Key Issues in Transition to Education and Employment for Students with Psychiatric or Emotional/ Behavioral Disabilities
"I'm Old Enough to Remember When Transition from School to Work Was Called Graduation"
Joe Marrone, Program Manager
Institute for Community Inclusion

Introduction and Review of the Literature

This paper and attendant workshop will focus on how the key system and clinical issues impact on transition services for students with psychiatric or emotional/ behavioral disabilities. Issues around successful transition to post secondary and employment situations transcend disability issues and center primarily on developmental and social issues endemic to the human experience. An excellent summary of these issues is contained in Borgen & Amundson (1995, 1998) who found in a longitudinal study that young people left high school unprepared for career realities and that many areas of their lives were in a state of change and uncertainty. At the end of their final year of high school, young people in the study expressed optimism about entering the career area of their choice, and they expected to be successful workers in challenging jobs, which offered personal satisfaction. About half the respondents indicated some concern about meeting post-secondary entrance standards. Within 18 months following graduation, depression, self-esteem, and anxiety were correlated with a range of perceived problems, including money, lack of support from family and friends, internal attribution of general transition problems, external attribution of career/employment difficulties, and lack of job satisfaction. Some of the young people were interviewed and asked about factors impacting post-high-school transition. Positive factors included supportive family and friends, making money, satisfying leisure activities, personal achievements, and educational success. Negative factors included relationship problems, career confusion, financial difficulties, unemployment, lack of satisfying work, lack of post-secondary educational opportunities, and difficulty in adjusting to post-secondary educational demands. 
These authors also postulated several strategies that would seem familiar to and resonate with advocates within the disability and rehabilitation communities. Counseling interventions recommended included assistance in areas such as developing multiple plans, self-advocacy, meeting basic needs, coping with stress, bridging programs, information and information access, meeting basic needs, and managing changing relationships. Many of these same concepts have been noted in the literature on transition issues for students with disabilities (Benz, 1997; Gallivan-Fenlon, 1994; Halpern, 1994; Morningstar, Turnbull, & Turnbull, 1994; Wehmeyer & Schwartz, 1995), including those dealing with emotional/ behavioral issues (Bullis & Cheney, 1999; Frank, Sitlington, & Carson; 1995; Hagner, Cheney, & Malloy, 1999; Malloy, Cheney, & Cornier, 1998). 
Jolivette et al. (2000) note that students with emotional and behavioral disorders experience the least favorable outcomes of any group of individuals with disabilities including: 

1. Poor educational outcomes, including high rate of drop out;
2. Plethora of employment related problems vis a vis students with other disabilities as well as students without disabilities. They include data from two longitudinal studies of this group (Wagner et al., 1992; Malmgren et al., 1998) showing longer delays in obtaining employment after graduation, lower employment after leaving school, and lower employment rates overall. Many may hold multiple, short-term jobs rather than a single job. Also, such individuals are more likely to be employed part-time rather than full-time and to earn less than individuals with or without other disabilities; 
3. Individuals in this group have more problems in social adjustment than other groups of individuals with disabilities. 

Recommended interventions from this study focus on: social skills training, peer mediation and conflict resolution, positive behavioral support, vocational training, transition planning, and wrap-around planning as remedies for these outcome deficiencies. 
Specific to post secondary needs, Hagner et al. (1996) have argued that future advances in employment assistance must focus heavily on the issue of career development for individuals with disabilities, because "entry level positions will not result in greater economic independence or... self-esteem for many individuals (p. 333)." They cite the need for comprehensive career planning, partially predicated on the clear link between postsecondary education and lifetime earnings. Supported Education as a preferred alternative for people with psychiatric disabilities has gained increasing prominence over the last decade (Moxley, Mowbray, & Brown, 1993; Unger, Danley, & Kohn, 1987) with data also generated that indicates many similar ingredients for educational success as for nondisabled populations, especially social support (Collins, Mowbray, & Bybee, 2000). With all this work as background, several key questions will be explored briefly in this paper.

