Introduction

Persons experiencing mental health problem are less educated than persons of the same age, and this puts them in a weaker position in relation to the labour market [21, 47]. Mental health problems increased 71% among individuals aged 18–25 years between 2008 and 2017 [54]. Being young is a crucial period when the person is to explore and develop their identity, manage relationships, increase emotional and economical independence, and develop vocational engagement [8]. Experiencing mental health problems at this age influences social, occupational, and other important areas of functioning [2, 49]. This may prevent the development of important milestones and changes associated with adulthood [9, 26, 48, 49]. Increasing the risk for long-term adverse outcomes is low educational level and interrupted career development [42]. Of those not involved in education, more than half want to return to school to develop skills and enhance career advancement, as well as to find different forms of opportunities for personal growth [25, 33. Were being able to continue education is a fundamental first step in the process of developing natural age-related life roles [12, 43].

Creation of an evidence-based mental health service that integrates recovery-oriented models and interventions [15, 17] that focus on the service users’ personal recovery as well as their clinical needs [11, 28], is critical to support long-term employment and mitigate the risk of marginalisation for the group of young adults with mental health problems. Personal recovery is defined herein as the processes of developing identity and meaningful life roles despite mental health symptoms and problems [3, 35]. Evidence is overwhelming for the benefits of integrated mental health and vocational services that support service users to gain employment in the regular labour market, compared to traditional services [16, 41]. The evidence is lacking, however, for the effectiveness of supported education (SEd) that is integrated in the same way. However, our current knowledge base substantiates the relevance of integrating educational support and mental health services for achieving long-term vocational goals and sustainable career development [30, 38, 39, 43]. Not only educational outcomes can be achieved with such integrated support. Earlier research demonstrates that the development of a work identity becomes possible, and forms an essential part of young adults’ identity development and personal recovery process from mental health problems [37]. The research also suggests that integrated mental health and vocational services may support young adults’ mental health and is linked to both their personal and clinical recovery [36]. Similarly, SEd may facilitate the development of a student identity and similar effects. Therefore, exploring the student role when participating in SEd is relevant to understand critical passages of identity development during transition into adulthood and future career development. This grounded theory study aims to explore young adult experiences of participating in SEd, a person-centred intervention that intends to integrate vocational and mental health services, as well as school and other welfare actors, and reflects on the process of developing a student identity while struggling with mental health problems.

Method

Design and Context

A grounded theory research design was chosen as an appropriate method of studying the process of developing a student identity [23, 24]. The COREQ guidelines for qualitative studies were used for reporting [53]. The study was part of a supported education research project within the national research network Centre for Evidence-based Psychosocial Interventions (CEPI) that is focused on developing knowledge of SEd for young adults experiencing mental health problems. The study was approved by the Ethical Review Board (Reg. No. 2014–277). The material consisted of 17 qualitative interviews conducted with young adults aged 18–29 years who were experiencing mental health problems and participating in SEd services in four medium-sized Swedish cities and one large Swedish city. The SEd services integrated educational support into vocational services that were serving young adults with a variety of mental health problems who had education as their primary support goal. Some of the services had been active for years and others had more recently implemented SEd into their services.

Informants

The SEd services included in this project were purposively selected for the present study because they had begun to integrate SEd support for the service users. Initially, the principal investigator (DR) asked the SEd services whether they were willing to participate in the primary study that was investigating the integrated services model. Then SEd service education specialists asked appropriate informants if they were interested in participating in the study. Seventeen service users agreed to participate in interviews. The inclusion criteria were ages 18–29 years, having mental health problems, and receiving educational support from SEd services. The age range of 18–29 years is in agreement with the Swedish welfare system definition of young adults with a disability [46]. All informants (n = 17) were given verbal and written information about voluntary participation, use of data in relation to the research aim, confidentiality protections, and ability to withdraw from the study at any time [10]. Written informed consent was obtained from each informant, and all data were handled confidentially. The study intended for informants to feel that they were a resource and contributed critical knowledge to the research field. Nine informants were women and eight were men, with a mean age of 24 years. Self-reported diagnoses included neuropsychiatric disorders, affective disorders, personality disorders, and psychosis disorders. Comorbidity occurred among 41% of the informants. More than half of informants (53%) studied at a high school/upper secondary school. The other 41% studied at college/university, and 6% at a grade school. Informants’ primary income was from the Swedish Board of Student Finance (CSN). However, 29% had support from the Swedish Social Insurance Agency and 18% received income support (municipality). A description of the informants is presented in Table 1.

