Psychiatric Disabilities in Postsecondary Education:
Universal Design, Accommodations and Supported Education
Nancy Rickerson, M.Ed., OTR/L
University of Washington
Alfred Souma, MA
Seattle Central Community College
Sheryl Burgstahler, Ph.D.
University of Washington

Abstract

This article provides a call for increased awareness and academic support for students with psychiatric disabilities in postsecondary education. The limited literature in this area is reviewed. The authors correct misunderstandings about these types of disabilities and provide information to increase faculty, administrator, and staff awareness regarding the rights and needs of postsecondary students with psychiatric disabilities. Three areas of focus are highlighted: typical academic accommodations, application of principles of universal design of instruction; and supported education through advising, counseling, and postsecondary preparation courses. Further research is encouraged. 

Psychiatric Disabilities in Postsecondary Education:
Accommodations, Universal Design, and Supported Education

A student with a psychiatric disability in postsecondary education may be one of the most misunderstood and under-served students in college (Weiner & Wiener, 1995).  A psychiatric disability is a clinically diagnosed behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress (American Psychiatric Association (1994). It is used when mental illness significantly interferes with the performance of major life activities, such as learning, thinking, communicating, working, sleeping, among others (Zuckerman, D., Debenham, K. & Moore, K., 1993). A psychiatric disability is a "hidden" or "invisible" disability, meaning that it is not obvious to the observer, unlike many physical or sensory disabilities. In addition, it is not obvious that an accommodation is needed. Because of these two factors, others may criticize the student with a psychiatric disability as not having a "legitimate" disability, may suspect that the student is taking unfair advantage of the campus disability support services system, and be reluctant to provide accommodations (Burgstahler, 2003; Burgstahler, Duclos, Turcotte, 1999; Dona & Edmister, 2001; Leyser, 1989; Vogel & Adelman, 1993).  Similar concerns have been voiced by students with learning disabilities and other medical conditions that are not obvious (Burgstahler & Doe, 2003). Ultimately, negative attitudes toward students with disabilities can impact the ability to learn (Upton & Harper, 2002).
The type of disability a person has can lead to stereotyped perceptions that are both inaccurate and discounting of the person as an individual (Yuker, 1994). This is particularly true for the student with a psychiatric disability since mental illness continues to be a stigma in our society. Many faculty members report limited knowledge about the rights and needs of students with invisible disabilities, including students with psychiatric disabilities (Burgstahler, 2003; Cafferella & Zinn, 1999; Filo, 2002; Vogel & Adelman, 1993). The combination of misinformation and societal stigma regarding symptoms and behaviors in students with psychiatric disabilities can contribute to fear and misunderstanding, and may result in a student being labeled lazy or uncooperative (Dona & Edmister, 2001; Leyser, 1989; Leyser, Vogel, Wyland & Brulle, 1998; Wagner, 1995). Few research studies reported in the literature identify success factors for students with psychiatric disabilities, and therefore, no clear relationship between psychiatric diagnoses, accommodations provided, and academic outcomes in postsecondary education has been established (Brackney & Karabenick, 1995; McLean, & Andrews, 1998). This situation is further complicated by the existence of many types of psychiatric diagnoses, each with a wide spectrum of severity of symptoms. The purpose of this article is three-fold: to raise the awareness of faculty, academic administrators and staff regarding the rights and needs of students with psychiatric disabilities; to summarize typical academic accommodations for students with psychiatric disabilities, and to identify other supports that can contribute to the academic success of postsecondary students with psychiatric disabilities.
Psychiatric disorders are prevalent and rates of diagnosis are rising in our society. The National Institute of Mental Health estimates that one in five people will experience mental illness in their lifetime (Zuckerman, et al., 1993). It is impossible to determine the exact percentage of students with psychiatric disabilities enrolled in postsecondary education due to the reliance on self-reporting and the lack of reporting standards. In addition, numbers of students with psychiatric disabilities are often figured into the broader categories of "health impairments," combined with "learning disabilities," or "other disabilities." Best estimates indicate that of all postsecondary students reporting disabilities, 15-21% report having a psychiatric disability (Henderson, 2001; Horn, Berktold, & Bobbitt, 1999; Lewis, Farris, & Greene, 1999). While these statistics indicate that students with psychiatric disabilities represent a small percentage of all students reporting disabilities, increasing numbers of students with psychiatric disorders are attending college (Matusow-Ayres, 2002; Weiner & Wiener, 1996). This increase is due at least in part to 1) Deinstitutionalization and community involvement of people with psychiatric disabilities (Weiner & Wiener, 1996); 2) Improvements in psychiatric medications that result in symptoms mild enough to allow people with psychiatric disabilities to enjoy the benefits and meet the challenges of postsecondary education (Weiner & Wiener, 1996); and, 3) Legislation such as the Rehabilitation Act of 1973 and the ADA that mandate that appropriate academic adjustments be provided to students with disabilities, including those with psychiatric disabilities. 
National data indicates that 9% of adults have mood disorders (e.g., bipolar disorder, major depression), 12% have anxiety disorders (e.g., phobias, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder), and 1% have schizophrenia (U.S. Commission on Civil Rights, 1999). Students with serious emotional disorders were found to have the highest high school dropout rates of all students with disabilities (Wagner 1995). Further, one-fourth of all students with serious emotional disorders enroll in postsecondary education compared to two-thirds of the general population. This may be due in part to a lack of clarity of the support needs of the student with a psychiatric disability. 
Postsecondary institutions cannot discriminate on the basis of a student's disability. When qualified students with psychiatric disabilities enroll in postsecondary education, institutions are required by Section 504 of the Rehabilitation Act of 1973 and by the American Disabilities Act of 1990 (ADA) to provide academic adjustments. The greatest number of discriminatory cases reported to the Equal Educational Opportunity Commission (EEOC) involve individuals with psychiatric disabilities. Specifically, 15.8% of all disability cases reported in 1999 to the EEOC were psychiatric disabilities (U.S. Commission on Civil Rights, 1999). This data suggests that individuals with psychiatric disabilities are experience difficulties in securing accommodations that they consider reasonable. 