Key Questions

1. Is post secondary education an outcome in itself or just a vehicle to lead to better employment results? There is a plethora of debate in the psychiatric rehabilitation field about this issue. On the one hand, greater educational attainment is associated with better jobs and more income. Similarly, in 21st century US society, the labor market need and social expectations around the acquisition of post secondary (academic or technical) credentials are immense. The US DOL comprehensive report entitled: "futurework - Trends and Challenges for Work in the 21st Century" (1999) amply demonstrates this latter point. However, as the political debate that led up to the seismic shift in US welfare policy in the 1990s highlighted, the path from education to employment does not rise unimpeded, especially for people needing added support, whether due to socioeconomic, intellectual, or disability related reasons. There are many anecdotal observations of people with psychiatric disabilities using greater access to education to attain employment goals; there are concomitantly, numerous anecdotal observations by both consumers and staff of people's using post secondary opportunities as a "delaying" tactic to deal with ambivalence or fear about working. Also, as the clamor rises for public systems (including mental health systems of care) to increase accountability for helping people gain greater economic independence through employment and lessened use of public assistance resources, the question occurs as to whether post secondary attainment is a legitimate metaphor for such success or whether it merely is a process measure signifying potential for, but not necessarily achievement of occupational success. 

2. What are the similarities and differences in transition services and programs for youth with psychiatric disabilities as compared to other youth with disabilities? As noted above in the brief review of the literature, many commonalities exist among youth whether with or without disabilities. The need for systems to offer services designed around person centered, strengths based planning, focus on social supports, develop work based learning strategies and "in vivo" assessments, develop "wraparound services" and interagency seamless linkages, and engage families intimately in the process all transcend disability labels. Some factors that may require some special attention vis a vis psychiatric/ emotional/behavioral disability include:

- Many times families of youth with psychiatric or behavioral problems are considered "part of the problem" by helpers whereas, especially in the last two decades, parents of youth with developmental disabilities are considered part of the team that must be engaged.
- Young people in school are more likely to be assisted in specialized transition services through an IEP while manifesting behavioral problems whereas youth with other forms of mental health issues, such as depression or early stages of schizophrenia, are less likely to be identified and assisted. Also, IDEA has some differing regulatory requirements, especially in regard to disciplinary issues for students whose specialized educational needs relate to emotional/behavioral problems.
- There is a significant gap in philosophical orientation, funding, and service delivery strategies between adult and youth mental health systems of care. Communication is often problematic even when these two systems coexist within one agency. "Youth" Mental Health (MH) services usually terminate at age 18, while IEP type services can be delivered up to age 22 (and in some states longer). Very often, youth identified as having emotional/ behavioral problems do not "graduate" into the adult MH system, as many students with DD do, but rather unfortunately gravitate more towards substance abuse and/ or criminal justice problems and associated systems. Finally, many youth MH systems of care are not conversant with issues specific to transition from school to work or post secondary options.
- Youth with emotional/behavioral difficulties have a somewhat greater tendency to have their disability related deficits interfere with educational and job stability than youth with other disabilities. Though it is important to keep in mind that this sort of "irresponsible" behavior is often a characteristic of youth development itself.
- Mental illness labels carry stigma and fear issues in society that often result in covert or overt discrimination in relation to job acquisition and retention. So youth with this appellation often experience this problem in addition to those intrinsic to the disabling condition itself. Coupled with this is the "double trouble" of mental illness associated with substance abuse and/ or violence, to both of which youth are more prone. 
- Youth with emotional/behavioral problems often have associated learning or cognitive processing deficits that get masked because of the dramatic nature of their behaviors.

3. What are the differing needs of students in post secondary settings who begin to experience mental health problems versus students with pre existing mental health problems who seek to access post secondary education? Many of these needs are similar and relate to developmental stages and problems with this life transition that all young people face as they adjust to post secondary environments. Some specialized problems that students with pre existing problems face stem from the issues identified in the similarities and differences between students with and without disabilities section above. Another distinguishing issue is that since the late teen years are the most common times for the onset of symptoms of serious mental illness, students may have to deal with very serious mental health problems that they and their families are "blindsided" by at a time of other stressful, though normative, transitions. Systemically, many post secondary, especially academic (two and four year), counseling settings are better equipped to assist students with more typical adolescent or young adult adjustment problems, than impairments attendant to serious mental illness. Furthermore, it is often difficult for staff in these centers to get assistance from public mental health systems that have expertise in the illness management components of serious mental illness but either lack knowledge/skill in rehabilitation elements and/or are not available as an ally to the counseling center because of lack of interest, lack of resources, and/or eligibility restrictions of clients they can serve. Students with pre existing serious mental health problems already being aided through mental health systems may not be dealing with an entity that values or supports rehabilitation and recovery oriented activities such as post secondary education through interventions such as community case management, recovery oriented treatment planning, use of community and peer supports, and utilization of "supported education" concepts, described in more detail in a separate section below. 

