Thanks. Hello, good morning, everybody. I wanna welcome you to today's webinar on helping individuals with a recent onset of psychosis thrive tips on supported education. I am Judith Doberman. I am the program manager for PEPMED at Stanford University School of Medicine. With us today, we have Dr. Kate Hardy, who's a clinical psychologist and a clinical associate professor in psychiatry and behavioral sciences in the Stanford School of Medicine. And also joining us today is Dr. Steven Adelsheim, who is a clinical professor at the Stanford Department of Psychiatry and Behavioral Sciences, the associate chair for community partnerships and the director of Stanford Center for Youth Mental Health and Wellbeing. Both Drs. Hardy and Adelsheim will be co-facilitating with our presenter your questions today. Today's webinar is brought to you as a partnership between PEPMED and SMI Advisor, which is a SAMHSA funded initiative implemented by the American Psychiatric Association. And we will be offering CEUs today for physicians and psychologists, and we'll share information on how to claim credit at the end of today's webinar. I just wanna share with you a couple of logistic items. Let me see if I can advance the slides here. So when you wanna, if you wanna contribute to the chat, we'd love your questions, and please introduce yourself as we start. And if you go into your bottom, you should have a bottom link for chat. If you open that up, you'll see the chat box. And if you click every one at the bottom of the chat box, that will then send your questions to all of us who are presenting. If you would like to communicate with just the presenters, you can do that as well. And now I would like to turn this over to Dr. Hardy, who will introduce Dr. Shirley Glenn. Thank you. Actually, Judith, I think we've lost Dr. Hardy, and I think if you could do the introduction, that would be... Okay, I see that. Okay, thank you so much. All right, Dr. Shirley Glenn, who is presenting today, is a licensed clinical psychologist who received her PhD in clinical social psychology from the University of Illinois in Chicago. She joined the UCLA Department of Psychiatry and Biobehavioral Sciences and the VA Greater Los Angeles Healthcare System at West Los Angeles to begin a program of research on psychosocial interventions in 1987. Her research highlights the critical importance of the environment in recovery from serious psychiatric illness, such as schizophrenia, bipolar illness, and PTSD. Dr. Glenn is also a key member of the National NAVIGATE Training Team, where she has overseen the training and consultation offered on supported employment and education in first episode psychosis, excuse me, in 20 states. She also conducts psychosocial research on several interventions on serious mental illness, including cognitive behavioral therapy for psychosis and oversees the national training and dissemination of evidence-based family interventions for the VA. Dr. Glenn. Good morning, everybody. Thank you so much for coming today. And I really appreciate talking with people who have an interest in first episode psychosis. I've been working in the field now for probably 12 or 13 years. And in that work, I've really wanted very much to have people, to have the folks with whom we work have positive educational opportunities if that's part of their personal goals. And when I was first involved in this work, we talked a lot about education, but it was college rather than high school or technical schools. And as I've come along, I've tried to expand sort of our practical knowledge about this topic. And I wanna try to share some of that information with you today. So I'm really, really glad you're here. You'll see, I'll be talking about research on this area, then talk about the kinds of accommodations that might typically be done if you're working with a high school or with this kind of challenge. And then at the latter part, we'll talk a little bit about overcoming cognitive deficits people might have if they're trying to do scholarship. So it's wonderful that you're all here and we'll share ideas together. So next slide, Judith. Okay, so one of the things we know is that people who are coming into FEP programs, I mean, they may say I'm really dying for that CBT for psychosis, or I'm really dying for that injectable medication, but typically what they really want is some return to normalcy in their lives, which often involves return to work or school or starting up a new program to address these functional challenges they may have. And that's the key to our discussion today. Next slide, Judith. I thought I might start with just a description of a case I worked with several years ago. This is someone who I met in the summer between junior and senior year of high school. Rachel was really a lovely girl, had done very, very well in high school, was very involved in track and field, came from kind of a resourced affluent family who had the highest aspirations for her. And then she had a psychotic episode towards the end of her junior year. Interestingly, not precipitated from medication as far as we know, but was very ill, hospitalized off and on for two or three months, would come home, get back, have trouble. And then came to me at the middle of the, kind of going into the senior year with a mother who just looked like, a deer in the headlights going, I don't know what we're going to do. I don't know how we're gonna get through this year. And we had tremendous aspirations for him. However, are we going to manage? Obviously, one of the things we tried to do from the get-go is start request an individual, an IEP, Individual Education Plan. I'll talk a little bit about that later. But it's the way the school can make accommodations to help somebody who's having trouble. And in this particular case, the school was, really wanted to help. You know, in my experience, schools sometimes feel overwhelmed about what we ask of them in dealing with psychosis in the students. But in this case, they really wanted to help. And so they gave a number of accommodations. They allowed him, he had high negative symptoms and paranoia as he was starting his senior year. They let him go to start school later. So he could start at 10 instead of 7.30. They made a plan that we understood he had significant cognitive deficits. So we were going to help him take as many classes as we could where he was working with his hands, which was great. And then we were going to, so this would be like art and cooking and woodworking. And there was kind of a financial class, basically anything where he could do things with his hand. She could do things with her hands, excuse me. And then the track and team coach asked her to start doing timing. She was so slowed down with medication. She couldn't really run anymore competitively, but she could time the other team members. And that was hard because the coach would have to get her up. She'd be lying down on the benches and he'd say, now's the time. But we all sort of worked together to get her through the school year. She did in fact graduate by the skin of her teeth. One of those things the school was willing to do, for example, is she had a health requirement and they were willing to count some of the first episode work she did as her health requirement. And by the end of the year, she was feeling a little better. We were able to get her into a community college. Again, her family had had much higher aspirations, but we were able and hook her up with disability services, get her to take just a couple of courses, which worked out well. She finally was able to transfer to a regular four-year school and graduate. Now, I think if you met her, you would think she's