Table 1 Description of the participants in the study of supported education services (n = 17)
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Supported Education

The SEd model in the present study resembles an integrated and person-centred intervention with practical and ongoing support to assist people with mental health problems to achieve their educational goals [30, 31]. There are several different models of SEd: those that emphasize skills training or teaching in separate classroom, and others with more individually adapted support. They differ in the extent of integration with mental health services and school systems. Most SEd services integrate needed support and offer learning opportunities for academic skills and social competencies through time and stress management, financial counselling, outreach to education contacts, and career and educational planning [42, 55]. A pilot study of the SEd model shows that it was feasible to support young adults with psychosis to return to education within six months [31]. The emerging trend in recovery-oriented services emphasizes that SEd should individually support vocational and educational needs of the services user, and existing supported employment services should explicitly focus on SEd. We proceed from this SEd model in the current study. The education specialists who delivered the SEd followed the following principles: (a) mainstream education is the goal; (b) educational and vocational services are integrated with mental health or other welfare services; (c) eligibility is based on service user’s desire to study; (d) personalized benefit counselling is provided; (e) rapid linkage to educational activities; (f) collaboration with outside educational institutions, programs and organizations; (g) continuous support; and (h) service user’s interests, preferences and needs are honoured [20, 22, 27, 30]. The education specialists had the key role in coordinating the process and supporting individuals according to the principles. They insured that the service was a person-centred and that education-related aims were integrated with mental health and vocational support. To be two instead of one in the process has previously shown to enhance experiences of self-esteem and engagement in everyday activities [37, 56) and community life in general [15, 17]. The delivery was approximately one hour per week, with a focus on enabling motivation for education, planning educational development activities, mobilized a supportive network, and supporting various lifestyle strategies, as well as developing a career profile and plan.

Data Collection

In total, 17 individual interviews were completed between March-July 2019. The interviews were conducted by the co-authors (HH, VL, DR, UB) in varied constellations, and an additional three interviews were completed by the first author (UL). The educational specialist first explored the informant’s interest in participating, and then an appointment was booked with those who were positive to the interview. Interviews were retrospective and aimed to have informants tell about their experiences and process of participating in SEd as openly and freely as possible. One informant chose to have the education specialist present during the interview. Interviews lasted between 20 and 70 min (median 47 min) and were conducted face-to-face in a private room at the SEd service premises, except for one interview when the informant chose to be interviewed by telephone. All interviews were digitally recorded with the informant’s consent. An interview guide was collectively developed by the authors. The guide formed the basis for each interview and started with six broad, open-ended questions based on experience of education prior to receiving SEd and during the process of receiving SEd. The interview was conducted as a conversation and included three central areas of questioning: (1) Have there been factors that have affected your ability to participate in education? (2) What did you think was the most important support you received from the SEd service? (3) Has the opportunity to study affected your life in any way? To reduce the risk for bias, efforts were made to focus on the informant’s experiences and minimize the researcher’s opinions during the interviews.

Data collection initially started by purposefully sampling informants participating in SEd services. After a first analysis, theoretical sampling governed the data collection [23] and continued until no new information that added new dimensions to the analysis emerged and theoretical saturation was reached. For example, interview guide adjustments were made prior to the second half of interviews with the goal of raising further questions and deepening the preliminary categories around barriers to study. For a time, theoretical sampling was used to guide future selection of informants with experience of education in order to raise further questions about developing a student identity to deepen the data. Memos were used throughout the entire process to document emerging categories and their characteristics [24], including statements from informants that could be explored further in future interviews.