Definitions of Psychiatric Disabilities

A psychiatric disability is "a mental impairment that substantially limits one or more of the major life activities of an individual; a record of impairment; or being regarded as having such an impairment" (U. S. Commission on Civil Rights, 1999, p. 5). A "mental impairment" is a diagnosable mental disorder causing severe disturbances in thinking, feeling, relating, and functional behaviors that results in a substantially diminished capacity for coping with the ordinary demands of life (Weiner & Wiener, 1996). A student with a psychiatric disability may have one or more diagnoses within the major categories of mood disorders, anxiety disorders, thought disorders, and personality disorders. Severity of symptoms of a specific condition varies greatly. Typically, the student who qualifies for postsecondary education experiences mild symptoms. A summary of common diagnostic categories, with their associated symptoms, according to the American Psychiatric Association (1994) follow.

Mood Disorders

Depression.

Depression is a mood disorder that can begin at any age. Major depression is characterized by a persistent depressed mood for at least six months or more, a lack of pleasure in previously enjoyed activities, thoughts of suicide, sleep disturbance, and/or consistent feelings of worthlessness and/or guilt.

Bipolar Affective Disorder (previously know as Manic Depressive Disorder).

Bipolar is a mood disorder with revolving periods of mania and depression. In the manic phase, a person might experience inflated self-esteem, extreme energy output, high work and creative productivity, disorganization, and decreased need for sleep. In the depressed phase, the person experiences the symptoms of depression described above.

Anxiety Disorders

Anxiety disorders are mood disorders in which the individual responds to thoughts, situations, environments and/or people with fear and anxiety. Anxiety symptoms can disrupt a person's ability to concentrate and focus on tasks at hand. Behaviors vary according to the specific anxiety and symptoms may be in response to real or imagined fears. Specific anxiety disorders include Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Social and Specific Phobias, and Post Traumatic Stress Disorder.