got challenges, but she was able to make her education to achieve that. And it was an important goal to her. And I think it was the help of our work and the disability services that are offered throughout our education system. And that's really what I want to talk a little bit more about today. Next slide, Judith. Okay, some of these slides, if you came to my supported education talk about six months ago, these will be familiar. This is just to contextualize. Again, we've got people who are living their lives and then they develop a psychotic illness. They may be going to school or working, have aspirations and dreams. And one of the important things for us to think about with school is they may have been like I was just talking about, they're successful at school, or they could have been many years before psychosis been in special ed and had trouble and may already be struggling. And so one thing as an employment and education specialist, you really want to try to understand what's the trajectory the person was on before they got diagnosed. Next slide, Judith. All right, and then we have to think not only what trajectory they were on, but how might symptoms impact on things? Obviously, if you're having positive symptoms, I'm thinking right now a client I saw last night, he has a tremendous problem with thought broadcasting. He was just, so he can't really sit in a lecture. He just found out he got accepted to a school that will likely have in-person courses in the fall. And he's now all in a jitter, how ever am I gonna do this? People obviously have negative symptoms, lack of motivation, and then cognitive problems, difficulty with attention, concentration, all the things you need for school that you may not have, that we may not fully focus on because the person's positive and negative symptoms may be clearing. And we didn't know that before they developed these more severe cognitive deficits. Next slide. Okay, just to briefly talk about the age group of people we're working with. We wanna think about what are the developmental issues that would impact on any 16, 17, 18 year old going to school, 19, 20 year old. That certainly peer relationships are very important. People have to, are working to individuate from their family at a time where they may be increasingly dependent on them. There's a high rate of substance use. So we have to think about that. There may be a desire, there's a desire to exert autonomy, which is kind of can be challenging. There's trial and error. People are trying new identities. They're taking the course or dropping the course or seeing what's going on. They may be reluctant to think of their situation as serious and there's a lot of stuff going on. I think for those of us who are older don't really appreciate how much social media, peer things, rejection and marginalization at school can really impact on people. Next slide, please. All right, just to remind you again, quickly principles of supported employment and education, just so we're all on the same page that everybody gets the services when they're coming into CSC, you don't have to be ready for them. But if people don't want them initially, we get them down the road, that we respect individual goals and preferences, that we're interested in getting people into competitive school, not specialized school. Next slide, Judith. If there are issues around benefits, perhaps are on SSI, SSDI, thinking of applying, we wanna be attentive to that, but not necessarily have the employment specialists take the lead. We want to work with the other team. I mean, we need to work with our individual therapist, with the prescriber, with the family person. I mean, you can imagine with younger people, particularly decisions around high school and college, families are gonna have a lot to say. We want to be working with them and all be on a collaborative team. We want to begin with working with people as soon as they say they're ready and want to take on something. Next slide. Again, we don't do a lot of pre-vocational work, we really get out there. And then we continue to provide support as long as people will give it to us, will let us. Typically, if you're running a two or three year program that you're continually working with people, I often say till they kick us to the curb and say, I got this. Next slide. All right. I wanna talk briefly about two recent research trials that talk about the efficacy of the work we do with regard to education. Next slide, please, Judith. All right. First one is the Kalaki study. You guys may have heard this. This is kind of an older study, but they recently published some somewhat troublesome outcome data, long-term outcome data, wanna bring to your attention. So you guys may know Ian Kalaki. He's in Australia. He did one of the first randomized controlled trials. It was on IPS, individual placement and support for people with first episode psychosis, compared that to customary care. People needed to say they wanted to go to work or school to get into the trial. Next slide, Judith. This is just briefly saying who came. You know, people in the average early 20s, mostly men as we see in our trials, been ill about a year. Next slide, please. These were the initial data. He presented, first of all, unemployment and then combined education. So these are the two groups. And as you see, the blue is how many people were not working. The white is how many people were working. And as you see, by six months, a majority of the people who got the IPS, the vocational intervention were working, which is wonderful. Next slide, Judith. And when you add how many were going to work or school, you can see there's still quite a benefit to the IPS intervention. So that again, this is offering IPS over six months. Next slide, please. Okay, here's the challenging thing, and I don't expect you to read all the text. The important thing is you see here from, in this slide, Glocky recently presented long-term outcome data. You see zero to six are, that's the first six months in the trial. That's what we were talking about. And you can see a clear advantage in the gray line to the people who got IPS versus the black line, excuse me, treatment as usual. But here's the thing you see. Once they withdrew the IPS at six months, you lost the effect. So basically the differences at 12 months and up to 18 months, you see that little crossover, but basically there wasn't a difference between the groups. So this is kind of a discouraging thing because it means that if we withdraw our treatment, maybe people won't do as well in education, but that's hard to know because this was such a short intervention, only six months. So now let me show you another trial. Next slide. Okay, Keith Echterlein, many of you know him. It may be that Luanna Turner, who's like the queen of the supported employment work they do there is on this presentation. But basically what they did is they take people who have been ill a little longer. You can be ill up to two years. This is a study they recently published where they had 69 people. They randomized them to get either a version of IPS and some clinic-based group on how to function well at work versus a referral to voc rehab and social skills. And they gave treatment for 18 months. Next slide, please. These are the results for school. And what you see is sort of interesting. So at the bottom, you see the 18 months, the broker, the referral to voc rehab is the broken line. IPS is the straight line. And what you see is that over time, even people in the treatment as usual, the voc rehab group were going to work. Excuse me, were going to school. Over time, they improved. But the people who got access to the employment specialist did it much more quickly. So that people, if they could get the employment and education person working with them, they went to school much quicker. Next slide, please. This shows almost a similar combination of data. This is just showing that with work, you also got a benefit of the employment. The specialized training compared to treatment as usual. So how we understand this is at least while we're giving longer term support, here 18 months, you got people who were doing better at either school or work. They tended to improve faster and they got more benefits. That's why we have you here working with people with the first episode of psychosis. Next slide, please. Now, why do we want to keep individuals in school? Certainly it's the way our society is designed. 