Data Analysis

According to grounded theory, the analysis stayed close to the empirical evidence through constant comparisons in the entire analysis process [24]. Analysis preceded through the stages of open and axial coding [23]. The process of open coding focused on dividing and joining the data into theoretical codes and common categories. Emerging categories were checked through axial coding where the relationships were investigated, and questions about created conditions were then posed. This part of the analysis focused on codes and categories that refer to the process, i.e., ongoing actions and interactions, of developing student identity among young adults’ experiencing mental health problem. Notes about links and contact points between the categories were taken throughout the analysis of initial interpretations [24]. From the emerging categories, three core categories corresponding to the research questions developed that reflect informants’ views and experiences in their studies. The three core categories are represented by 11 categories with supporting subcategories that further characterize the variation in the process. They are illustrated in Table 2. According to the grounded theory framework, the categories are presented in a storyline to facilitate the theoretical integration of the findings [19]. In a final analytic step, integration of the categories formed a tentative model of the development of a student identity, describing a process of informant experiences in their studies [23]. The analysis was conducted in ongoing consultation with the co-authors (DR and UB), and the first author (UL). All authors agreed to the final analysis of findings.

Table 2 Description of the categories in the analysis process
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Results

Informants experienced structural barriers and challenges to engagement in education, which presented a wide gap between the informants and available regular education in the community. Access to support from SEd was reported to decrease this gap and formed a bridge that helped to facilitate educational achievements. These achievements were related to several personal benefits important for the experience of meaning, identity development, and career advancement in a future life perspective. Figure 1 gives an overview of the informants’ experiences of participating in SEd and of studying while having mental health problems. Three developed core categories illustrate the experienced aspects and are further represented in categories (subheadings) that characterize links in the processes.

Fig. 1
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Study experiences among young adults participationg in supported educatioin services intergrated with vocational and mental health services

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Structural Barriers and Challenges When Attempting to Study

The first core category reflects challenges with structural barriers that informants experienced when engaging in studies prior to participating in SEd. Realising educational goals whilst struggling with mental health problems was made difficult by structural barriers. The barriers are grouped in five categories, presented below.

A Restrictive Welfare System Limits Possibilities for Studying

The Swedish welfare system with its regulations and bureaucracy, including both the authorities and the educational system, presented challenges for engaging in studies while experiencing mental health problems. To apply for and receive study allowances and loans from the Swedish Board of Student Finance (CSN) or part time activity compensation from the Swedish Social Insurance Agency were described as a challenging, prohibitive bureaucratic process. Informants found it almost impossible to get a study allowance for part time studies, and a further complicated task to combine this with other welfare benefits. Utilizing the study allowance involved taking financial risks that required courage to manage several parallel life changes. Informants felt trapped in a dead-end situation where they were dependent on the welfare system and had difficulty re-establishing financial independence or stability. One informant explained,

I only receive a study allowance of 50%, which means that I have to start working at the same time because I am not allowed to keep the Social Insurance Agency benefit for 50%. There is no support for re-entering the labour market, which I think should be in the interest of the public welfare system. (Interview 12)

Regarding the education system, opportunities for individual adaptions were experienced as few, with a low acceptance of social deviations. At times informants were stigmatized and discriminated against when they carried out their education. They had low self-esteem and were uncertain as to whether there was a way to proceed with their studies while having mental health difficulties. One informant stated,

When we asked the school if it was possible to reduce the hours and study part time, they found out that I was not feeling so well. When I came back to school after a week, I set out to start my studies again, but the principal took me in and said that it might be good if you end your studies, take a break and start again when you are well. (Interview 6)

The understanding of mental health problems was experienced as poor within the education system. This situation decreased acceptance of deviations and opportunities to assimilate, which in turn made it difficult to accommodate special needs. The education system missed opportunities for success among students with mental health problems. Furthermore, the mental health service system did not integrate treatment and support in relation to educational programs. This presented informants with challenges in achieving their education goals and receiving treatment at the same time, and involved high demands to complete education or risk losing treatment continuity. The overall experience was a misfit between the different systems and a lack of understanding that did not encourage young adults to invest in education while experiencing mental health problems.

