Introduction

Education is an important milestone in the development of young adults and an essential step in establishing themselves as adults. Education also contributes to creation of social capital for individuals experiencing mental health problems. Among those who are not involved in education, about half wish to return to school to develop skills and enhance career advancement (Corrigan et al., 2008; Knis-Matthews et al., 2007). Previous research findings suggest that mental health services should adopt person-centred and work-oriented models, such as supported employment (SE) and supported education (SEd) for young adults (Bond et al., 2008; Rogers et al. 2010). SE and SEd consist of individual support for work and study goals from a person-centred approach (Bejerholm & Roe, 2018; Bellack & Drapalski, 2012). In addition to vocational and education outcomes, this support may promote student and work identity development (Liljeholm & Bejerholm, 2019; Liljeholm et al., 2021; Anthony, 1993; Leamy et al., 2011) that form a critical part of the personal recovery journey. An earlier observational study showed that an integrated mental health service and supported employment intervention can enhance personal and clinical recovery in persons with mental health problems (Liljeholm et al., 2020). What the support process may entail and what qualities are vital for such individual growth are unknown.

Over recent decades, young adult mental health problems have achieved considerable attention from governmental authorities, organisations and researchers. In Sweden, as in other high-income countries, mental health problems have increased threefold since the turn of the millennium. Sixty-six percent of young women and 42% of young men experience mental health symptoms (Public Health Agency of Sweden, 2019). Reports from the United States show an increase of 71% between 2008 and 2017, indicating serious psychological distress among young adults aged 18–25 years (Twenge et al., 2019). When problems occur before post-secondary education, students often dropout of education and this has long-term adverse consequences such as low educational level, interrupted career development, and consequent difficulties in entering working life (National Board of Health & Welfare, 2013, 2017; Mowbray et al., 2003; Social insurance report, 2014). Concurrently, the present labour market places higher requirements on education and competence. These increase the risk of being social isolation and inability to fully participate in community as a student or an employee for this vulnerable group.

Transition of young adults to school and working life is not linear (Wilson-Clark & Saha, 2019). The transition process entails multiple opportunities that enable them to move backward and forward depending on how they make use of their skills. Accordingly, the transition relies on whether the young adult has the opportunity to develop required skills and use them in real-life settings. Traditional services are faced with unique development challenges in meeting these needs for support and transition. For instance, it is critical to develop support that enables the vital identity development process (Liljeholm & Bejerholm, 2019; Liljeholm et al., 2021) and improves mental health through engagement in meaningful experiences. Such experiences may in turn enhance a sense of well-being in connection to a social context (Bremberg & Dalman, 2015). Taylor & Kielhofner (2017) state that such lived experiences and social connections contribute to the development and change of one’s so-called occupational identity, a sense of capacity and certainty over who we are and wish to become, as well as our position in the community. Therefore, the social environment is an important area for supporting young adults’ transition to school and work, and adaptions can increase the person’s ability to study and work independently. Lexén and colleagues (2013) point out that vocational service, in collaboration with the current support network, is central in providing onsite adaptions and support. This support is complemented with off site support, and is an important part of the overall support processes. Furthermore, research highlights the importance of the service not merely paying attention to service user work performance, but also to psychosocial, behavioural, and environmental workplace factors (Kinn et al., 2021).