Thought Disorders

Schizophrenia.

Schizophrenia is a thought disorder that can cause a person to experience difficulty with activities of daily living and may experience delusions, hallucinations and paranoia. Schizophrenic individuals typically demonstrate concrete thought preoccupation with internal thoughts. Individuals often function optimally with structure and routines. A very small percentage of students with psychiatric disabilities attending college have schizophrenia. Typically, thought disorder symptoms interfere with consistent academic performance.
Personality Disorders and ADA Exclusions.

Borderline Personality Disorder (BPD.)

Borderline Personality Disorder. BPD, is a personality disorder that includes mood, thought, and anxiety disorder symptoms. This diagnosis has both biological and environmental determinants. Individuals diagnosed with BPD may have experienced childhood abuse and family dysfunction. They may experience mood fluctuations, insecurities and mistrust, distortion of perceptions, disassociations, and difficulty with interpersonal relationships and stress management skills. Other personality disorders not recognized as disabilities under the ADA include: transvestitism, transsexualism, pedophilia, voyeurism, gender identity disorders, compulsive gambling, kleptomania, and pyromania (Blacklock, 2001).

Accommodations and Campus Practices

A diagnosis of a mental illness does not in and of itself qualify an individual for accommodations. The individual must also have a substantial limitation in at least one major life activity, resulting in functional limitations that make it difficult for the individual to participate effectively in the daily tasks involved in academic pursuits. Academic accommodations are not linked to the diagnosis, but instead assigned to compensate for functional deficits that interfere with academic performance. An accommodation is the removal of a barrier to full participation and learning, thus providing the student with equal access to the content and activities of a course. The provision of equal access does not guarantee specific grade outcomes.

Specific Accommodations for Functional Limitations

The most common academic accommodations provided on postsecondary campuses for students with psychiatric disabilities involve classroom, assignment, and exam accommodations and include:

- early provision of the syllabus and textbooks for review and preparation;
- syllabus, assignments, and lectures on disk;
- notetakers, or tape recording of sessions; 
- prearranged and regular breaks during session;
- assignments and exams in alternate formats;
- extended time and separate quiet rooms for test taking; and 
- flexibility in assignment and exam due dates if absent due to hospitalization or other medical absence.

The following specific functional limitations related to psychiatric disabilities may affect academic performance and require the accommodations noted (Center for Psychiatric Rehabilitation, 1997):