Having to Fit into a Standardised Structure Within Education

The education system was experienced as being primarily designed to fit conventional students, and as lacking responsiveness to individual needs or requests. This affected access to support of mental health needs and increased feelings of being relegated to standard contexts. One informant stated,

During the time I was in high school, I was depressed. I did not think the school considered this, they just wanted me to apply to another, special school and did not get me any of the help that I needed. (Interview 16)

The informants’ opportunities to influence their education or have a dialogue with the school were often limited. Having a diagnosis could be experienced as a circumstance for receiving study support. However, being labelled with a diagnosis could also be perceived as stigmatising. One informant stated,

I started in a high school that targets those who have difficulties like me. They said it would be good for people like me. It was not good for me. My goal was to go to college, but my mentor said that college would not suit me, and that vocational high school would suit me better. I started and was barely there for a few weeks. (Interview 15)

Having little influence and control over the conditions for studying, including the choice of education, contributed to lower self-esteem and feeling stigmatized. The informants found it as difficult to fit into the standardised pedagogic structure and regulations in the education system, and this decreased the opportunity to manage their studies.

Feeling Overlooked When Needing Study Support

Gaining access to support and helpful adaptions within education was a complicated process. Most informants studied without adaptations and support since this situation was granted on the basis of a diagnosis, and hence not available for undiagnosed students. Furthermore, the administrative system used to apply for support was complicated to manage, as was communicating the decision to responsible teachers. One informant said,

I have to submit a decision on special educational support for each course. Even when I study in the same department for a whole year and they have me in the system, I have to apply to every course leader for the support. Some course coordinators do not even answer (me). (Interview 3)

In addition, having an approved application was no guarantee that the adaptions worked well. The adaptations could be overlooked or not materialize. The informants felt exposed when they repeatedly had to remind the supporting teachers and to ask that the adaptions be implemented. This sometimes led to students ignoring the support to which they were entitled. An informant said,

I have asked to sit separately when there is an exam. But they have not always allowed this. I did not pass the first exam because they put me with many other students. I misunderstood the questions, (and) could not or did not dare to ask the teacher. Because I feel that I disturb the others when the teacher has to stand and explain to me, and they wonder why I do not understand the question. ‘Is she stupid?’ (Interview 10)

The informants suggested that to get their approved support enacted, a working relationship with the teachers was essential. However, having individual contact with teachers was not common and was difficult to accomplish. The responsibility for obtaining support relied on the informants and required that they were high-functioning in terms of planning and managing necessary contacts.

Lacking Integration of Mental Health Services and Education Support

The informants found it difficult to combine mental health treatment with ongoing education. Struggling with mental health problems necessitated several essential treatment contacts that needed to be coordinated with educational obligations. Rescheduling booked meetings, treatment and group therapy within the mental health care was difficult. Hence there was a risk of falling behind in studies due to absenteeism. Missed educational experiences were always a possibility while struggling to coordinate mental health care contacts and treatment with education. Further, mental health services did not pay attention to the individual’s everyday life activities during treatment. An informant told about the experience of being a service user as well as a student,

It was school and then psychiatry in a mess, and I tried to balance both. I got help from the mental health services but it is mostly with my thoughts. There was a lack of focus on me in the practical world. It would have been reassuring if it was included. When you are in the middle of your illness, it would be good to have help with efforts to return to normal chores, your daily chores, if you work or study. I know because I was very worried when I fell ill and was at the hospital. I walked around and said: ‘No, I want to finish my degree.’ (Interview 9)

In cases where the mental health service system did not pay attention to their support needs for education, informants found it a challenge to continue their education.

Challenging to Maintain Motivation on a Long Journey

Many informants felt that it was challenging to maintain motivation to study over a long period. Mental health problems early in life often affected educational achievements. Preparatory studies were usually necessary in order to resume education and qualify for new educational goals and one’s desired education. Furthermore, resuming studies after a year implied starting new relationships with fellow students and this made it difficult to maintain social contacts with peers. One informant explained,

Now I was not so keen on getting to know people anymore. I got to know people well the first and second time. But now, the third time, it did not feel worthwhile. (Interview 2)

Along with the structural barriers presented above, maintaining motivation throughout the journey of education was crucial and a personal challenge, both in regards to educational achievements and social contacts.