18, 19, 20, 21 year olds tend to be in school. But we also know that there's some benefits in terms of getting an education and then being able to stay in the labor force and make more money. So let me show you a little of those data. Next slide, please. This is just a slide showing that the more education you have, the more likely you are to be in the workforce. And that's really true for women, okay? So if you look at what percent of people are in the workforce, and you look at high school graduates, this is people who had high school and then held jobs. You can see that it's not quite 75% for men and it's less than 50% for women. So essentially, if you haven't graduated from high school, if you're only a high school graduate, let me take this back, if you've only gotten that far, the rate of participation you have in the workforce is quite low compared to, for example, if you went to college, you know? There's a 10% more likelihood that you're gonna be in the workforce if you finish college. And I'm sure I'm not the only one who has, men in my family, typically men, who didn't graduate from high school or just graduated, and now they're 20 or 30 years out from school and haven't got a hell of a time getting a job, you know, that it's very, very hard. So just getting an education increases your likelihood to be in the labor force. And not surprisingly, next question, next slide, it also increases the money you make, right? That's, you know, part of the reason people go to school. So if you look at the average wage, this is from 2016 US Department of Labor, what's the average wage that people made for a high school graduate? What is it? About $650 a week, perhaps. Whereas if you look for, if you look for people who have bachelor's degree, they're making almost $500 more a week. So we try to keep people in school, both because it's socially normative and because it indicates they'll be more likely to work down the road, and hopefully they'll make more money. Now, these studies were not done on people with psychosis, but there's no reason to think that we can't use them to kind of bootstrap our work. Next slide. Okay, so I've been talking sort of in some broad generalities. Now I wanna get down for the last half of the talk, the nuts and bolts of ways I think about this, potential tips for you if you're doing supported employment and education work when you're focusing on school. Next slide. Okay, so these are just some quotes to tell you what do people need. This is again from Keith Nectarline's trial that we just talked about. First of all, that people want a range of educational opportunities. Some people want a GED, some people want a four-year college. Many people, in fact, most in their trial look with looking at a community college. And I would say that's true of the work we've done too. You'll see here, they don't have high school. They weren't taking as many youngins. I think at least in our navigate sites, we typically always have at the sites maybe 10 to 20 people in high school. So I'll talk a little bit about that too. Next slide. Okay, people needed help with study habits. I can't overemphasize the importance of paying attention to cognitive difficulties people have. There'll be some attention to that in the individual therapy, but it's really, really true that what makes or breaks many of the successes of folks we work with have are whether they can organize their notes. I mean, I have a client I worked with who just started graduate school and I've known him since junior college and he has a problem with psychosis. And he was so proud of himself because he's got this whole elaborate color screening, color scheming for notes in the book because he has a really hard time organizing what's a fact, what's an opinion, how to think about these things. And now he can look at those books the night before, know what it is and study. It's wonderful. Next slide. Okay. And another thing we need to think about, this is just, again, from a key study where Luana was part of, that some people wanna go to work, some people wanna go to school, and some people wanna do both. It's always a fine line for us because we wanna support personal preference, but we don't want people to get overwhelmed. So figuring out how we're gonna manage that can sometimes be challenging. Next slide. All right. So overall, the strategies we use in education are quite comparable to the ones we use in employment. There are a few subtle differences. First of all, many of the people you work with may have had no work experience. So when you try to get them to figure out an ideal job, they may really struggle a little bit. We've all talked about this, what's your dream job? And somebody who's 22 may look at you quite blankly. But everybody you work with pretty much is gonna have experience in school. They're going to have some things maybe they're proud about, some things they're ashamed about, some things they are worried about. Many of them may also have what's called an IEP, which I'll talk about in a moment, which is a plan to help them because somebody's already identified they have performance deficits. And I think this work is a little more hands-on than supported employment. You know, when we do supported employment, we try to match somebody with a job, give them some intensive work in the next two or three weeks. But then they can often work towards getting the skills and we don't need to necessarily do a lot of intensive work with them. School stuff, there's hard stuff every semester all the way through the semester, sometimes for five or six years. So it really requires being a little bit more down in the nitty gritty, I think sometimes. Next slide, please. Okay, thinking about high schoolers, all right? Obviously, as I mentioned with my story with Rachel, psychosis can disrupt learning and school adjustment. Oftentimes, if people are having difficulty in performance at school because of their psychosis or other mental health challenges, we need to help them get either a 504 or an IEP plan. And I will talk a little bit more about the distinction with that in a moment. One of the things, of course, if you're working particularly with a minor, the only way you're gonna get access to the school and to talk with counselors, which you often wanna do, is if the parents allow this. So one of the things you're trying to do is work with the parents to see how you can really have some interaction with the school so you can really get a sense of what's going on. Even if you can't have access to the school, you can certainly help people with homework and learning strategies. I mean, I just spent some time on Tuesday working with a lovely young girl who's applying to colleges. I've been working with her for about three or four years, and now she has to do some live interviews and auditions for college. And we spend a lot of time talking about how she can do this and how she can do her homework and those kinds of things. As I said, you may or may not get access to the school, but it's wonderful if you do, if the parents agree. Social development in high school is critical. I'm gonna go back at the end and talk a little bit about why that's particularly important in the high school context. And as I said, academic work requires us to be pretty hands-on. Next slide, Judith. Okay, this is a little hard to read, and I would not connote myself as an expert in IEP versus 504 plans. But I do think this, if you're working in this field and you are working with high school people, you need to start educating yourself about this. The distinction between these two programs, you may have heard of both. 504 plans tend to be a little less elaborate. But in both of these situations, these are combinations that the student, the family, and the school agree to, to manage some kind of performance deficit or challenge that the student is having in the schools in the academic setting. 