Current mental health services focus on developing integrated support services to provide young service users with career opportunities and to support their study achievements, and thus their long-term establishment in the labour market (Christensen et al., 2019; Killackey et al., 2017; Mueser et al., 2016; Manthey et al., 2015; Rinaldi et al., 2010; Nuechterlein et al., 2008). Such an integrated service may be seen as a direct response to the recovery needs of young adults, allowing them to resume their education as the first step in development of natural and age-related life roles (Bejerholm & Areberg 2014; Leamy et al., 2011; Anthony, 1993). New research reflects the complexities of providing career services for young adults (Ellison et al., 2022). The research suggests such services should include help to complete high school and ease the transition to college, coaching and skills development to improve work and school functioning, coaching to manage symptoms of mental illness, flexible strategies to ensure self-determination, longer-term career and goal planning, and close collaboration with families. Research on SEd continues to increase (Hillborg et al., 2021; Lövgren et al., 2020; Becker et al. 2015), but knowledge regarding how integrated SEd can be developed and delivered by mental health services is still limited. Components of the SEd process are important to consider in relation to education and employment success, and require additional investigation. Further investigation of the support process, and individual trajectories to more fully understand the guiding principles for SEd best practices are therefore relevant (Ennals et al. 2014). This study aims to illustrate a practice example of the process of supporting careers for young adults with mental health problems, and thereby their transition to school and work, by studying those involved in an 18-month SEd program in Sweden.

Materials and Methods

To illustrate a career support process in an integrated SEd and employment program in a Swedish context, a case study design seen as suitable because the phenomenon of SEd is not well known. This method involves capturing the complexity and contextual conditions of a case, including temporal changes over an extended period of time (Yin, 2018). The study was guided by criteria from the Consensus-based Clinical Case Reporting Guideline (CARE Guidelines) Development (Gagnier et al., 2013).

Case Setting

The study was bounded to a single case that consisted of a municipal unit for vocational rehabilitation in the Swedish city of Södertälje. SEd was integrated with an existing SE program (Södertälje Supported Employment and Education model-SSEE) over an 18-month period. Young adults, aged 18–25 years, can directly register themselves to this unit. Those aged 26–29 years can be referred from other mental health services. However, all service users had accessed the program through contact with mental health services. The study was a part of a larger project (co-authors of UB, HH, VL, and DR) within the national research network Centre for Evidence-based Psychosocial Interventions (CEPI), A working life on the horizon—Supported education for young adults with mental health problems (Forte Dnr. 2016-00946). The study was approved by the Ethical Review Board (Reg. No. 2016-00946) and focused on developing knowledge of SEd for young adults aged 18–29 years who are experiencing mental health problems. The study aimed to translate and adapt basic support principles to a Swedish and educational context and that research will be published elsewhere.

The emerging knowledge base emphasizes the relevance of existing SE services integrating manual-based educational support (SEd) in order to individually support career needs as a whole (Hillborg et al., 2021; Lövgren et al., 2020; Manthey et al., 2015; Murphy et al., 2005). The SEd program offered a person-centred approached service, with educational support as an integrated part. Person-centred describes a partnership between the service user and the professional, where it is considered essential to instil hope and belief that employment and education are possible. This is done by focusing on the individual’s resources, interests and preferences (Rogers, 1986). SEd focuses on support of young adults’ career opportunity decisions and choices by offering specific expertise, practical and ongoing support, and coordination with mental health services. The goal is to achieve educational goals and completion in different educational settings and academic environments (Hillborg et al., 2021; Killackey et al., 2017). The education specialists follow the SEd 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 a service user’s desire to study; (d) provision of personalized benefits counselling; (e) rapid linkage to educational activities; (f) collaboration with outside educational institutions, programs and organizations; (g) continuous support; and (h) the service user’s interests, preferences and needs are honoured (Bond et al., 2008, 2020; Drake et al., 2013; Frounfelker et al., 2014). In addition, attention is paid to needs and challenges in the study environment and structure, psychosocial context, and student role as emphasised in previous research in the Swedish context (Hillborg et al., 2021). The education specialists had education and competence for supporting work according to the SE principles, similar to the SEd principles (Drake et al., 2013). They were all employed at the vocational rehabilitation unit in Södertälje, with the aim to support service users to reach their work or study goals in accordance with the SSEE model. They had previously undergone SE and SEd training at Lund University, and were additionally introduced to the SEd principles and implementation knowledge in connection to the larger project. Two worked exclusively with young adults, the others worked mainly with young adults. Several were occupational therapists by profession, but social workers and psychologists were also represented. Education specialists were responsible for partnering with the services user, coordinating the process, and supporting individuals according to SEd principles. Previously research shows that “being two instead of one” is essential for enhancing experiences of affiliation in social coherence, self-efficacy, and enabling engagement in everyday activities (Liljeholm & Bejerholm, 2019; Liljeholm et al., 2021). The dose of delivery was approximately one hour each week. The contact began with talking through the user’s individual needs and preferences in relation to education, and was followed by person-centred planning and support that focused on personal resources and efforts to live a meaningful life (Bejerholm & Roe, 2018; Bellack & Drapalski, 2012). Accordingly, SEd focused on enabling motivation for education, planning educational development activities, supporting various lifestyle strategies, and developing a career profile and plan. A supportive network of concerned family, friends, mental health services, and other support at the education context was mobilized.