Supported Education Helps to Overcome the Gap to Engage in Studies

The second core category reflects the SEd support that helped to facilitate educational achievements and form a bridge for overcoming barriers, reducing the gap between the education requirements and the informant’s ability to engage in studies, despite having mental health problems. The core category included three categories, presented below.

Being Treated From a Personal Perspective Enhanced Motivation

SEd was an important prerequisite for managing education. Informants were treated from a personal perspective with responsiveness to personal conditions and wishes. Having one’s own influence over the choice of education and the design of support spurred motivation to address challenges and make necessary life changes. SEd increased opportunities to obtain the support needed in order to engage in studies. One informant explained,

She (education specialist) was very good at listening to my wishes. She very much took into account what I wanted and my stress problems. She was very good at giving me exactly the help I needed. (Interview 15)

To receive support to find and explore different educational alternatives was also important. This included finding education that matched the informant’s personal conditions and preferences in relation to available schools, universities, and educational forms. Informants found that it was possible to implement education when it was selected on the basis of personal preferences. The combination of being treated as a person and having personalised support was viewed as crucial for maintaining motivation to study.

Being Two Instead of One in the Process

The value of “being two instead of one” throughout the process of applying for and accomplishing studies was reported as an essential ingredient of the support. The continuous and personalised support contributed to a partnership between the education specialist and the informant. Participating in SEd provided an opportunity to share and connect with someone when facing challenges. Ongoing support also made the education specialist familiar with pre-conditions and challenges of the informant as they established the student role. The specialist was available for personal guidance and confirmation during difficult parts of the studying process. An informant explained,

To talk about what I find difficult, to sort things out, and get advice on how I can move forward. The feeling that you are doing it together. If I lose my grip, someone else will notice. You can slow down before it goes downhill, instead of giving up. I would not have made in through education without this support. (Interview 4)

“Being two” when interpreting educational information and conditions or when exploring perceived challenges was decisive for being able to study. The support also created security in order to manage difficulties that had previously led to dropout from education. In addition, shared follow-up and study planning were experienced as valuable support. An informant said,

We talk about how it has been, how much I have read and for how long. What has worked and not. We plan how I build up the week, what I will do and when. How to prioritize, what topics and tasks. So even if she (education specialist) is not familiar with what I study, she can still help me a lot. (Interview 9)

Not feeling alone was attributed to regular shared planning with the education specialist, and this decreased the experience of self-stigma among informants. “Being two” was important for informants during the SEd process. The establishment of long-term contact with the education specialist functioned as a protective network that gave capacity and strength to cope with what they faced and thereby facilitated sustainable progress in education.

Having Support to Implement Practical Things

SEd provided valuable support to handle practical things connected to the student role. To be a student required having to deal with administrative bureaucracy and manage several contacts, e.g. with welfare authorities when applying for and getting study allowances, with educational counsellors when trying to find suitable education, making the application or an individual study plan, and applying for and getting access to needed adaptions or materials. Obtaining partial or complete practical support increased the availability of education and the opportunities to manage education, despite having a mental health problem. As an informant described,

She (education specialist) helped me find schools and to apply. She checks if I need help with any contacts… She has contacted the school, my teacher, the public employment service. When there was trouble with the teacher, she helped me write to the principal. She also went with me to visit the psychiatrist. (Interview 6)

The education specialist helped with all study-related administration and offered follow along support to sort out practical things connected to the student role. Prior to participating in SEd, many informants had experienced these as unmanageable and needed to depend on parents and family for support. Receiving this practical support contributed to development of a greater degree of independence, which in turn supported the transition to adulthood. Overall, access to practical support made it possible to take part in student life, and was decisive for being able to choose, apply for and conduct education while experiencing mental health problems.

Participating in Education Implies Personal Benefits and Opportunities

The third core category reflects the benefits of studying and how it contributed to personal development process at several levels. This is presented in three categories below.