- Difficulty with medication side effects: Side effects from psychiatric medications such as drowsiness, fatigue, dry mouth and thirst, blurred vision, hand tremors, slowed response time, and difficulty initiating interpersonal contact. Accommodations may include allowing water bottles in class and offering preferred seating near the door.
- Difficulty screening out environmental stimuli: An inability to block out sounds, sights, or odors that interferes with focusing on tasks; limited ability to tolerate noise and crowds. Accommodations may include a separate quiet room for testing, a notetaker for lectures, and tape recording class lectures and discussions. It is helpful to have course material online for ease of access.
- Difficulty sustaining concentration: Restlessness, shortened attention span, distraction, and difficulty understanding or remembering verbal directions. Accommodations may include a separate quiet room for testing, a notetaker for lectures, and tape recording in class to capture content. It is also helpful to place course and lecture material online or on disks for easy access. The availability of a scanner with optical character recognition software, which allows scanned text to be read aloud by a computer with speech output capabilities, may be helpful to some students.
- Difficulty maintaining stamina: Common for students with health impairments that drain energy, many of these students may experience drowsiness due to medications, and be unable to sustain enough energy to spend full days on campus. Accommodations may include an adjusted schedule to allow for breaks during the day and flexibility in assignment due, extended time for examinations and assignments, and examination proctoring in a hospital.
- Difficulty managing anxiety and stress from time pressures, multiple tasks, and exams: Difficulty with organizing and managing assignments, prioritizing tasks, and meeting deadlines; an inability to multi-task. Accommodations may include a quiet testing room, adjusted timelines for assignments and exams, extended time on tests and assignments. Using day planners (electronic or written), taking scheduled breaks during the day, avoiding back-to-back courses, and attending school part-time may be appropriate. Students with anxiety and stress management difficulties may also benefit from taking academic preparatory courses in stress management to include organizational components and coping skills training.
- Difficulty interacting with others: Problems getting along with other students and instructors, fitting in, contributing to group work, and reading social cues. Accommodations may include limiting group work or providing other assignment modifications that do not compromise academic standards. It is also helpful to provide immediate feedback when inappropriate interactions occur.
- Fear of authority figures: Difficulty approaching instructors or teaching assistants. Accommodations may include setting up scheduled meeting times in a non-threatening environment between student and instructor for the purpose of rapport building.
- Difficulty accepting and/or responding to negative feedback: Difficulty understanding and correctly interpreting criticism or poor grades; inability to separate a person from a task; personalization or defensiveness due to low self-esteem. Accommodations may include: include regularly scheduled as well as immediate reality-based feedback provided in a calm, consistent and respectful manner.
- Difficulty responding to change: Coping with unexpected changes in coursework, assignments, due dates or instructors and limited ability to tolerate interruptions. Accommodations may include providing a syllabus online that contains clear assignment and grading rubrics and consistency in expectations and information.
- Severe test anxiety: Involves emotional and physical inability to take an exam because of anxiety. Accommodations may include extended time for testing, and proctoring exams in a quiet room. It may also be helpful to allow the student to wear headphones and listen to calming music during the test. Submission of an exam in an alternate format in which a student may show proficiency. Dramatic demonstration or artistic expression may be appropriate in some cases.
- Low self esteem: Often the result of past failures. Accommodations may include positive verbal and written feedback about performance and specific suggestions for growth. Also referral to non credit workshops that address issues of personal growth may be useful.
- Difficulty in planning: Trouble setting realistic goals taking steps to reach them. Accommodations may include providing structure and specific guidance in goal setting. Use of an organizational system, either electronic or written, may be helpful.  

Campus Policies and Practices

In postsecondary education, it is the student's responsibility to register a disability with the disability support services office, request academic adjustments, and fulfill the academic requirements of each course. The best accommodation solutions result when the instructor, student, and disability support service professional meet and work cooperatively. Routinely, disability support service staff work with the student and instructors to determine and implement academic adjustments. Academic standards and essential course requirements are not lowered but the accommodations do provide a level playing field for the student. The student is provided equal access to information and course activities. Respecting the privacy of the student and not discussing his/her disability or accommodations with others outside of this meeting is important. In addition, it is sometimes helpful when the student and instructor set up regular feedback sessions to review academic performance and the effectiveness of the accommodations provided so that adjustments may be made in a timely and effective manner. 
Not all accommodations requested by a student may be considered "reasonable" by the institution. For example an accommodation is not reasonable if:

- providing the accommodation or having the individual involved in the activity poses a direct threat to the health or safety of others.
- providing the accommodation means making a substantial change in essential elements of the curriculum.
- providing the accommodation imposes an undue financial or administrative burden to the institution. 

Meetings between instructor, the disability support service professional and the student can go a long way to facilitate problem-solving alternatives.