Data Collection

A case study protocol guided the research with a research aim, data collection procedures and analyses. Data collection of information to help illustrate and triangulate the case occurred over an 18-months period between May 2018 and November 2020. SEd education specialists helped recruit and ask appropriate service users if they were interested in study participation. Purposeful sampling was used to recruit cases that were “information rich” (Patton, 1999). Inclusion criteria were aged 18–29 years, experiencing mental health problems, and participating in the SEd program. The 12 service users who agreed to participate were followed prospectively from baseline through 18 months. Multiple data sources were collected. See Table 1 for details of the data material used. The first author (UL) and the education specialists documented sociodemographic factors, obtained support status, and study and work status for each participating service user (N = 12) every third month using Research Electronic Data Capture (REDCap). Five self-report questionnaires that measured recovery-related outcomes were administered (N = 10) at baseline, 9, and- 18-months (i.e., Manchester Short Assessment of Quality of Life (Priebe et al., 2012), Questionnaire about the Process of Recovery (Neil et al., 2009), New General Self-Efficacy Scale (Chen et al., 2001), Internalized Stigma of Mental Illness (Boyd et al., 2014), and Social Inclusion Scale (Secker et al., 2009). All service users were offered introduction and guidance but most chose to complete the instruments independently. Triangulation of collected data was allowed by using interviews. Four service users were interviewed individually about their study experiences. One was performed by HH, VL, DR. The additional three were interviewed by the first author (UL). The interview guide was collectively developed by HH, VL, DR, and UB who all have extensive experience in vocational rehabilitation, mental health services research and social work. The guide had broad, open-ended questions on the educational experience and process of supporting careers, covering three key areas of questions: (1) Have there been factors that have affected your ability to participate in the program? (2) What did you feel was the most important support you received from the SEd service? (3) Has the opportunity to study affected your life in any way? Interviews were conducted once at the Södertälje service centre, performed face-to-face, and lasted 24–45 min. All participants gave written consent to participate in the study after receiving verbal and written information about voluntary participation, use of data, confidentiality protections, and ability to withdraw from the study at any time (Beauchamp & Childress, 2013). In addition, a focus group interview was conducted with education specialists to provide an understanding of the support and staff perceptions related to the intervention delivery. Thus, a convenience sample was applied (Sedgwick, 2013). The principal investigator (DR) asked SEd education specialists whether they would like to participate in the interview. Seven of them took part and discussed the principles of SEd support. The interview was held at the unit in Södertälje. DR moderated the discussion, while HH and VL were facilitators and took notes. All interviews with service users and education specialists were digitally recorded with consent.