Finding Meaning and Hope for the Future as a Driving Force

Finding personal meaning proved to be important for the entire process of starting to study and developing a student identity. Once one’s own personal meaning for study was identified, this meaning became an important driving force and made education part of a personal plan. Envisioning meaningful goals for a future career and working life, such as working with people in need or obtaining a special vocational education, are examples of the driving force. Although what was meaningful varied among the informants, a common goal was the desire for a future that had previously been lacking. One informant described,

It has been a great help to find an education that is important to me, and to be able to study what I want. In the past, it was very hopeless, but now I feel there is a future, a road for me to go [on]. I have goals now for the first time in my life. It feels so good. I see a meaning now, I want to be something, it really matters. When I wake up every morning, I know I want to go to school. (Interview 15)

To identify the personal meaning for education became a driving force to study and to engage in other everyday life activities—a determinant factor for finding the strength to struggle and achieve educational and future goals.

Enabling Engagement on an Activity, Social Environmental, and Personal Level

To perform educational activities increased engagement in everyday life activities, and that in turn affected the informants’ pre-conditions in life. In addition to achieving academic competence, educational activities provided opportunities to develop practical competence and to explore and develop personal interaction skills. They also helped to create daily routines and structure, and to increase the feeling of being in control of one’s life. One informant said,

I have been coming back to this with routines. To wake up in the morning and know that you have tasks that need be done. You have structure for the day. I never had the control I have now, in life. A lot has happened that I did not think I could handle. The whole process has made you feel more alert, stronger, and above all, that you are capable. I really feel better today. (Interview 13)

To engage in activities connected to the student role influenced the informants’ view of themselves as being more competent, and this strengthened their self-esteem. Being engaged in studies with SEd support facilitated a development process that influenced self-confidence, and most importantly, how the informants viewed themselves in everyday life. The educational activities further increased informants’ social coherence, and provided new opportunities to build relationships with others. As a result, self-worth increased and they were able to re-evaluate themselves and develop social roles as students. The increased engagement in study activities enabled the development of academic, personal and social competence that influenced self-worth, identity, the feeling of control, and having a positive direction.

Developing a Student Identity

When taking into account all the beneficial experiences of studying, an active component was the personal identity development process that occurred. This process was influenced by the dynamics of their own perspectives and the outside world. The student role contributed to the development of competence, achievements that were affirmed by others, and development of student identity. Informants experienced real changes for career advancement with more possibilities for future working life. As one informant explained,

When I went to the Daily Activity Centre, it felt a bit like a place where you could get stuck for the rest of your life. To get help to study makes you feel that life is moving forward. I think it has been extremely motivating. Before I was terrified to start working, now I am eager to start working when my studies are finished. When I was at a job fair and met employers, they were interested in recruiting me when I finished with my education. (Interview 11)

When informants became aware of opportunities that could move their lives forward, their beliefs about their abilities changed and made it possible to identify themselves as more independent and as adults. Dependence on family and parents for personal, practical and financial matters decreased with the help of SEd. The opportunity to provide for themselves through study allowances, and later in working life, increased their feelings of independence. Being a part of student life was experienced as reassuring. The fact that they were on their way forward in life influenced their identity and future perspectives in a positive way.

Discussion

The current study provides an understanding of the challenges young adults with mental health problems experience as students in the regular education system and how SEd may contribute to sustainable education and personal growth. In this sense, SEd may be viewed as bridging the gap between experienced barriers posed by the welfare system and the opportunity of engaging in education regardless of the presence of mental health problems. Participating in SEd and entering social roles as a student enabled the development of student identity. This study identifies important components of SEd, and their critical role in the development of a student identity among young adults with mental health problems.

