To tell or not to tell about your mental health problems? An intervention for students

ABSTRACT

Worldwide, an increasing number of students in higher education have mental health problems. Talking about these problems at the university is often not that easy. Students fear to be stigmatised if they disclose their problems to others. However, if they do not disclose their problems, they may not get the support they often need. Existing interventions to help people with this disclosure-dilemma are not specifically aimed at students, and lack certain important aspects. Therefore, we developed an intervention to help students with making a personal, well-informed decision regarding whether or not to disclose their problems. We examined the experiences of students and professionals with the new intervention. Moreover, we studied whether the students were less concerned about disclosure and experienced less decisional conflicts after using the intervention. Students with mental health problems from three universities of applied sciences in the Netherlands completed questionnaires prior to the intervention, directly after and three months after. In addition, the educational professionals reported their experiences with applying the intervention. Both students and professionals appreciated the contents and structure of the intervention and students’ level of concern about disclosure and level of decisional conflicts were lower after using the intervention.

KEYWORDS:

• Students
• mental health
• disclosure
• decision
• supported education

Introduction

Worldwide, there is an increasing number of students with mental health problems in higher education and consequently there is an increased need for mental health and educational support (Auerbach et al. 2018, 2019; Bruffaerts et al. 2018; Hunt and Eisenberg 2010; Stallman and Shochet 2009; Storrie, Ahern, and Tuckett 2010; Zivin et al. 2009). This is also the case in the Netherlands (De Boer 2017; Dopmeijer 2018; Council for Public Health and Society 2018; Schoemaker et al. 2019). However, only a small amount of students experiencing mental health problems does actually seek help which is often caused by a fear of being stigmatised when disclosing their mental health problems (Kranke et al. 2013; Jennings et al. 2015; Martin 2010; Li, Denson, and Dorstyn 2018). For instance, students fear that their mental health problems might be regarded by others as a form of weakness and that it could have a negative influence on their future employment chances (Chew-Graham, Rogers, and Yassin 2003; Quinn et al. 2009; Venville, Street, and Fossey 2014). In addition, students are afraid of being excluded by others or not being taken seriously because of their mental health problems. However, if students do not disclose their mental health problems, they might not get accurate mental support or the right support they need to remain at school (De Cesarei 2015; Kaper and Pilat 2014; Kranke et al. 2013; Martin 2010).

Because of the fear of being stigmatised and discriminated, many students experience a dilemma concerning whether or not to disclose their mental health problems (Collins and Mowbray 2005; Farkas 2014; Mungovan and Quigley 2003; Venville, Street, and Fossey 2014). A study conducted in Norway, Portugal, Czech Republic and the Netherlands among students with mental health problems and professionals from education and mental health showed that the students expressed a need for support with solving the disclosure-dilemma, but the professionals indicated not to have the expertise to support the students with this dilemma (Hofstra and Korevaar 2016). Also, the Health Council of the Netherlands (2014) recommended to invest in the expertise of educational professionals in supporting students with mental health problems as this expertise is necessary, but is often lacking.

A literature search conducted before the start of the current study in 2016 on existing interventions to support people with mental health problems in order to deal with the disclosure-dilemma yielded two results: the Conceal or Reveal decision aid (CORAL; Henderson et al. 2013) and the Honest Open Proud programme (HOP; Corrigan, Kosyluk, and Rüsch 2013). The CORAL decision aid, however, is specifically aimed at disclosure in a work setting and the HOP programme is also not specifically aimed at students but aims to support people with mental health problems more generally with their disclosure-decision in different settings. At school, students have to work together in several groups and have to deal with different expectations. Besides, students are in a dependent position with regard to teachers who mark their work and they also may experience peer pressure. These aspects are not part of the existing interventions. Besides, both the CORAL decision aid and the HOP programme do not contain all the aspects that the authors of the present study regard as important to consider when making a disclosure decision in an educational context. For instance, in the CORAL decision aid and in the HOP programme, there is no attention for what the most appropriate means of communication and tone of voice are when conveying the disclosure message (‘how’ to disclose); and furthermore, the HOP programme does not consider what the most appropriate situation or moment is to disclose (‘when’ to disclose). In addition, both interventions are developed for use in a mental health setting. Based on the preference of students and educational professionals, we desired an intervention for professionals from education to support students with mental health problems in their own educational context, meeting the needs of educational professionals for additional expertise in the support of these students.

Therefore, an intervention was developed that can be used by educational professionals to support students so that they can make a personal, well-informed decision about whether or not to disclose their mental health problems in an educational context (at school as well as during an internship) (Hofstra and Korevaar 2016; Korevaar 2004).

Aim

The primary aim of the present study which was conducted in the period from April 2016 until April 2018, was to evaluate the experiences of the disclosure intervention ‘To tell or not to tell?’ (Hofstra and Korevaar 2016) in higher education from both the perspective of students with mental health problems as well as from the perspective of educational professionals using the intervention. Students and educational professionals were asked to share their experiences about the usability and applicability of the disclosure intervention. To improve the analysis and interpretation of findings we used a mixed-method approach with qualitative (written explanations of scores, evaluation form and group discussion) and quantitative methods (questionnaires).