Table 1 Data material used in the study
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Data Analysis

The audio-recorded interview material was transcribed verbatim. The initial analysis procedure involved reading through the data sources and transcripts to gain an overview of the data as a whole. For each service user, data sources were transferred to an excel file to capture and discern similarities and differences and to illustrate the process. A cross-case analysis was performed for each qualitative data source, as described by Yin (2018), to identify and illustrate characteristics of the SEd process and the transition to engagement in school and work. Latent content analysis (Graneheim & Lundman, 2004) was used to analyse the qualitative documentation and interview data. The content analysis was conducted manually, using documents and table of Microsoft Word. Content from the transcripts was identified and the first author (UL) performed an initial coding close to what was apparent in the text. Then interpretation and clustering of similar codes into categories and then themes to describe the transition process (Graneheim & Lundman, 2004) was performed. Next, the descriptive analysis was validated with accepted concepts in the support principles (Bond et al., 2008, 2020; Lexen et al., 2013). Descriptive statistics were used to analyse sociodemographic characteristics, e.g., vocational and recovery-oriented outcomes of the service users, using IBM® SPSS® Statistics (Version 26). When conducting statistics in this small sample, there were not enough valid cases to perform calculations (Altman, 1991). The analysis was conducted in ongoing consultation with the co-author (UB) and the first author (UL). All authors agreed to the final findings.

Results

Socio-demographic characteristics of the 12 service users are presented in Table 2. To illustrate the practice example of the SEd process, the 12 service users were followed longitudinally and all data sources were used. However, one user left the study at 15 months and another at 18 months due to personal reasons. Four service users were interviewed individually. In addition, a focus group interview with seven SEd education specialists contributed to several perspectives on the SEd case and this allowed triangulation of data.

Table 2 Service user socio-demographics at baseline and data material used in study (N = 12)
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Figure 1 illustrates the service users’ transition and support process to engage in school and work. An across-case presentation of service users’ and education specialists’ perspectives of the SEd process and critical characteristics is illustrated by service user quotations. These illustrate support delivered and received over time in relation to the SEd principles. There are five categories with the overarching theme the process of supporting and enabling career advancement.

Fig. 1
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Service users’ transition and support process to engage in school and work

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Transition and Support Process to Engage in School and Work

The service users’ SEd process (Fig. 1) shows their transition to and engagement in studies and work, as well as the type of SEd support over time. Characteristics of the support categories are further illustrated in Table 3. At baseline, none of the service users were engaged in studies or work. Each of them had study as a goal. In addition, half of them started the process of achieving work. All service users engaged in studies during the 18 months of data collection (75% full-time and 25% part-time), and the number of users who studied increased over time. The most common timeframe for starting to study was four to six months. Ten service users started to study between four and nine months (50% full-time, 33% part-time). Five users studied at a high school level to secure eligibility for further education. Three entered specific vocational studies, another three studied at a preparation education level, and one started at university. They shared a common goal of having their studies as part of a work-oriented plan that was linked to career goals. Six also engaged in part-time work, three did so after nine months, and another three were working at 18 months. Areas of work were trade and services (n = 2), health care (n = 2), operation and maintenance (n = 1) and restaurant (n = 1). Furthermore, service user income type changed over time and some users became self-sufficient. Those who had income support from the municipality or had no income at the beginning of the study did not have this income status at 18 months. The vocational and income status at baseline and 18 months is presented in Table 4. According to service users’ scoring of the self-report questionnaires that regarded recovery, mean scores changed between baseline (N = 4) and nine months (N = 8), however, scores decreased at 18 months (N = 8), to baseline levels. Quality of life baseline, nine-, 18-months sum = 53/58/53, process of recovery = 25/28/23, self-efficacy = 13/16/13, internalised stigma = 25/23/24. Social inclusion scores not followed this trend (sum = 52/51/51).

Table 3 The support categories characteristics
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Table 4 The vocational and main income outcomes between baseline, 3–9 months, and 10–18 months (N = 12)
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The Process of Supporting and Enabling Career Advancement

The formulated overarching theme was the process of supporting and enabling career advancement. The categories included: The importance of initial career-oriented goal planning, Challenge of personalized benefits counselling, Person-centred ongoing SEd support is key, Collaboration with educational organisers is critical and Integrated support for careers in the mental health service.

