to Academic Inclusion and the means of the Personal Confidence and Hope subscale of the RAS (r = −0.258, p = .026). Strong statistically significant inverse correlations were found between the Social Inclusion Difficulties subscale of the DSEIN Scale and four of the five subscales of the RAS: The Personal Confidence and Hope subscale (−0.440***), Goals and Success Orientation (−428***), Reliance on Others (−0.428) and No Domination by Symptoms (−0.390). These findings indicate that a higher mean level of difficulties in three of the four DSEIN subscales (except for the Accessibility subscale) is related to a lower mean level in subscales of the RAS measuring the perceived level of recovery.

Discussion The findings illuminate the significant role that the SMI may have in students’ academic and social experience when they attend universities. In each of the subscales, the difficulties that ranked the highest were in areas that could be attributed at least partially to the impact of the SMI (e.g., difficulties of completing assignments during mental health relapse, difficulties in social interactions and dilemmas about whether or not to reveal the mental health difficulties). These findings are in line with findings of other studies about the dual challenges that students with SMI face: meeting the academic requirements and managing academic tasks, while coping with the implications of the SMI (e.g., Corrigan et al. 2008; Mowbray et al. 2001).

Table 5  Correlations between the DSEIN subscales and the RAS subscales Measures/subscales

Learning Skills and Management of Academic Tasks

Barriers to Academic Inclusion

Social Inclusion Difficulties

Accessibility Barriers

RAS, Personal Confidence and Hope RAS, Willingness to Ask for Help RAS, Goal and Success Orientation RAS, Reliance on Others RAS, No Domination by Symptoms

−0.245* −0.188 −0.234* 0.084 −0.351**

−0.258* −0.020 −0.162 −0.173 −0.147

−0.400*** −0.212 −0.440*** −0.428*** −0.390**

−0.017 −0.037 −0.077 −0.101 −0.030

RAS Recovery Assessment Scale *p < .05 **p < .01 ***p < .001

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The difficulties related to social and academic inclusion as well as Accessibility Barriers show that students with SMI face difficulties that may not be limited solely to academic functioning, the natural focus of attention within universities. Thus considering perspectives that include contextual factors in the university environment, such as the social model of disability, could be useful to understanding the students’ difficulties. According to this model, the difficulties that students with SMI may experience in universities are not an inevitable result of their impairment, but may stem from the social and environmental barriers (Doughty and Allan 2008; Jordell 2010; Kiuhara and Huefner 2008; Becker et al. 2002). For example, the dilemma about whether or not to reveal the SMI could be related to a culture within the university that does not encourage openness, and their difficulty to find their way around in the university could be a result of a physical environment that is not accessible for students with disabilities.

university that, in addition to their focus on helping students with SMI with the difficulties they may experience, will focus on recovery promoting processes (e.g., helping students improve their level of hope). It could also be done by collaboration between the helping systems within the university and mental health systems in the community (e.g., helping students improve their medication management). While this study focused on self-reported barriers, this method of research may have limitations because the participants may not disclose their difficulties openly. To overcome such difficulties, future studies should examine, in addition to students’ views, the views of persons who may be familiar with their difficulties, for example, the staff of the supported education programs or the academic staff. A longitudinal study could examine whether and in what ways students’ perceived difficulties may change as a result of receiving support, and which services have been most effective.

Practice Implications

Acknowledgments  This research was supported by the National Insurance Institute of Israel: The Research Fund. The authors would like to thank the staff of the supported education programs in Israel for their support and help with this research.

Because of the centrality of the difficulties that students with SMI may experience as they cope with the challenges of the effects of the mental illness while meeting the academic requirements, support systems should be developed and made available to them within the university context. This could be done through support and advice being offered by specialized services, such as supported education programs, as well as through the development of other support systems within universities that would be available to them when needed (e.g., developing support networks aimed at helping students with SMI obtain the material they missed in periods of psychiatric hospitalization). Since the difficulties ranked high by the students were not only meeting the academic challenges, but also social, the helping services should extend their efforts and provide students means helping them to overcome social inclusion related difficulties. For example, the students can be offered opportunities to participate in support groups where they can discuss socially related difficulties and acquire social skills about how to overcome such difficulties. By adopting a social disability model, the efforts to help students overcome social inclusion related difficulties could be expanded beyond direct work with students. The focus could be on systemic change, such as changing the culture in the university towards students with SMI by making an effort to reduce the stigma towards persons with mental illness. The efforts to help these students should also include a nonlinear perspective. This perspective considers that helping students with SMI overcome difficulties they may experience during their studies in the university could be related to improvement in their perceived level of recovery. This could be done, if possible, via helping systems within the

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