Secondly, experiencing a disclosure-dilemma can be very stressful because one feels uncertain about what to do. As the ‘To tell or not to tell?’-intervention aims to support students with their disclosure-dilemma, we expect that this support leads to lower levels of concern regarding disclosure and of experienced decisional conflicts. Decisional conflicts occur when one feels insecure about which decision to make. It reflects a state of uncertainty about a course of action and is more likely to occur when people have to make decisions that involve certain risks (O’Connor 1995). Research into the decision aid for the work context, also showed that after using the intervention the participants experienced less decisional conflicts regarding disclosing their mental health problems (Brohan et al. 2014; Henderson et al. 2013). In addition, an RCT on the effect of the HOP programme showed that disclosure-related stress decreased after being supported by the programme (Rüsch et al. 2014). Therefore, the second aim of this study was to examine whether using the ‘To tell or not to tell?’-intervention was related to lower levels of concern regarding disclosure and of experienced decisional conflicts.

Methods

Participants and procedures

This study has been approved by the ethical board of the Hanze University of Applied Sciences in Groningen and all participants proved written informed consent. Students with mental health problems were recruited at three universities of applied sciences in the northern part of the Netherlands through mailings, posts on the internet and via educational professionals. In order to be included in the study, the students had to meet the following inclusion criteria: aged above 18 years, experiencing mental health problems severe enough to need professional treatment, and having a score of five or higher on the question about experienced level of concern regarding whether or not to disclose their mental health problems. If the participant met the inclusion criteria and had signed the informed consent form, the participant was included and was linked to a trained educational professional with whom the student had ‘To tell or not to tell?’- sessions.

In total, 44 students were included in the study. In Table 1, the descriptive characteristics of the participants are presented.

Table 1. Descriptive characteristics of the participants

	Number of students/Mean (SD)
Gender
Male	24
Female	20
Age in years	23 (3.3; range 17–36)
Mental health problems
Treatment	43
Mood disorder	24
Anxiety disorder	22
Developmental disorder	12
Use of medication for mh problems	20

The students (self) reported 15 different mental health problems in total, such as depression, anxiety disorder and personality disorder. Some of the students indicated to have multiple diagnoses. All students indicated to (have) receive(d) treatment, except for one student who reported to have the diagnosis of autism but did not receive treatment. The students followed different kinds of educational programmes (25), ranging from Ocean Technology to Social Work.

The students were supported by twelve educational professionals (four study advisors and eight student career counsellors; two male, ten female) from the three participating universities. They were recruited through a call for participation in the study that was sent to them by email. The educational professionals received a two-day training in the ‘To tell or not to tell?’ -intervention. This training was given at the Hanze University of Applied Sciences by a trained professional and a student of Social Work with lived experience who also provided feedback on earlier versions of the intervention. During the training, the background and contents of the intervention were explained; the educational professionals practised with the worksheets, for instance using role plays; and the procedure of using the intervention in general and of the accompanying research were discussed.

At the end of the project, a group meeting was organised. The educational professionals (n = 9; three of the educational professionals could not be present because of other obligations) filled out an evaluation form consisting of four questions (of which three were open-ended) about the ‘To tell or not to tell?’-intervention. The answers to these questions were discussed further with the group afterwards. This group discussion was led by the third author, and the first author made notes of the remarks of the group.

Prior to the first session with the educational professional (t0), the students (n = 44) filled out an online questionnaire. Unfortunately, five students dropped out of the study before the start of the support using the ‘To tell or not to tell?’-intervention. Two students dropped out of the study because their mental health problems became too severe and three students dropped out because of unknown reasons. Eventually, 39 students have been supported using the ‘To tell or not to tell?’-intervention. Directly after the final session with the educational professional a second online questionnaire was filled out (t1; n = 36). Three months after the final session the students were asked by email about their level of concern regarding disclosing their mental health problems at school, to which 20 students responded answering the question on a 7-point Likert scale (t2).

The disclosure intervention for students

With the intervention ‘To tell or not to tell? Disclosing your mental health problems in an educational context’,¹ students are encouraged to think carefully about five aspects that are important in order to come to a well-informed decision regarding whether or not to disclose their mental health problems in an educational context:

• Whether to tell

• Who to tell

• When to tell

• What to tell

• How to tell

Students should consider ‘whether to tell about their mental health problems’ by thinking about the benefits and disadvantages of disclosure. Once decided to tell, it is important that students think about ‘who to tell’ and why to tell that specific person. ‘When to tell’ is another aspect that needs consideration: what are appropriate moments during the educational programme to think about disclosure and what are specific circumstances, e.g. location, presence of others, in which someone wants to disclose or not. In addition, ‘what to tell’ is an important aspect: is it relevant to disclose the mental health condition and what is the aim of the message to convey? The final aspect is ‘how to tell’. Students should think about the means of communication, the tone of voice and the structure of the message. For each of the five aspects an accompanying worksheet that helps the students with considering these aspects was developed. Students can fill out the five worksheets alone or together with a trained educational professional (e.g. a study advisor or lecturer).