The Importance of Initial Career-Oriented Goal Planning

All service users received initial support with personalized career-oriented goal planning. This initial support proceeded from several of the SEd principles, of integrating career planning at an early stage, and focusing on competitive employment or mainstream education. Further, the career-planning honour the service user’s interests, preferences and needs in accordance with the principle of individualized support. According to one of the principles of SEd program enrolment was based on the service user’s desire to study. While all service users in the program had the goal of studying, several had a work goal prior to enrolment. During the initial career-oriented goal planning, where they created a personal work profile according to the SE method, these users chose to study as a part of their long-term career development. One user stated:

We first tried to find me a paid job. One employer said that ‘I think you should study sociology.’ But to qualify, I needed to study [other] subjects first. That was what pushed me, more than the program itself, to take up the studies and start studying. (SU3)

Initial support by the employment specialist was often given in collaboration with a career counsellor and included similar components for all service users, e.g., study and work counselling, personal goal setting, establishment of a study or work plan. This also included individual preparatory activities to explore educational opportunities and resources, identify eligibility requirements and academic level, consider questions of social structure and environment while in school, as well as support of the application process. Some service users maintained career-oriented goal planning across the 18 months. The education specialist thought that user openness to focusing on both studies and work contributed to enhanced study motivation and advancement of work-related goals. The integration of SEd and SE support, however, was seen as challenging since the education specialists needed to be updated in education and work contexts as well as the two models even though they were similar.

The Challenge of Personalized Benefits Counselling

All service users agreed that the support principle of personalized benefits counselling and planning was vital activity to enable studies. Support consisted of exploring funding pathways and economic issues, and the education specialists gave hands-on support during user contacts for benefit applications. As one user said,

Contact between her (education specialist) and the Swedish Social Insurance Agency has been the most important. She helped me apply for another grant. As far as the Swedish Social Insurance Agency is concerned, they are not easy to have contact with. I think they should have a little understanding when you are actually trying, but it is not always so. She was a very good support there, and she does the fighting for me. She is the best, she listens and she understands their language a little better than I do. (SU3)

The hands-on benefits counselling and support was also needed during studies, but often changed or lessened over time. The education specialists thought there was a difference between providing benefits counselling towards education and employment. For education it was more difficult and time-consuming to find financial pathways and get approval from concerned authorises, especially when it regarded part-time studies. Furthermore, benefits counselling for education often involved finding benefits and funds that did not involve significant future economic risks for the service user. Employment, on the other hand, meant the opportunity to provide for one’s own livelihood and was an important motivational factor. The preparations for financing education and realization of financing was identified as more complex and time-consuming than counselling for employment (SE).

Person-Centred Ongoing SEd Support is Key

According to the principle of continuous support according to preferences, service users received ongoing person-centred support that continued for as long as they wanted or needed to continue to study, work or advance career opportunities. As one user said:

I received help to apply for studies and start my CV. Then this made me think more about school. To get started on things earlier than I would have done if I did it myself. And now during the time I am studying she (education specialist) follows up. I always have support for planning in case I need [it]. Getting this push has really meant a lot, and without this support, I do not think I would have started studying so early. (SU12)

At the beginning, the support had many equal components for all service users. Once users started to study, the type of support differed according to each individual’s counselling needs with regard to hands-on support and follow up of the student role and motivation. In addition, the ongoing support became more flexible when it concerned moving back and forth between work and studies. If a service user asserted work as a goal, their support included job-seeking activities. Once the user started work or study, there a distinction was made as to whether support was provided at the work/study site or offsite. Offsite support entailed academic support, time planning, structure and strategies, crisis and relapse planning, stress management techniques, skills training, motivational conversations, and encouragement. Examples of onsite support included identifying academic needs and need for an adequate physical and psychosocial study environment, and follow-along support. The education specialists thought of it as a balancing act and more challenging to provide offsite support since the student role had responsibilities and demands and the specialist could not be there in person (onsite). The offsite support was primarily provided through physical meetings between the service user and the study specialist. As studies proceeded, the contact often became more digital. The challenge of providing onsite support education specialists highlighted the importance of collaboration with educational institutions, programs and organisations.

