September 2004 • Vol. 3, Issue 1
By Michael N. Sharpe, Brett D. Bruininks, Barbara A. Blacklock, Betty Benson, and Donna M. Johnson
Issue: An unprecedented and growing number of postsecondary students report psychiatric disabilities. How can postsecondary personnel support the success of these students?
A significant development in the field of postsecondary disability supports in the last decade has been the proliferation of individuals with psychiatric disabilities. This phenomenon has emerged at a pace that one observer characterized as a “rising tide” (Eudaly, 2002). Measel (1998) found that within one year, five institutions in the Big Ten Conference encountered an increase from 30% to 100% in the number of students served with psychiatric disabilities. At one institution, the University of Minnesota, the number of students reporting a psychiatric disability as their primary disability (285) was more than the combination of students reporting learning disabilities and attention deficit disorders (269). Although there is little systematically collected data to provide a reliable estimate of the emergence of psychiatric disabilities in postsecondary education, information from current sources provides evidence that this issue is likely to come into sharper focus as data from more studies become available.
Despite recent recognition in the postsecondary setting, the growth in the number of individuals declaring a psychiatric disability is consistent with national statistics. Each year about one in five Americans experience a diagnosable psychiatric disability, which includes major depressive disorders, schizophrenia, eating disorders, and anxiety disorders (National Institute of Mental Health, 2002). Some psychiatric disabilities remain dormant, manifested only at critical stages of human psychosocial development or by physiological events.
Unger (1992) noted that the onset of major mental illness often occurs between ages 18-25—a time when many young adults are seeking postsecondary education, preparing for future careers, and developing social relationships.
Perhaps the most influential factor resulting in more individuals declaring a psychiatric disorder in the postsecondary setting is how such disabilities are identified and treated. Today diagnostic criteria have expanded so that the term “psychiatric disability” represents a much broader range of disorders and syndromes than before. While once attention was largely focused on the diagnosis and treatment for the “major” psychopathologies (e.g., schizophrenia), the field has broadened to encompass disorders generally requiring less intensive treatment interventions. For example, there is a dramatic increase in the identification and treatment of a number of anxiety disorders within the last decade, particularly those related to social anxiety, post-traumatic stress, and various types of phobic disorders (Swinson, 1997). As diagnostic criteria continue to improve in identifying other types of mental health disorders, it is likely the population of students with psychiatric disabilities in postsecondary education settings will continue to grow.
Some early efforts to address the needs of individuals with psychiatric disabilities within the postsecondary setting occurred as a result of the emergence of supported-education programs. Based on the definition of “supported employment” in the Rehabilitation Act Amendments of 1986, supported-education programs began in the 1980s as a way of providing supports to individuals with psychiatric disabilities in the postsecondary setting (Unger, 1998).
According to Unger (1998), supported-education programs involve three prototypes: (a) a self-contained setting, where students are reintegrated into the postsecondary setting; (b) on-site support, where ongoing support is provided by the institution’s disabilities support staff or a mental health professional; and (c) mobile support, where support is largely provided by community mental health service providers. It is estimated that about 30 supported-education programs currently exist in the United States to serve individuals with psychiatric disabilities in postsecondary programs.
While supported education is a model for serving the needs of students with psychiatric disabilities, the more typical case is that they are served by disability support services (DSS) staff at the postsecondary level, or by community agencies not necessarily affiliated with DSS or the postsecondary institution.
Many DSS staff have traditionally received training in a disability area related to learning and instruction (e.g., learning disabilities) and do not feel adequately trained to address the needs of individuals with psychiatric disabilities. Indeed, some DSS staff report that they are often challenged in meeting the needs of students with psychiatric disabilities. They indicate efforts to provide accommodations are not as clear as in other disability areas (Sharpe & Bruininks, 2003) or that working with students with psychiatric disabilities might require addressing multiple, complex problems such as social isolation, withdrawal, and academic failure (Blacklock, Benson, & Johnson, 2003). In addition, many DSS providers are not fully informed about services available in the community. The resulting lack of collaboration prevents some students from accessing needed services (Whelley, Hart, & Zaft, 2004). Clearly, serving students with psychiatric disabilities in the postsecondary setting represents new challenges to many DSS providers.
While there is only limited research on this issue to guide practice, information has recently become available that helps identify some barriers faced by students with psychiatric disabilities and service providers alike (Blacklock, Benson, & Johnson, 2003). Based on the results of 39 focus groups conducted with postsecondary DSS staff, faculty, administrators, and students with psychiatric disabilities, Blacklock et al. (2003) identified five primary barriers that impact the educational experiences of students and service-delivery issues for providers. These include:
Stereotypes and Stigma—All of the focus groups stated that students with psychiatric disabilities often face incorrect, stereotyped views about their disability and endure the stigma and negative consequences that frequently accompanies disclosure of such a disability.