4. How do "cutting edge" concepts such as person centered planning, empowerment, individualized funding, and service brokerage relate to this group of students? Person - centered planning cannot be viewed as a mechanistic strategy that serves as a total response to the plethora of life problems that people with disabilities face. It is obvious that adaptations to the methodology must be made to account for factors such as:

- Adolescents and young adults living at home might be more amenable to involving family than older people.
- Youth should be assumed to need more information in order to exercise effective choice because of their smaller range and length of life experiences. There is also greater responsibility on both parents and school systems to provide a more secure safety net for youth than would be necessary for adults.
- Adolescents might be more secretive about employment problems vis a vis involving peers than older people who may be comfortable with what is seen as "networking".
- People with non-apparent disabilities like mental illness might be reluctant to expose themselves to disclosure by an open, group problem-solving proceeding.

Another empowerment and person centered methodology is support brokerages, which in conjunction with individualized funding policies in various guises have been incorporated in a wide variety of places in the US and Canada over the last 10 years. This has been due to a variety of contributory factors with each instance influenced in varying degrees by one of more of the following: court decrees (especially based on the Olmstead decision reasoning but also predating that case), family advocacy, formal group advocacy, foundation system funded change projects (e.g., the RWJ demonstration), and philosophical shifts within federal and state governmental structures (to some extent fueled by a politically conservative view of government as a problem not a solution as well as some assumptions about cost savings to be made by this more informal community structures these efforts have often spawned). The approaches most philosophically consistent with the social policy roots described above combine independent support brokers or service brokerages with some sort of individualized funding stream, controlled by the individual and/ or their families. Some of the specific state and local interventions have separated the control of funding (leaving this decision within the public contracting process) from the concept of independent brokers or service coordinators hired by the person with a disability or his/ her families, but it seems that it is technically possible but intellectually difficult for brokering to exist without funding control.  
While the above concepts are not disability specific per se, the energy and systemic momentum has come from advocates within the developmental disabilities field much more so than from other settings and have been much slower in being applied to individuals labeled as having psychiatric or emotional/behavioral problems.  This is due to factors like societal stigma, concerns about impaired judgement resulting in creation of representative payeeships for many, safety and liability issues, and last but not least, people with psychiatric disabilities are not as politically powerful a group as the more traditional "middle class" parent advocacy within development disabilities systems. Additionally, family controlled groups influential in the mental health field such as NAMI have not focused on the person's ability to control or direct their services through funding or person centered planning as much as they have addressed issues around patient safety, medication breakthroughs, and scientifically based mental health interventions (often lumped together under the rubric of "evidence based practices").

5. What is Supported Education for youth with psychiatric disabilities? Supported education is a relatively recent rehabilitative intervention for people with psychiatric disabilities. It is designed to help them succeed in postsecondary educational environments. Program principles are congruent with those of general psychosocial rehabilitation and include integrating participants into normalizing environments; providing access to leisure, recreational, and cultural resources available on college campuses; and establishing educational competencies, such as study skills, attendance, and time and stress management. They also include giving participants opportunities to identify and explore vocational interests; supporting them in mastering the educational environment, such as troubleshooting stress situations and connecting them to support networks; and ensuring peer support from other consumers in supported education or another psychosocial rehabilitation alternative (Moxley, Mowbray, & Brown, 1993; Collins, Mowbray, & Bybee, 2000). Published reports of evaluations of supported education have found increases in college enrollments, preparatory steps to postsecondary education, and competitive employment; increases in self-esteem, empowerment, quality of life; and a high level of consumer satisfaction with supported education programs (Collins, Mowbray, & Bybee, 1998; Cook & Solomon, 1993; Hoffman & Mastrianni, 1993; Mowbray, Collins, & Bybee, 1999).
 	The types of accommodation that are needed in post-secondary settings obviously depend on the needs of individuals more than disability label. But elements that occur consistently in many different venues where Supported Education is practiced include changes in instructional strategies such as more individual tutoring, varied emphasis on auditory versus visual information processing, increased time for assignments, use of technology such as recording devices or computer enhanced notetaking, alternate testing methods and more generalized emphasis on universal instructional design as well as structural/ institutional accommodations such as personal support staff assigned to individual students or peer support groups on or off campus. An excellent comprehensive summary of such typical modes of assistance is available in Souma, Rickerson, & Burgstahler (1999), Academic Accommodations for Students with Psychiatric Disabilities. 
There are several strains of discussion and inquiry within the Supported Education field related to its impact on both the institution and the student. These include:

- One of the major debates within both academic and vocational training in post secondary settings is the contention about how much accommodation is too much (i.e., how far can and should traditional structures be altered and still retain educational integrity). 
- Similarly, if a student requires "extraordinary" levels of pedagogical adaptation or emotional support to succeed in the post secondary setting, then is that diluting the value of the post-secondary educational attainment or in the case of faculty resistance, impinge on academic freedoms or tenure issues?
- Post secondary settings operate under the mandates of the ADA and Section 504 of the Rehabilitation Act of 1973 regarding the need for consideration for "reasonable accommodation" for students with disabilities.  In a parallel dimension, publicly funded entities such as the state-federal VR system and rehabilitation components of the public mental health system exist to assist eligible clients of those systems succeed in various environments, sometimes including the provision of Supported Education in post - secondary schools. Therefore, whose responsibility is it to identify and finance the accommodations necessary?
- Where accommodations are needed, how much information or disability documentation must a student disclose in order for the school to implement its accommodation policy? This disclosure dilemma is fraught with concern especially in regard to transition age students with emotional/behavioral or psychiatric disabilities that predated or manifested themselves outside the specific post-secondary educational setting where the accommodation is sought. On the one hand the school does not wish to inappropriately modify curricula or take on an expense they can ill afford if there is no need. Conversely, despite the assurances and legal mandates for confidentiality of this proffered information, students, family members, and advocates are quite concerned about the very real discriminatory and stigmatization dangers attendant to divulging mental health diagnostic information. 
- A section of the Lansing Community College Handbook for the Disability Student Services tellingly identifies various concerns. It states: "One barrier to serving students with psychiatric disabilities is the stigma surrounding mental illness. It is an illness that can stir deep and unconscious fears in many of us. A second barrier to serving students with psychiatric disabilities may be a perceived lack of knowledge about where or how to serve these students when they return to college. The student may be viewed as disruptive and some students... may not be able to judge when or where to draw the line on pushing for special accommodations. A third attitudinal barrier is that some postsecondary administrators may believe that if the institution gains a reputation for effectively serving students with psychiatric disabilities on campus, they will be overrun with students with a history of mental illness or become a 'dumping ground' for resource-poor mental health agencies" (Lansing Community College, 2001).
- Where accommodations and/or supports are provided in the form of some level of personal support (e.g., tutors, notetakers, on campus personal assistants), then a variety of opinions exist on whether the student is best served and included by external resources (thus maintaining his/ her confidentiality among student peers) or by the traditional use of peers in these support roles as for other students with special needs (thus increasing student-student social interaction and "normalcy").

There is still major system improvement needed for both on campus support for students experiencing mental health problems initially while in post secondary programs and on/off campus interventions for students with pre-existing psychiatric disabilities using "best practice" models. Examples of these stellar programs can be found in both community college and university settings around the country including innovative interventions in places such as University of Michigan, University of Minnesota, University of Massachusetts, South Seattle (WA) CC, Spokane (WA) CC, and Quinsigamond (MA) CC. Strategies used in these programs utilize a range of approaches, including specialized classes for students with psychiatric disabilities that can be credit or non credit accruing, specific accommodations of the type mentioned earlier, on- and off campus psychiatric support, mental health specialist coaches, peer support groups, services run from one or more of the following: Office of Disability Student Services, college counseling setting, mental health center, or community rehabilitation program.