Education specialists found that there were many similarities but also some differences between providing education and work support. Studying entailed a mutable setting, with new courses and new demands. This was in contrast to a workplace that was more permanent and had fixed tasks. Therefore, SEd involved a greater need for ongoing support, with constant need for new assessments, adaptions, and planning. Those with cognitive disabilities found it harder to adapt to the changing setting than to more permanent settings. A workplace setting was observed to provide social coherence for the service users. Overall, compared to SE, education specialists experienced education as more complex and challenging for the service users, and more demanding to be able to provide collaboration.

Collaboration with Educational Organisers is Critical

The onsite work/study support become increasingly important when service users began to establish contacts and resources in the educational setting. According the principle of collaboration with educational institutions, programs and organizations, education specialists gave hands-on support during contact with the school. A user said:

I am in contact with my mentor (at school), but sometimes it is hard to talk to him about certain things. Therefore, she (education specialist) also has contact with the school. She talks to teachers and finds things out. What has become so good for me, is that today I am positive about getting support and going to school. (SU 7)

Support was also provided to access study and educational resources such as tutoring, finding a mentor, extended time for exams, and other pre-conditions. Users who studied were struggling with their mental health problems and said that they met mixed public attitudes in their educational setting. This idea was also noted by the employment specialists. Treatment of students with special needs, and opportunities to access resources in the educational setting, were experienced to vary by school and diagnosis. For example, a user with a neuropsychiatric diagnosis was given easier access to resources. To collaborate on a system-level in education was experienced as hard to actualize. From an individual perspective, the education specialist’s collaboration with others varied for each service user. This was a successful way to unify planning that increased user opportunities to engage in studies.

Integrated Support for Careers in the Mental Health Service

Education specialists argued that it was hard to enable the principle of program integration of mental health and other welfare services on a system level, but were more successful on an individual level. The program fostered mutual acquaintance and understanding among the involved collaborators by encouraging service users to share their study or work-related plan within the support network. This made it possible to co-produce a good base for the user’s overall health and career engagement (education and work). Collaboration was found to be necessary to access of benefits and use existing service structures in the education and welfare system. The mental health service played an important role in benefits applications since diagnostic assessments and certificates had detailed information on specific diagnosis-related needs. Furthermore, sharing study plans with welfare services provided better opportunities for adequate funding and finances of the user. This integration of support resulted in improved pre-conditions as well as better mental health and welfare services because they benefitted from the SEd service and knowledge about mental health. One user stated:

I opted out of group therapy last year to focus on my studies, and it didn't work out. So now I balance both. But the group therapy, it is at very strict times—days. But the school knows about it now, and the teachers understand that I supplement [my studies] after [therapy]. (SU9)

Service users and education specialists felt that the fit between the SEd process and welfare and education structure was unsatisfactory. Service users often felt that that the community frame and structure did not supported their return to school. The education specialists said that there was a challenge to finding pathways for individual adaptions and educational resources when the service user’s mental health fluctuated.

Discussion

This study illustrates a practice example of the vital complement of SE to support of the school and work transition for young adults with mental health problems. On an individual level, important components of the support process were identified that enable education and career advancement for young service users. Components on organisational and system levels were essential for the development of this kind of recovery-oriented intervention in mental health services.

The present study contributes to the research evidence base of SEd (Ennals et al., 2014), and an understanding of how the basic SE principles may co-exist with an SEd program in a Swedish context. The current case demonstrates a promising example of how careers may be supported. Flexible service that provides support for education and work can be successful for supporting highly individual trajectories among youth. All service users in the program started to study, and half of them engaged in part-time work over the 18 month study period. This indicates the need for attention, and how adaptable career planning and hands-on support can increase opportunities to alter trajectories for young adults with mental health problems and allow them to engage in education and establish in the labour market according to individual needs. Such flexible service, integrating SEd and SE, is particularly suitable for youth who are developing their identity, because this is an important time to provide the opportunity to try things out and change in order to develop.