The informants met several barriers to education in the welfare system. In particular, they were challenged by the negative attitudes from others while they were struggling with mental health problems. This situation may be due to low mental health literacy among professionals in the education and welfare systems, including little knowledge about mental health and education, negative attitudes, and few strategies to support persons with mental health problems who wanted to study. Lövgren et al. [38] advocates that improved mental health literacy for educational actors is a key factor for accommodating the needs of these students. In addition, previous grounded theory research on supported employment that focused on professionals in the welfare system and employer support corroborates the understanding generated in the present study [45]. Applying for, and engaging in, education often is a stigmatising experience for the student. The social environment in the regular education system was experienced as less available for young adults experiencing mental health problems. This is in line with previous research that shows that students with so-called “hidden disabilities” are the ones who are the most adversely affected by stigmatising attitudes and bear the risk of discrimination [40]. The informants felt that they needed to fit into the regular education system. Being divided into different groups and categories may thus contribute to the worsening of self-esteem and decrease hopefulness among students with disabilities. This in turn negatively affects their identity development and transition to adulthood. Moreover, when the support needed in everyday life was lacking from mental health services, informants found it difficult to have mental health problems while pursuing educational goals. The current study recognized that a unintegrated mental health and educational welfare system builds barriers for young adults who dare to invest and participate in education. Mental health literacy within the education system is critical in increasing the ability of SEd to facilitate education. As recently observed, the relationship between students and professionals in a school is more important to student mental health than good peer relationships [32]. Investing in the creation of good and supportive relationships with students is therefore urgent. This is most clearly seen in the category of “Being two instead of one”. Here the partnership and supportive relationship between the informant and the education specialist was decisive for managing studies, and allowing students to be themselves and develop their goals while having mental health problems. This kind of togetherness and support that makes it possible to develop optimism has also been observed in previous supported employment research [6]. This partnership support is a critical factor for all recovery-related efforts.

The present study shows that a personal development process occurs when informants start to influence their decisions and study goals, and engage in study activities. The three categories reflecting the benefits of studying can be anticipated to construct a process that contributes to the development of student identity and future perspectives in life. From a theoretical perspective, this can be understood in relation to the transaction between the person, the occupation and their environment [34]. At the intersection between the informants’ engagement in activity, the study environment, and development of personal factors is the process of identity formation. This provides an understanding of how essential the engagement and meaning-making process are for personal identity development. A tentative model of the process of developing student identity (Fig. 2) illustrates that study increased engagement in activity and gave a sense of meaning and motivation in life, which in turn made further engagement in productive activities and social coherence possible. This ongoing engagement provided the students with opportunities to practice and develop competence as a student, and thus develop new beliefs and self-perspectives. As stated in occupational therapy theory, the lived experience is the basis for a person’s occupational identity, involving the feeling of who we are, wish to become, and our position in the community [52]. Research has shown that increased engagement in activities, and provision of routine and structure in everyday life is important for the recovery process [5, 7, 14, 36, 37]. By becoming involved in study activities through SEd, overall activity engagement increased and an engagement process began. This resulted in changing a previously passive lifestyle, often linked to social isolation and little activity, into increased engagement that was conducive to personal development. The effects of integrated vocational and mental health services on engagement in everyday activities has also been shown in a longitudinal study among young adults [36].

Fig. 2
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A tentative model of the development of student identity

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The model also shows that evolving independence and self-worth may facilitate the transition to adulthood and career advancement, give a future perspective, and result in a more positive student identity. This model of developing student identity has several similarities with the theory of developing work identity, as reflected in a previous supported employment study [37]. These similarities include the value of a hopeful, future-oriented perspective, the relevance of vocational and educational activities in relation to establishing oneself as an adult, and the benefits of these activities for self-esteem and self-efficacy [37]. Both models contribute to our understanding of how change and self-development may be facilitated in a positive direction. In previous research, this change and shift of experiences are shown to be important in reduction of self-stigma and facilitation of personal recovery while experiencing mental health problems [56]. Furthermore, changes taking place during the identity development process may help explain the statistically significant changes in mental health found in previous supported employment longitudinal and trial results [5, 36, 44].

The process of student identity development includes several components important for personal recovery that are identified in the CHIME (Connectedness, Hope and optimism, Identity, Meaning in life, and Empowerment) recovery framework [35]. The CHIME components form a valid basis for measuring recovery [18]. The informants’ experience of finding meaning and hope for the future, such as hope for a future worker role, was an important factor for the study preconditions. According to the CHIME framework, positive thinking, being able to dream and have aspirations about the future, and influencing motivation to change are important components for the recovery process [35]. Bejerholm & Roe [15] explain that recovery refers to a process where a person acts to develop new goals and meaning in life despite limitations of an illness and its consequences. This is seen in the process of student identity development that gave a future perspective and a more positive student identity, and included parts of rebuilding a more positive sense of identity and self-worth that are close to components of rebuilding identity, hopefulness and empowerment. That is seen in the CHIME framework as the experience of hope and optimism, being able to picture a positive future, and belief in one’s own possibility of recovery. SEd made informants feel they were not alone, “being two instead of one in the process”, which helped students gain access to community offerings and the ability to choose. These are found in the CHIME components of connectedness, representing support from others, being a part of the community, and empowerment. These are identified as important components for recovery-oriented clinical work [35].