504 ones tend to be less elaborate. A typical one might be, my niece had one. She developed diabetes when she was in high school, and she was a very good student. There were no problems with performance, but she needed to leave insulin with the school nurse, and the school had some expectations about what was gonna happen about managing her medical care, okay? Not an elaborate program, not that hard to accomplish. 504 plans tend to be more elaborate. Those are the typical programs, those are the typical plans that the folks we work with might have. I'll go through the steps in a moment, but really it's about somebody who's having either a significant performance, a performance deficit in school or in some other severe aspect, in some other part of their lives. But of course, the schools are particularly attentive to if somebody, for example, was a good student and is now a poor student or falling asleep in class or more irritable and causing trouble because they're symptomatic. You're not gonna be the people writing these plans, of course, but you may be the people educating family members about them or sitting in on those meetings. So let's talk a little bit more about that. Next slide, please. I wanna talk more specifically about an IEP because that's actually a legal process. This is sort of the, I'm gonna talk the generic way it goes. There may be some slight differences, public school, private school, those kinds of things. But first of all, a parent has to request that their more elaborate plan is the IEP. And the parent has to request an IEP in writing from the school saying what they're worried about, so where their performance deficit has happened. And this is an example of a typical kind of letter. You don't have to, it doesn't have to be like this, but it says what the problem is. It's in writing and it's requesting a response in a timely fashion, I think 15 days. Next slide, please. Okay, so what are the steps then? The parent makes the request in writing, the district, the school district has 15 days to respond and basically say, you know, we'll do testing or we see there's a problem or here's what we're gonna do. And then the parent has time to respond to that. Based on whatever agreement is made at that point, the school typically will then agree to an evaluation for disability and conduct that assessment. Any of us who know teachers, special ed teachers or school psychologists have heard people talk about this. Occasionally a school will say, I don't see the problem because there isn't a performance deficit. But I think often with first episode psychosis, we really do see those problems that schools usually are amenable to doing these assessments. And this is typically done by school personnel. They may not even request the medical records that the person has in the coordinated specialty care program. Next slide, please. Okay, then the school is looking during this assessment period to see whether there's a disability and what are they looking for? Discrepancy between performance and ability, limited progress, cognitive difficulties, behavioral disturbances, the kinds of things you might imagine. And they're typically giving the student a battery of tests to see what's happening with regard to that. Next slide, please. Okay, then the individual education plan is developed. Typically the school will have some ideas. They'll be putting a plan together. They'll actually present that to the family members. The school has a, there are timeframes on all this, how long they have to do the assessment, how long after the assessment they present the plan, whether the family can then appeal the plan. But somewhere in there after they've done the assessment, there's usually a meeting, a conjoint meeting, school personnel, parents, students, and maybe you. Next slide, please. Okay, and when they're presenting the plan to the family and the student, these are typically the topics they're covering. And I wanna draw your attention to the two bolded items at the bottom. Basically, most department of education programs, state department of education programs, and vocational rehabilitation programs, state voc rehab programs, have specialized programs for kids who are 16 or older who seem to be having trouble in high school or are gonna need some career guidance. So one thing you guys could definitely do is start exploring that if you're not familiar with that in your state. So that if you're working with a kid who's 16, 17, high schooler, maybe gonna have trouble with school or needs money for school or talking about career work, that they often have programs you can kind of lean into a little bit to perhaps get a little vocational testing or some ideas on technical schools. So these are two good programs for you to be thinking about. Next slide, please. All right, as I said, the IEP is presented to the family, the student, and typical school personnel who have developed it. And then they negotiate a little bit, okay? What seems to work? What are the family's ideas? How do we work with this? Next slide. Okay, and then once that program is implemented, it's up for yearly review. And a really good thing you can have an eye on, particularly if you've been part of the planning process, is paying attention to whether it's actually respected. For example, I was just telling you about the girl I saw this week who was doing the high school, she's doing auditions for college. She has an IEP that where she only has to do half the schoolwork in every course. Well, you know, that's kind of hard to figure out. What's the half the schoolwork in math? Is it every other question? What is it in English? It's reading half the book? I mean, the teachers sort of struggle. And one of the things that employment specialists and the family have to kind of do all the time is sort of remind the teachers and help them think this through. So that could be a way you can be helpful. Next slide, please. All right. I wanted to talk with you just a little bit about the kind of accommodations you might be able to get in a first step in an IEP with an individual with a first episode psychosis. Now, some of these I've already mentioned that we've gotten, other ones I'll share with you. First of all, if somebody's groggy in the morning, maybe they can have a shorter school day. Now, the challenge with that is the school may say, they can have a shorter school day, but we don't have a bus to get them there at 10 o'clock. That can be a problem. But, you know, it's something you can, then the family has to provide transportation or maybe they're close enough to walk. As I mentioned, if somebody has difficulty with abstraction and concentration, maybe they can take more photography, cooking, computers, less