Our case emphasizes and helps visualize some differences with regard to how study- and work-oriented goals are supported. These findings may be important for in this type of integrated program. SEd was found to involve a greater need for support. First, the benefits counselling support was more extensive and continuous for education because finding funding options was challenging. Second, the roles of student and worker influenced the magnitude and challenges of the required support. The student role was linked to high demands for individual performance. As a student, the service user was alone in their responsibility to perform, while the worker role entailed being part of a working group and having colleagues with demands related to a limited workload and particular work tasks. This visualisation of support and its process is consistent with a previous case study of SE support and processes among adults with psychosis (Lexén et al., 2013) in a Swedish setting of SE support. In this study, both onsite and offsite adaptations and support were equally important. In the present case, onsite adaptations and collaboration in education served as a critical complements to offsite support. The opportunity to provide support and adapt educational performance and settings were restricted by the prevailing welfare and educational structures. In such circumstances, co-production through shared knowledge and acquaintances between the relevant actors is crucial in finding ways for service users to study. Participants and education specialists thought that is was more difficult to collaborate and integrate SEd in educational settings than in workplaces and with employers. Cooperation consisted mainly of separate, isolated contacts with the director of studies, the disability service or the teachers in the school. Lövgren and colleagues (2020) argue that cooperation between SEd services and education in Sweden has evolved to more consultative in character. Possibly, the large and obligatory educational system influences the opportunities to collaborate in a flexible way, at least as compared to smaller workplace settings as shown in previous SE research (Lexén et al., 2016). At the same time, the importance of collaboration is highlighted. Earlier findings show the potential of integrating SEd in school to help bridge the gap between young service users and accessible community education (Liljeholm et al., 2021). The educational environment was more inflexible in adapting to cognitive disabilities as compared to the work environment. Research on cognitive remediation reinforces this assumption that the educational environment and its associated tasks are clear, compulsory, and not easily adaptable. Moreover, demands increase over time, and social and cognitive skills are needed for adaptation (Kidd et al., 2014). Christensen and colleagues (2019) found this connection between cognitive skills and studying in a larger randomised trial of integrated SE/SEd, where social skills and cognitive training enhanced studies but not work. These high demands illuminate the importance of providing flexible support paying attention to the study environment and structure, and psychosocial context as vital components of the SEd support (Hillborg et al., 2021). Our results further corroborate that there is a great need for ongoing SEd support that compensates for high social and cognitive demands of the educational structure and form.

Service users’ scores of recovery-oriented outcomes show an improvement between baseline and nine months; this improvement subsequently reverted to the baseline scores at 18 months, when everyone was studying and had been doing so for some time. Although no causal explanation can be given, the descriptive statistics or data source may validate the qualitative data of high demands and few opportunities to modify the student role. We assume that the burden was greater at 18 months when everyone was studying, which was not the case at nine months. Possibly, improvements at nine months may not be directly linked to studies or work, but rather to the person-centred career support with attention to the service users’ individual recovery goals.

In the current case, the individual focus and investment of each service user and professional was successful in making the service more person-centred as a whole. At the same time, support became more fragile because collaboration was tied to user needs and flexibility of the professional, and not to the system. According to the education specialists, the SEd principles that consider the need to guide and advocate for users through solid collaboration with other stakeholders (Bond et al., 2008, 2020; Drake et al., 2013; Frounfelker et al., 2014) was difficult to achieve in the support process. The principles of how to organise and deliver support within the SEd program were easier to facilitate when experience, knowledge and skills already existed. Earlier SE research around service users in Sweden has found low mental health literacy among professionals in the welfare system (Porter et al., 2019). Lövgren and colleagues (2020), argue that improved mental health literacy among educational actors is a key factor for accommodating the needs of young service users. It is therefore important to reflect on the integration of mental health, education and work by increasing collaboration between actors in the welfare structures. In addition, when mental health literacy is low within organisations that support the process, the ability of these students to participate in studies is affected. Porter and colleagues (2019) suggest that the regulations of the professional's respective organisation frame the process in relation to the individual. In this study, the Swedish regulations were felt to discourage young adults with mental health problems from participation in studies because of difficulty in finding financial pathways and obtaining approval from relevant authorities to study. There were also problems in establishing solid cooperation with other stakeholders. A previous study demonstrated that opportunities to study were also negatively affected by the standardized structure of the Swedish educational system. Youth with mental health problems often felt overlooked when they needed help (Liljeholm et al., 2021). By contrast, when the service managed to integrate with the users’ support network according the SEd principles, there was success in providing onsite adaptions and support in school that were an important part of the support process as a whole (Lexén et al., 2013).