Forming of a student identity with the support of SEd facilitated the recovery process. We therefore assume that the process of student identity development may be a part of the personal recovery process for young adults with mental health problems. Education is cited as the most important factor in marginalised young adults leaving the NEET-group (Not in Education, Employment, or Training) [1]. However, SEd is not widely available for young adults with mental health problems in community mental health services. The current study suggests that providing SEd with a model that integrates mental health services contributes to good conditions for recovery of young adults, as well as positive student identity formation with possible reduction in stigma [9].

Clinical Implications

Mental health services should include person-centred career-oriented models for young adults that take into account support for both education and employment [30]. This includes services such as SEd [4], supported employment [13, 16, 20] and the Södertälje Supported Employment and Education model [36]. This conclusion is already in progress in international research [15, 17, 28]. In Swedish national guidelines and policies, supported employment is recommended to be integrated with mental health services [50, 51]. Understanding the specifics of the student experience and the development of student identity as a form of work identity can support clinical reasoning among professionals who support young adults in their transition to working life with interventions that respond to their needs. Paying attention to young adults’ resources, needs and preferences in selecting interventions is critical to a person-centred practice [35], and should be applied to the design of resources and support, and development of a practice that sees studies as a natural part of a young adult’s recovery process.

Methodological Considerations

Grounded theory is an appropriate inductive research method for studying young adult experiences of SEd and the process of developing a student identity when the aim is to generate theories from data and apply them to practice [24]. We used several measures from the Consolidated Criteria for Reporting Qualitative Research guide [53] and checklist to ensure the quality and credibility of the study and to strengthen the dependability of the results. A theoretical sampling was used to deepen data, check interpretations, and test evolving categories [24]. Use of a study protocol and description of study design and procedures according to grounded theory were used throughout the study to strengthen trustworthiness of the results [23]. Credibility and trustworthiness of the data are about truth and believability [29]. The first author (UL) has extensive experience of working with mental health and vocational rehabilitation. The other authors have extensive experience in mental health services research. Preconceptions provide a good starting point for qualitative research, with recognition of informants’ experience, context of the study, etc. Preconceptions may also influence data, and therefore triangulation was used throughout the analysis process. To reduce the effect of preconceptions, triangulation was used between the first author (UL) and DR and UB, and secondly among all authors. Because qualitative researchers and study participants always interact in a social process, the pre-understanding was viewed as part of the results in the form of experiences, perspectives, and interaction with the study structure [23], 29]. The informants who agreed to participate might have been those who had positive experiences of the SEd service, which may have influenced the results in a positive way. Finally, our findings are useful as they identify important components of support for young adults toward their educational goals, and they are anticipated be a part of a personal recovery process from mental health problems. In this way, the findings may contribute to future research and policy-making.

Conclusions

Currently there is a lack of adequate support from the Swedish system for young adults with mental health problems who wish to study. Supported education can (1) assist with bridging the gap between service users and available education in the community by creating greater accessibility to that education, (2) enabling development of a student identity that involves an engagement process, positive identity formation, reduction of stigma, future-oriented perspective. Young adults with mental health problems who want to study should be supported with SEd that is integrated with mental health services, and other welfare services and the educational system in a co-produced manner since the development of a student identity seem essential for career advancement and can be anticipated to be a crucial part of the personal recovery process for the individual. Finally, the authors suggest further research with a longitudinal perspective to give a more comprehensive picture of SEd and the implications for study tenure and health- and career related outcomes. It would also be helpful to investigate this model of support in other contexts, for example those where SEd might be valuable as a preventative intervention.