abstract things. If somebody, as I said, has difficulty with completing assignments, negotiating fewer assignments, maybe you only have to do half. If somebody gets overwhelmed at school, becomes symptomatic, then you can go for respite in the nurse's office and the family can often go and often prep the nurse. And in my experience, some school nurses, if they're in the schools, do a wonderful job helping people calm down. Some schools also have these programs where there's another room you can go to. Next slide, Judith. Couple other things we've done. As I said, meetings with the CST team may count as, CSC team, sorry, may count as a health credit. I wanna do a shout out to the people we worked with at the Minneapolis, in Minneapolis. They were some of the most creative employment specialists I've worked with. They did all kinds of things. They would have their meetings with their individuals and play basketball. And that could count as a phys ed credit or they would take them to the museum. That would count as an art credit. And one of the things they also did is they sort of served as the interface between the IRT and the student about how they were gonna manage symptoms at school. They got suspicious if they got paranoid, whatever. Next slide, please. Okay. Sometimes high schools wanna refer people out either for homeschooling or continuation of high school. This is probably the point where I should say that of course with COVID, everybody's on homeschooling. And most of us know it doesn't work so well with people with any, many high schoolers, some thrive, but many struggle. But people have, when people go back to the classroom school, high schools often say, this is too much for us. Can we do homeschooling or send somebody to a special high school? I think that's really hard for the kids we work with. I think if that's the only option, that's the only option. But remember, we're often working with people who have compromised executive functioning. And we can just see now with the work with COVID how much effort it takes if you're not in a school environment to plan and structure your time and your schedule and get there and be doing the work at the right time without the input of teachers and stuff like that. And the ongoing basis. Somebody wants a copy of the PowerPoint. I think you guys can get it, but we'll figure out. All right. So I really try generally to keep people in school if it's at all possible in a traditional school. Not easy with COVID, but next fall, if it's possible and try to bolster people up. Next slide, please. Okay. Another thing you need to keep an eye on while you're working with your person if they're a high school is about applying to college, okay? You know, now is the time where people may be applying. I mean, the kids I'm working with who are seniors are applying to college, four-year colleges, junior colleges, maybe in the spring. Hopefully the school has an infrastructure to help with that. But some schools are not really good at that. And you wanna be in on that as well. If you're working with somebody who has a desire to go to college, you wanna be sort of helping them think about what's the academic calendar gonna be? When's the FAFSA due? When's your essay due? How are you gonna manage this? And maybe even take people over to look at the junior college or whatever. You know, you really wanna be having that. One of the things about this part of the job is you really want to be aware of the academic calendar and how that impacts on expectations of people, both students and when people are applying to college. Next slide, please. Okay, before I leave high school, I wanna talk about how important social development is. You know, our world lets high schoolers, it's a place where there's a lot of expectation about how people are gonna learn, right? And, you know, it's the time we often have our first relationship, we learn to drive, we may get our first job, may get our first checking account. A lot of developmental things happen. And socially, there's a lot going on. And that's very tricky because you can imagine if you had a first episode psychosis and you were bizarre at school and the other kids know it, how very hard it can be to go back. And we don't ask other people to do this. I mean, I've certainly worked with first episode folks who quit their job. They're not going back to the job they were on at, or they're not going back to the college. But in high school, this may be the only high school in town. And so we really need to help people think about that, deal with that, figure out about shame. I saw, I think Kathy had an article about dealing with substance abuse. I think about one client I worked with who smoked a lot of pot, developed schizoaffective disorder, and had to now go back to school. And he had been bizarre in front of his friends, and they all smoked a lot of pot. And now he was terrified. I can actually think of two people I've worked with like this. So part of what we really had to work on was him, he understood on some level, if he was going to go back to school, he couldn't smoke a lot of pot with them. And he had to have some way to relate to them because he'd been bizarre at school. And so we taught, you know, it took him three or four months to actually get there. But finally, he had enough courage. He could reach out to a couple of them. And we spent a long time talking about how he was going to interact with them. They started inviting him to parties again, and he knew he couldn't smoke pot. And how was he going to deal with that? How was he going to say no without feeling like an oddball or making them feel odd? So really working with people. I are, you know, if you've got an individual therapist, that can help, but you'll be there too. Next slide, please. Okay, so hopefully you've either gotten the kids through high school or they've come to you when they're in college. And so what do you need to think about if they're contemplating college or going to college or there's a college that's floating out there? So I always like, I think it's wonderful, difficult with COVID times. But if someone is contemplating going to a college and you can possibly, and it's within like an hour's drive so you can drive there at some point. Again, we'll be talking either in the before times or maybe next fall. I think it's great if you can go on campus with people, walk around, find the disability office, find the library. I love to take people in and peek in a classroom and just sort of say, you know, imagine yourself here, what would be exciting? What would be scary? Sometimes we'll actually talk about what seat would you like to be in? You're the kind of person you wanna be in the front, you wanna be in the back, you wanna wait for a cute girl or guy to sit down and sit next to them, wanna sit next to the door. How close, how soon do you have to get to class to get that seat? To really help people begin to think about what that would be like. Next slide. Okay, obviously there's also a million issues to discuss. FAFSAs, you know, helping people. Most of the time, in my experience, parents will help their kids with FAFSAs. You occasionally get parents who will not and then you really have to help the kid figure out what they're gonna do. And the parents, there's been a difficult divorce or something like that, that can be hard. The other big issue, you want, you know, we always struggle a little bit about many of the students wanna take on a big thing, they're excited to go to college, they wanna take four or five courses and they're gonna be hard. And yet we may also have people who we think would do better if they only take a couple of courses. So thinking about that, you