Figure 1 illustrates service users’ transition to engagement in school and work, and shows the required support process on a day-to-day basis. Young adults are at a critical stage of their identity development and transition to adulthood. Giving attention to their career planning as a whole, allowing them to move back and forth between studies and work according to their preferences, is particularly vital. Previous research draws attention to how development of work and student identity can enhance young adults’ opportunities for recovery (Babajide et al., 2019; Liljeholm & Bejerholm, 2019; Liljeholm et al., 2020; 2021). Although unpredictable trajectories of users may have challenged the support and service, committing to and allowing the identity process to unfold may have supported their recovery journey. The flexible service of the SEd program, according to the SSEE model of integrating both SE and SEd, can be applicable in other contexts when it is critical to assist professionals in their clinical reasoning about how to support young adults in development of meaningful life roles as a means for recovery and community life.

Limitations

The vocational outcomes in this study appear promising: all service users started to study and several began to work over the 18 month study. These outcomes indicate that SEd increases service user opportunity to study and participate in regular education. The outcomes do not show study-related results since the data collection about approved courses or received credits were incomplete. Continuing follow-up around these outcomes would be interesting and could have strengthened study reliability. Unfortunately, the data from the self-reported questionnaires were limited by insufficient data collection and service users who failed to complete the questionnaires. Therefore, the quantitative data solely illustrate and describe the time in the SEd process. There were not enough valid cases to perform a non-parametric statistical tests. The young age of the participants may have made it more difficult for them to follow through with the data collection. Pre-study understanding of the informants with recognition of the context provide a good base for research, but also provide risks that may influence the data. The first author (UL) has extensive experience of working with mental health and vocational rehabilitation, and the other authors also have wide-ranging experience in mental health services research. The dependability of the results is strengthened by the use of a study protocol, description and transparency of study design and procedures, and by using triangulation between the first author (UL) and UB, and secondly among all authors throughout the analysis process.

Implications for Future Research

A quantitative and longitudinal research perspective would provide a more comprehensive picture of the SEd program and information about the effect on study tenure, career-related outcomes, and mental health and recovery. Investigation of this integrated SEd and SE model of support in other contexts or as an early, more preventive intervention would be helpful. There was some divergence between SEd and SE in relation to the welfare system and structure. Further research is warranted to untangle these similarities and differences so as to increase the quality of implementation of SEd with the aim to facilitate young adults’ transition to school and work and recovery.

Conclusion

Integrated career-oriented planning in mental health services is promising for young adults’ transition to school and work and for support of their careers. The transition process of young adults in this study was highly individual, and required a flexible SEd service to support user needs and preferences. The flexible and integrated SEd and SE service may allow the user identity process to evolve towards recovery through student and work roles. Mental health services should include person-centred and career-oriented models for young adults. Models such as SEd (Hillborg et al., 2021; Killackey et al., 2017), SE (Bejerholm et al., 2015, 2017; Bond et al., 2008) and, advantageously, the SSEE (Liljeholm et al., 2020) should pay attention to support of both education and work. Access to this type of support is part of an important social rights movement for young adults who are experiencing mental health problems early in life. Such support may prevent their lives from evolving around being a patient and instead support them in their life roles of student and worker (Bejerholm & Roe, 2018).