6. What are effective service strategies that lead to career track employment? There have been increasing concerns over the last decade about the ability of employment service providers to assist students with psychiatric or emotional/ disabilities to enter age appropriate career tracks, which in many cases are inexorably linked with skills or certification only obtainable through post-secondary training.  Useful ways of ensuring that students transitioning from school to career are encouraged and enabled to pursue goals that lead to successful and fulfilling careers and jobs, rather than merely better vocational programming, mirror the best practice techniques of person centered planning. Person-centered planning is not for all people, for all occasions, to be used in all contexts, nor does it work in solving all problems. But it is an effective way to address many problems of focus and direction that plague students with disabilities. It also provides positive direction for helpers to assist people to achieve personally fulfilling lives and careers. The format and direction of each person's planning can be quite flexible, meeting a wide panoply of individual needs, while maintaining adherence to core principles:

a) The process should not just be person - centered but person-driven.
b) The process needs to involve people who are passionate about helping the person.
c) This type of planning is a way of transforming the power relationship between a dominant helper and a person with a disability who is usually in a subservient role.
d) Person - centered planning involves action as well as planning.
e) Person - centered planning is based on positiveness, dreams, and aspirations not deficits, barriers, and problems.
f) The most important thing to be facilitated is the process not meetings themselves.
g) Getting multiple perspectives as a way of generating creative brainstorming forms the base of the process. (Marrone, Hoff, & Helm, 1997).

7. What are effective partnerships with community systems to support transition to post secondary opportunities for youth with psychiatric disabilities?  Partnerships with various systems to assist students are similar to any other potent team efforts, which can be defined by these critical characteristics: common purpose (based on a culture of client benefit, not just getting along), group and individual expertise, resources (time, energy, ideas, related staff, money, etc.) brought "to the table", measurable goals to judge success, clear roles and expectations for team members and their organizations, climate of trust developed and maintained, and conflicts not avoided but directly addressed.
Mental health systems can play a role, especially those that provide Supported Education services, whether through a guiding philosophy of community service coordination or direct educational support. Generally, the adult service piece of mental health systems has more expertise and interest in transition assistance than those involved in childrens' services. Thus schools serving youth with psychiatric/ behavioral disabilities will most likely need to expand their established relationships within the mental health provider community to include adult service providers. 
 Public Vocational Rehabilitation (VR) is not an educational funding vehicle per se and thus its staff often recoil at being perceived that way. But, as long as post secondary education is described as part of a longer-term vocational achievement plan then VR can provide valuable career counseling as well as money to support this plan. While VR staff are supposed to be active in transition planning for youth as young as 14 under IDEA mandates, the reality is that it is difficult to engage VR staff meaningfully at this early age where employment and even post secondary outcomes remain far in the future. School personnel must both understand this fact and develop ways to keep linkages in place so that services for post secondary support can be brought to bear on behalf of the student in partnership with VR at the appropriate time.
The One-Stop system created under the Workforce Investment Act (WIA) of 1998 can provide information and assist young people in identifying appropriate training and education opportunities available. WIA regulations require these systems to play a significant role in the delivery of services to youth, including youth with disabilities. In some ways, this partnership creates an ideal match in that a major emphasis during transition is identification of resources in the community, and collaboration among various organizations such as funders of adult services, educational providers, families and the school, to help the student develop and pursue his or her goals.  A major role of One-Stop systems is serving as a mechanism for access to information and resources for individual's employment and training needs (ICI, 2000).  Given these complementary objectives, the One-Stop system can be of great assistance in assisting students to achieve their educational goals, including the possibility of training funds for post secondary opportunities. While the availability of and procedures for accessing these funds vary from locality to locality they still should be a resource to be explored.

Conclusion
 
Attention to all the issues cited in the preceding pages will not eliminate the barriers that students with psychiatric disabilities face in achieving educational and employment success through the provision of post secondary opportunities. Many of the problems appear intractable or insoluble due to social issues, continuing lack of service resources, lack of knowledge and skill in staff, and the impediments caused by mental illness itself. Nonetheless, advocates, family members, service providers, and people with psychiatric disabilities themselves have a responsibility to make an impact and create change, however incremental, in various systems and programs.  Consequently, these combined efforts should open more doors to the full benefits of post secondary options and ultimately full participation and citizenship for students with emotional/ behavioral problems seeking to advance themselves through education. 

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