know, I haven't had a lot of success encouraging people to ratchet down initially. They sometimes need to do trial and error to do that. But, you know, we try to at least help people contemplate, if you're taking physics, chemistry, algebra and some kind of literature course, what will it be? Always thinking about accessing disabled student services. They can be a wealth of resources for your student. Typically a student needs to acknowledge that they have a disability and at least where I am, they have to put, have an ICD diagnosis from a mental health professional. But that can be really wonderful. And some places state folk rehab will pay for school. And so certainly it's something worth you exploring to see if that could be a resource for your students. And always keep in mind application and acceptance dates. Next slide. Okay. As I said, it's wonderful if you help people hook up with disability services. Some won't want to because they can feel a little ashamed or want to do things alone. But boy, the resources are really, really wonderful. Sometimes the school will apply a note taker. I had a recent client who started a school at a university in California. They just took his phone and put a transcription thing on his phone. So he can just get tapes of every lecture he goes to. They may get early enrollment if school classes tend to be impacted and there's full. They may get more time for testing or a special room for testing, special career counseling, tutoring, wonderful services. And as I said, I often encourage people to think carefully about how much they want to take on. Better two A's than four C's is my theory. But not everybody believes that. So we do the best we can. Next slide. Okay. A critical thing, and I alluded to this before, but I want to highlight it again, is you knowing the dates, the critical dates of the people with whom you're working around school issues. And the big thing to notice is when's the drop date? When's the date they can drop without a penalty? You're going to get people who, as I said, take on a lot of courses, maybe more than they feel successful at three or four weeks in. So if you know the drop date, you can help them figure out, should I drop and what should I do? I want to say something else, which I don't think I have here on a slide, but I do want to mention this. Oftentimes, people coming into a CSC program, part of how they've gotten here is they've bombed out of college. That is, they became symptomatic, they left school, they may have never paid another bill, they didn't withdraw from their courses, and now they're either trying to go back or they're trying to get a loan or they're trying to get a transcript. And they found out there's loads of cleanup to do at that school. My experience has been employment specialists can do this work, employment education specialists, you guys, can do this work, but it can take a few months. So if you have somebody coming in who has had prior college work that sort of ended badly because they became symptomatic, you really need to help that person reach out to the school, find out if there's a bill, is there forgiveness, are there unpaid loans, can we get on the program, or is there forgiveness. What can they, they often, if they write, if they can get a letter from their current psychiatrist saying they were symptomatic back then, at least they can maybe get withdrawals instead of Fs. But so another thing you want to keep in mind in the college thing is really understanding what happened with somebody at their last college experience. And they may not know. They may be very unclear about it because they were symptomatic. So we want to help people with that so they can go forward. And then finally, I'm a big fan of encouraging people, even in COVID times, to take maybe an online course if they're wanting to figure out what to do. I always refer people, you know, the Coursera Yale happiness course, which is, I think it's called like well-being, the science of well-being. You take that for free. It starts every couple months. It's a nice way to people put their toe in the water if they had a bad experience in school and they now want to go back and see a little bit about what it's like to sit there. It's free. The Khan Academy is kind of another place that you can get free courses. So just something to think about, ways people can get a little experience. Oh yeah, Judith, next slide. Okay, then what are the supports we offer people? I mean, I think it's wonderful if you can get regular feedback from the professors or they can get regular feedback from the professors that they're sharing with you. They can be hard to do, but it can be wonderful. You can take a role in teaching study skills. Again, hands-on. I mean, I have one woman I'm working with right now who really wants to get back to graduate school. She was in math. She has a lot of symptoms and one of the things we're doing in preparation, her symptoms trigger her and then she needs to put work down. So one of the things we're doing now is we read a little bit of a textbook or a newspaper every day. The woman I meet with, she's usually twice a week, and then talk about the trigger, see if we can move forward so she can continue the scholarship. You can read papers and help with grammar and everything you might do for somebody who needs help in this area, but you do need to plan it and kind of be hands-on. I'm going to talk a little bit about cognitive skills in a minute as a special case, and then I think talking about socialization. Again, I talked about this in high school. It's important in college. Thinking about one kid I worked with who was really, really great, went to Tudor College, had had some symptoms, so now they're all meeting in the cafeteria. Again, this is pre-COVID, and he didn't know whether he should go up to them, how bizarre he had been, would they be nice to him, how was that going to go. Everybody spends their time there. He had horrible shame. We worked on this quite a bit for a couple of months, and then he finally had the courage to sit down with them, and they were nice to him. It was wonderful. They were like, hey, where are you? What are you doing? But helping people with that aspect of things, how you ask for notes, who you talk to as a lab partner, all that kind of stuff. Next slide. Okay. I always like to reflect on Ellen Sack's work, discussion a little bit. She talks in the Sutter Wilmot Holden, of course, here that about what happened to her when she became symptomatic in law school, and you guys probably know Ellen. Ellen has schizophrenia, and she's got a MacArthur award and is a dean at a law school, one of the deans at USC, and she says, you know, this is talking about when she got ill in law school and what help she was getting. I learned to be a student before I became ill. It gave me a great deal of satisfaction. My time was scheduled. My time was flexible. I could do work without interaction with others. A menial job for me would be much worse. So even though she became symptomatic in law school, taking a crappy job rather than going back to school might have been more stressful for her. Next slide. There's a piece missing there. That response, I apologize, that response was to a psychiatrist suggesting she withdraw from law school and take a menial job, and her point was that that would be good for her, that she actually did better as a student than she ever would at McDonald's, and because of the flexibility, because of the capacity to set your own hours, work individually, and those kinds of things, and that was important. Okay, I want to briefly talk about GED programs. We often have people who want to, either they want to finish their