Universal Design

Academic adjustments are legally required to assure equal access to postsecondary education for qualified students with psychiatric disabilities. However, the number of individual accommodations required may be reduced for these and other students with disabilities when instructors employ universal design principles as they develop curriculum and deliver instruction. Typically, instructors focus on the capabilities and needs of the average student when they develop a course. Universal design requires consideration of the broad range of characteristics of potential students in order to promote the success of all students (Bowe, 2000; Burgstahler, 2000; 2001; McGuire & Scott, 2002). Characteristics include gender, country of origin, cultural background learning styles (e.g., visual, auditory, tactile, and kinesthetic learners), and abilities with respect to sight, mobility, hearing, and learning. Universal design of instruction maximizes the usability of educational materials and environments for all students by anticipating a variety of student needs. Thus, it minimizes the need for special accommodations (Burgstahler, 2000; Rose & Meyer, 2002). 
Architects, engineers, and other professionals at North Carolina State University developed universal design in architecture to create accessible environments (Center for Universal Design, 1997). Electronic doors, elevators, ramps and curb cuts were developed to assure access for people with disabilities, yet people of all abilities use them. Workers with delivery carts, parents with baby strollers, skateboarders, elderly citizens, and many others make use of barrier-free environments. There are seven universal design principles. These include equitable use, flexibility of use, simple and intuitive use, perceptible information, and tolerance for error, low physical effort, and size and space for approach and use. Similarly, when basic principles of universal design are applied to instruction, physical, sensory, and cognitive barriers to learning are minimized. Specifically, instruction is provided in ways that meet a variety of learning needs. Universal design can be applied to use of the Internet, multimedia presentations, handouts, discussions, and experiential activities. For example, Web sites should be in accessible format; handouts made available in accessible format (e.g., creating disks of handouts so that they may be adapted for accessibility by the user as needed); lab instructions written clearly along with verbal instructions; and visual information delivered in overhead projection and/or video along with spoken information (Burgstahler, 2000; McGuire & Scott, 2002; The Center for Universal Design, 1997). Applying techniques of universal design to instruction will minimize, yet not eliminate, the need to provide individual academic accommodations for students with psychiatric disabilities as well as for students with other types of disabilities.

Supported Education

Students with psychiatric disabilities often report learning difficulties in studying and learning within the educational environment (Unger, 1993). In addition to academic adjustments, students with psychiatric disabilities may benefit from assistance in adjusting to and functioning within the educational culture and environment (McLean & Andrews, 1998). Advising and counseling supports offered to all postsecondary students can be of particular benefit to students with psychiatric disabilities. In addition, the student with a psychiatric disability may at times lag behind his/her peers in social skills and therefore can benefit from structured assistance when participating in study groups, academic clubs, and other extra-curricular activities. Students with serious emotional disorders who are involved in clubs and/or sports and receive peer and coach/advisor support are far less likely to drop out of school than students with psychiatric disabilities uninvolved in these activities (Wagner, 1995). Students with psychiatric disabilities benefiting from supportive education programs are shown to have more positive academic outcomes than those without such supports (Mobray, Collins, & Bybee, 1999; Wagner, 1995). For example, the Michigan Supported Education Project found that a postsecondary program that provided academic support in the classroom-including group exercises and experiential activities, advising, social skills and stress management training, assistance with student services (registration, financial aid, organizational skill building, and resource acquisition)--resulted in positive academic outcomes for the students with psychiatric disabilities (Mobray et al. 1999).
Disabled student services personnel, faculty, and other staff should encourage the student with a psychiatric disability to access supportive student services offered on campus. In order for support services to be most effective, it is important that staff members within these service units receive adequate training to work with students with psychiatric disabilities.  Communication and networking of services on campus can help assure consistent support. In addition, it has been found that assuring a long-term personal relationship with an academic counselor advocate on campus who also focuses on career planning and counseling will promote academic success for the student with a psychiatric disability (Wagner, 1995). In short, optimum supported education for students with psychiatric disabilities includes the assignment of a long-term counselor and the provision of academic tutoring, study sections, advising, career planning, and social and emotional supports.
Some postsecondary institutions offer academic preparation and orientation courses for incoming students who need academic skill-building prior to entry into higher education. These courses often include an overview of educational resources, development of study skills, discussion of stress and time management strategies, and academic and career advising. For many students returning to school after treatment of a psychiatric disorder, participating in these study skills classes provide a solid foundation to begin the process of successfully re-entering an educational setting. For example, Seattle Central Community College has offered such a course with positive results as documented by observations and reports from faculty, staff, and students. They indicated that the course is a contributing factor to the academic success of students with psychiatric disabilities (Personal communication with Al Souma, April 17, 2003). 