Complex Nature of Psychiatric Disabilities—Students feel challenged to simultaneously manage their disability and maintain academic performance that reflects their abilities. Service providers and faculty share students’ concern about this complex issue.
Access to Resources—All focus groups indicated that students with psychiatric disabilities face additional barriers because of their need to seek out services within bureaucracies (educational or governmental) that are unclear and uncoordinated. These extra efforts are necessary to maintain their health insurance, student status, and access to mental health and disability services.
Access to Information and Services—Many students in the focus groups expressed frustration with the lack of information about psychiatric disabilities and limited access to services that would allow them to effectively manage their disability.
Organizational and Institutional—Focus group participants identified a lack of coordination and communication between service providers on and off campus as additional barriers students with psychiatric disabilities face at the postsecondary level.
The identification of these barriers appears to be consistent with other observations (Collins, 2001; Eudaly, 2002; Loewen, 1993; Angle, 1999; Unger, 1992). To address these barriers, Blacklock, Benson, and Johnson (2003) advocate four strategies: (a) implementing universal instructional design strategies to improve the learning experiences for all students, including those with psychiatric disabilities, (b) creating sub-communities to foster social connections for students with psychiatric disabilities, (c) improving clarity, coordination, and communication with all key stakeholders, including inter-organizational and community-based service providers, and (d) promoting access to resources for all key stakeholders through information sharing and training efforts.
A common theme in the literature relating to the support of students with psychiatric disabilities is how such services should be configured at the postsecondary level. This issue not only involves the “mission” or “values” of the program (Unger, 1998), but also the need to articulate the parameters in which students will be served. Efforts to outline overall program mission and values will establish a scope of services relative to the institutional and community resources available. This activity can also be helpful in clearly defining how support services will be accessed and maintained by students with psychiatric disabilities. Through a series of interviews conducted with DSS staff in Big Ten universities and colleges, Sharpe and Bruininks (2003) identified several basic requirements common to these institutions:
Documentation—Students with psychiatric disabilities must provide current documentation by a qualified medical or mental health professional to qualify for DSS services.
Diagnostic Criteria—Generally, a diagnosis must reflect criteria established by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) or the International Classification of Diseases Manual, Tenth Edition (ICD-10). Moreover, the diagnosis must meet disability criteria established by the Americans with Disabilities Act (ADA).
Accommodations—Although clinical input regarding functional limitations and instructional accommodations are considered, DSS staff generally make the final determination regarding what specific accommodations will be provided.
Accountability—In nearly all cases, the declaration of a psychiatric disability does not exempt one from a code of conduct and similar policies established by the institution.
The processes used to notify postsecondary instructional staff about the need for accommodations are not always consistent. In some cases, the student is obligated to discuss the need for accommodations directly with the instructor. In others, a letter or memo was sent to the instructor by DSS staff regarding accommodation needs for a student (Sharpe & Bruininks, 2003).
While this provides a basic overview of current research and practice in serving students with psychiatric disabilities within postsecondary settings, much more work needs to be done. At this point, only a small glimpse has been captured about this growing population of students. Much needs to be learned about the overall nature of students with psychiatric disabilities entering postsecondary education settings. Currently little accurate information exists regarding the overall prevalence and variability of students with psychiatric disabilities. For example, little is known about how many students exhibit severe and persistent mental illness in relation to those whose illness is considered “mild.” This evidence would do much to illuminate the extent to which the students with psychiatric disabilities need psychological treatment concurrent with their educational experience.
Despite little empirical evidence regarding strategies leading to increased positive academic, social, and employment outcomes for students with psychiatric disabilities, a range of instructional accommodations has been collected and disseminated through various studies, professional networks, and training activities. The accommodations shown in Table 1 are most common and can be implemented with cost-efficiency and relative ease.
The accommodations are universal in the sense that they are equally applicable to most types of disabilities. This is good news for students with psychiatric disabilities in the postsecondary setting—accommodations differ little from those typically provided to all students with disabilities (Sharpe, Johnson, & Murray, 2003). What remains unknown, of course, is how effective these types of accommodations are for students with psychiatric disabilities.
Table 1. Accommodations for Students with Psychiatric Disabilities
Muckenhoupt (2000) has suggested that the impact of untreated psychiatric disabilities is “staggering.” Only recently has this population been recognized within the postsecondary setting, presenting a challenge to service systems and providers alike. While research on best practice in this area is clearly lacking, efforts continue on behalf of many disability support service providers to develop and implement models of service to meet this challenge. To support these efforts, a “rising tide” of research, information sharing, and training will also be necessary to match the growth that in all likelihood will continue.
Michael Sharpe, Brett Bruininks, and Donna Johnson are with the Institute on Community Integration at the University of Minnesota; Barbara Blacklock and Betty Benson are with Disability Services at the University of Minnesota.
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