GEDs, or it becomes clear to us that would be a good recommendation from the treatment team. These programs have evolved a lot. Oftentimes now you're going to a physical place when COVID is over, but you're mostly working independently on a computer. They can be expensive. Sometimes you need two or three hundred bucks to take the course, so finding out if there's any scholarship programs or if there's any local groups like a Rotary or something who might help people who want to do that, I think that's really important. You want to think about, as I said, most of them now you're sitting in front of a computer, so it's just like the challenges people have with Zoom, so helping people think about that and how they're going to structure their time and take breaks is all important, and if you have the capacity to get to know the teacher and kind of present your students and talk about how you can be helpful, that's great. Next slide. Okay, every program I have been involved with, with Navigate I think, ends up having one or two people who have applied to graduate school, and often they're lawyers. I don't know why, but these people of course often tend to be older, and many are trying to get either back into school or work on their profession, so I would expect that this is going to be floating around at some point. Mostly you'll be working behind the scenes. You want to pay attention. People in these kinds of professions need executive functioning support. They really need to be able to organize and plan their time and think logically and those kinds of things. We can help a little bit, but I also think it's wonderful if we help those folks connect with academic mentors if they've had any. I think that can be really, really helpful. Okay, next slide. All right, the final thing I want to talk about, and just to kind of contextualize, we'll probably go for about another 10 minutes or so. I'm going to talk briefly about addressing cognitive difficulties, and then I know there's a lot of questions. I can't answer them all, but I'll answer what I can. If you get our C manual, which is at navigateconsultants.org, or you can email me, we have an appendix on how employment specialists and education specialists can help people deal with cognitive difficulties at work or school. And the big message, final message I want to give to you is pay attention to this. Really try and understand what are the cognitive difficulties the people with whom you're working have. We've got a handout. I'm going to briefly talk about this, but this is really, I think, where a lot of the work we do. Next slide, please. Okay, as I said, you can find that in our C manual. We break it down into some domains. The handout itself, it's kind of bulky. I wouldn't just give this to a participant and say, let's work on this. I would do it in very small chunks over several sessions, but I'll show you the topics we do and what we suggest. Next slide, please. Okay, so first of all, people may have trouble with attention and concentration, right? So what are the kinds of things they can do? Take a break, take away distractions, get a special study space, say things out loud to themselves, write down steps of what they need to do. Next slide. People may have difficulty not responding quickly enough. There we think about overlearning material. They can practice with timed tests, or you can help them think about more efficient ways of doing things, like their strategies for multiple choice exams and such. Next slide, please. People can have problems with memory, remembering things. We ask them to repeat what they've heard. They can use notes, writing things down. The more times you write it down or say it, the more likely you are to remember it. Getting organized a little bit, using mnemonics. Next slide, please. And then problems with executive functioning, which is really a challenge. I think one thing you can really do that's really helpful, help the folks you work with get scheduled. You know, use their phone, figure out how schedules are going to plan the night before so they know what they're going to try to accomplish, or recognize early if there's a problem in what they're doing and figuring out how to get help. You can teach them the steps of problem solving. You can use pro con list. You really want to help people begin to think as logically and as planfully as possible. Next slide, please. Okay, I made this point before. I just want to say families can make or break how people do in school. So we want to, you know, I would encourage you strongly to collaborate with families. If the family doesn't want someone to go to college, even if they want to go, the family may be able to, may have some anxiety about it. And unless you can help rectify that situation, you know, the person may have a hard time achieving their goals. So we really want to engage families as much as possible. Next slide. Okay, I'm supposed to say something about cultural and racial differences. Unfortunately, I think in the area that we work in, which is C and first episode psychosis and school, there's really not a lot of data that I know. And I know there was a question about long-term outcome. I think, you know, we're going to have to navigate long-term outcome. But we don't really know a lot yet when you withdraw the support of C, how people do in first episode psychosis. We do know long-term patients, many do well. Debbie Becker and her group have published on that. Shake here with us. And the other thing I want to say is a lot of programs use peers, which I think is great, but the peer, I think it affected peer in an education program. The peer needs to have graduated from college, have to graduate from college because they're helping people graduate through college. And they have to have had some jobs so they can sort of understand how the world works. Okay, next slide. Hi, here are a couple resources. You know, Nev Johnson, her group has a wonderful toolkit that came out through Nashville. I would encourage you to look at that. It's about how to disability in college. Debbie Becker's group also has a kind of an IPS toolkit for education. And then we have our senior. Next slide. I think that is it. Here are my preferences. Okay. And I know we don't have a lot of time, but I know some questions have been coming in. So I'm not quite sure how to manage that part of it. Does someone want to read me a few questions? Yeah, I'll help. Thank you, Steve. Of course, Shirley. And thank you. Thank you for this wonderful presentation. And I just have to tell you as a child and psychiatrist and someone who has done school mental health for a long time, seeing this wonderful information about 504 plans and IDA, it's really wonderful to have this all included in the discussion. Or try. It's really terrific. And a lot of the questions really seem to relate to some of the IEP related issues and some of those components. You know, and I know that some of the questions that came up, I know Kathy asked about where does substance abuse issues fit in with sort of addressing some of these issues with school. And I know that, you know, within 504, there are important issues in terms of when substance abuse can be included or not as a disability. I wonder if, you know, one of the things I was also wondering related to these questions, there's a lot of, you know, you mentioned the looking at the issues of 16-year-olds looking into vocational support. I think one of the things that's important for maybe people to understand better is what it means around IDA supporting young people up through 21 and what some of the options might be related to some of that support through secondary school settings. I wonder if you could