Recommendations for Practice

Providing an inclusive postsecondary environment with equal access for all qualified students as legislation requires, requires that academic programs accept, welcome, and provide academic adjustments to qualified students with psychiatric disabilities. These students have additional learning needs that may require academic accommodations, advising, counseling, stress management, and social support. The provision of academic support for students with psychiatric disabilities has positive implications for the participation and success of these students. However, academic support for these students is complex due to a wide range of diagnoses, individual diagnostic severity and functioning, and accommodation needs.
Three approaches to academic support for students with psychiatric disabilities are recommended and encouraged at the pre-college level as well as continuing in higher education: 

1. Academic adjustments tailored to individual disabilities and functional limitations that may include classroom, assignment, and testing accommodations; 
2. Application of the principles of universal design to instruction to meet diverse learning needs, and 
3. Supported education that provides advising, counseling, mentoring, tutoring, academic skills training (e.g., planning and organizational skills, time management skills, stress management skills), and social skills training. 

In order to enhance the academic success, disability support service staff, faculty, advisors, mental health counselors, and other academic units must be coordinated in the delivery of these supports, and assure that each student has a long-term mentoring relationship. Professional development of faculty and staff is critical for academic success of students with psychiatric disabilities. This may include:

1. Attending education and training sessions offered by disability support service coordinators and counselors that focus on  students with psychiatric disabilities, and
2. Exploring online resources such as The Faculty Room at http://www.washington.edu/doit/Faculty/Strategies/Disability/Psych/.

Conclusion

Further research is needed to explore success factors and barriers in postsecondary education for students with psychiatric disabilities. Faculty, administrators, and staff must increase their awareness of the rights and needs of qualified students with psychiatric disabilities and take action in order for these students to feel welcomed and supported on campus, and succeed in higher education and, ultimately, careers. We need to determine the full complement of educational and social supports required for academic success of students with psychiatric disabilities, and document the postsecondary outcomes that result from providing these accommodations and social supports.
 
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About The Authors

Nancy Rickerson, M. Ed, OTR/L

Ms. Rickerson holds a Masters in Educational Leadership and Policy Studies in Higher Education from the College of Education, University of Washington and is a Ph.D. prospective candidate in the same program. Ms. Rickerson is a program and research coordinator at Disabilities, Opportunities, Internetworking, and Technology and a clinical faculty member in the Division of Occupational Therapy, Department of Rehabilitation Medicine, University of Washington. She has a twenty-year history of occupational therapy clinical work, specializing in mental health. Ms. Rickerson also conducted a qualitative survey research study examining instructional design and success factors for postsecondary students with hidden disabilities through the University of Washington College of Education, 2001-2003. 

Alfred Souma

Mr. Souma is the Director of Disabled Student Services at Seattle Central Community College. He has an extensive history as a counselor at psychiatric facilities, both inpatient, and outpatient mental health. He has been a postsecondary academic counselor for students with disabilities for many years and specializes in psychiatric disabilities. Mr. Souma has delivered presentations at national conferences on accommodating postsecondary students with psychiatric disabilities. Mr. Souma was awarded an outstanding professional achievement award by the Association of Higher Education and Disabilities in 2001.

Sheryl Burgstahler, Ph. D.

Dr. Sheryl Burgstahler directs DO-IT (Disabilities, Opportunities, Internetworking and Technology) at the University of Washington. DO-IT projects and programs promote the success of students with disabilities in postsecondary programs and careers and the development of accessible facilities, computer labs, electronic resources in libraries, Web pages, classroom instruction, and distance learning programs. DO-IT has been the recipient of many awards, including the National Information Infrastructure Award in Education, The President's Award for Mentoring, the Golden Apple Award in Education, and the AHEAD Program Recognition award. DO-IT is funded by the National Science Foundation, the U.S. Department of Education, the State of Washington, corporations, foundations and private donors.
Dr. Burgstahler has published dozens of articles and delivered presentations at national and international conferences that focus on the full inclusion of individuals with disabilities in postsecondary education, distance learning, work-based learning, electronic communities, and employment. She is also the author or co-author of six books on using the Internet with pre-college students. Dr. Burgstahler has extensive experience teaching at the pre-college, community college, and university levels. 
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