comment on that. Yeah. Yeah. And some of those accommodations. I find that to be a little tricky because my experience that there are certain circumstances where the public school system is supposed to offer resources up to the time when someone's 21. However, my experience has been several of the people, and I've seen that happen, particularly around developmental disabilities. The challenge we have is I think oftentimes the people we work with want to get out of high school. And so there they're really looking for, is there a college, technical school, something like that. So it's a tricky kind of area. And it often involves trying to sort of work with both rehab and work with the high school and maybe the Department of Education and really trying to see what's available. And it differs somewhat by state and by enthusiasm of bureaucrats. So there's some struggle there. Right. And related to that, I think your comments about some accommodations in community college or colleges, one of the questions that had come up was about early enrollment. How does one develop the opportunity to actually do that? Right. So where I am, I'm in Southern California, all the community colleges are over-enrolled and people can never get the courses they want. And so one of the things that we encourage people to do as soon as they're transitioning and to hook up with the disability office, and then they are able to get access to early classes. They're the first ones every semester who get the courses. The other way to do it is if you've got somebody who's like a senior in high school, who's having a really hard time managing the whole day, sometimes what you can do is get them to transition to a junior college earlier. Like maybe they're going to go to the second semester of their senior year because really they can only do two or three classes and they've had it with high school and the marginalization they feel. So early enrollment can be both in terms of the semester or when you're going to go a little bit before you graduate from high school. And I would say the other thing about the substance abuse, I did mention that I think a lot of that, you can certainly have parts of it in an IEP and people can get in special programs and stuff. But I do believe a lot of the work with us at this point is really helping people see that when they use substances, they don't do as well in school and help them begin to get a little bit motivated so that they can say no to their friend. I mean, I was talking with a guy just last night. He just started an IOP program. He is 20. He is having trouble with college. And he said, so there were eight of us there yesterday and six of us were saying we smoked a lot of pot before we got and we ended up in this program. I really need to pay attention to that. Right. You know, one of the other questions that just came up that I think relates back to some of the earlier ones, you know, someone asked about if they're in a more rural setting or some setting that doesn't have the same capacity for resources where IEP related services and, you know, was asking about accommodations. And I think you did a really nice job of sharing some of the basic accommodations. But one of the questions comes up around if there are schools that maybe don't have the same degree of access to additional resources. And even a question that just came up, you know, is it even preferential to have a student having a first episode move to a non-traditional public high school to a specialized school? Or does it make sense to continue to learn how to get the accommodations and stay within the social and complex learning environment of a traditional high school setting? So I will say, here's my experience. The non-traditional high schools I'm aware of in Southern California, they often take all the kids who are really having trouble in the high school and get them together. And it can be very hard for a first episode kid to thrive in that environment. There's often, there can be a lot of drugs. There can be a lot of people who aren't so academically motivated. That's why they ended up in that program. So I would say you really need to know the alternative high school well to try to find out from other family, other people in the community, how it has gone. I have seen people do well there, but to be honest, I think they can also, it's pretty easy, I think, to fall off in that kind of environment. So I tend to see, can we keep people mainstream for as long as possible? But, you know, there are differences across the country. Right. It's really helpful. I think one of the other questions that came up that's critical right now, and I think relates to even the question about one that came up about, you know, you mentioned when services and when people lose their IPS or SCE services, there's often a loss in terms of sustaining employment or school involvement. And now, particularly during the times of COVID, when it's often really hard to build and maintain those connections, you know, what are the suggestions you have about how to continue the support during this complicated time? What seems to work in terms of helping people stay employed and in school, maybe, you know, after their time is up within the context of a program? I would say the whole notion about what happens to people after they end, what happens specifically with regard to work in school, after they end their participation in our programs, wide open, I don't think we really know. What we have done in our work in Navigate is we spend much more time, we have a whole packet now, trying to help give people resources, so they can sort of be their own employment specialists and education specialists after they leave. So we have suggestions about giving them a CV and interview tips and places to look for information. So we're trying to do more planful discharges. I think that's one thing. I think some of the people I've worked with have had a lot of success over multiple years working with voc rehab. I think that can be, if you're in a state where they provide services for education, that can be a wonderful, wonderful resource. Disability services, you could also use them after you leave as well. But I mean, in a college setting. But I do think this is an area where C specialists really need to be planful as people are being discharged to try to help them have whatever resources we can think of. And it's challenging. Yeah, for sure. Well, so we're going to stop here and say thank you to you very much for your wonderful efforts. Please stay here right now, everyone else, to get your credit claim for this effort. So Judith, maybe you can take people through that. And then these slides will be available probably on the SMI Advisor website. How do we get our credit? Log in. There you go. And here's the code for today. And it's a long one. What's that? It is a long code. So we'll leave it up for about a minute. So you can please write it down. P-E-P-F-F-8-4-3-P-3-E-E-1 There you go. Click Submit. So this is great. We really, really appreciate your time. Thanks to all of you who have this interest and attended. And thank you for the wonderful questions. I'm sorry we didn't get to all of them, but I tried to pull some groups of them together. And I'm going to go ahead and get some questions. So we can generally cover the areas of your questions. And thank you, Dr. Glynn. Thank you, Judith. Thank you, Dr. Hardy. And thanks to all of you for joining us. And we'll see you all next month. Thanks, everybody. Bye. Okay.

webinar

Dr. Shirley Glynn

psychosis

educational pursuits

Individual Education Plans

504 plans

accommodations

school performance

disability services

study habits

social development