Measures

Experiences with the ‘to tell or not tell?’-intervention

In order to get information on the experiences of the students with using the ‘To tell or not to tell?’-intervention, the following questions were asked. At t0 and t1, the students first were asked to indicate which choice they prefer: to disclose or not to disclose their mental health problems at school. Furthermore, after the final session (t1) the students were asked to indicate on a 7-point Likert scale (1 = very poor(ly)/very unsatisfied to 7 = excellent/very satisfied) to what extent the sessions helped them to come to a well-informed decision; how satisfied they were about the sessions; what they thought of the contents of the sessions and the worksheets; and what they thought of the support they received from the educational professional. Finally, the students were asked whether they would recommend the ‘To tell or not to tell?’-intervention to other students experiencing the disclosure-dilemma. Students were asked to write down a short explanation of their answers.

During the group meeting at the end of the project, the educational professionals filled out a short evaluation form with three open-ended questions about working with the ‘To tell or not to tell?’-intervention. They were asked what they thought of the ‘To tell or not to tell?’-intervention in general, and also how they experienced working with the work sheets and what the critical elements of the sessions were to their opinion. Finally, they were asked whether they would continue working with the ‘To tell or not to tell?’-intervention. In a group discussion afterwards, the answers to these questions were discussed in more detail.

Level of concern regarding disclosure

At all three time points, the level of concern of the students regarding disclosure was measured based on the question that has been used by Rüsch et al. (2014): ‘How concerned are you about disclosing your mental health problems to others at school or during your internship?’. Answers could be given on a 7-point Likert scale ranging from 1 (not at all) to 7 (totally). Students who answered this question at t0 with a 5 or higher were included in the study, in order to only include students who were in an actual need for support.

Level of experienced decisional conflicts

At the start of the intervention (t0) and directly after the final session (t1), the level of experienced decisional conflicts was measured, using the Decisional Conflict Scale (O’Connor 1995). The Decisional Conflict Scale consists of 16 items. Answers could be given on a 5-point Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree). The Decisional Conflict Scale consists of five subscales. An example of an item from the Informed subscale is ‘I know which options are available’; from the Uncertainty subscale ‘I feel sure about what to choose’; from the Values clarity subscale ‘I am clear about which benefits matter most to me’, and from the Support subscale ‘I have enough support from others to make a choice’. Directly after the final meeting (t1), the subscale Effective decision was measured, with items like ‘I feel I have made an informed choice’. This subscale was not measured at the start of the intervention, as the items refer to the decision that has been made after having received support with making this decision. The validity and reliability of the total Decisional Conflict Scale and of the subscales have proven to be satisfactory (see O’Connor 1995).

Analyses

Statistical analyses on the quantitative data were conducted using SPSS v.25.0 software (IBM, Corp., 2017). Means and standard deviations were calculated for the scores on the evaluative questions. The outcome variables ‘level of concern’ and ‘level of experienced decisional conflict’ were examined for normality using the Kolmogorov-Smirnov test. Because the normality assumption was violated, Wilcoxon signed-rank tests were used to determine differences in the outcome variables between t0, t1 and t2. The Mann-Whitney test was used to determine whether the scores on level of concern at t0 and t1of the dropouts at t2, differed from the non-dropouts. To test whether there were differences in age and gender between the dropouts and the non-dropouts, an independent samples t-test and a chi-square were performed, respectively.

The explanations that the students gave for their scores on the evaluative questions about the intervention at t1 are used in this manuscript to illustrate the quantitative findings. The answers of the professionals to the three open-ended questions on the evaluation forms were put together in a file. The additional remarks that were given by the educational professionals in the group discussion about the intervention were added to this file. Subsequently, all answers and additional remarks with more or less the same content were marked with the same code. By coding answers, one can more easily distinguish categories in the answers (Miles and Huberman 1994).

Findings

Experiences of the students and the professionals with the ‘To tell or not to tell?’- intervention

On average, the total trajectory to run through the five worksheets took three hours and 15 minutes. The number of ‘To tell or not to tell?’-sessions varied between three and five sessions; and the duration of the sessions varied between 30 minutes and one and a half hour.

Directly after the final ‘To tell or not to tell?’-meeting (t1) the students (n = 36) answered some evaluative questions on a 7-point Likert scale (1 = very poor(ly)/very unsatisfied to 7 = excellent/very satisfied). They indicated that the sessions helped them in a ‘satisfying to good’ extent in coming to a well-informed decision (M = 5.7, SD = 1.03, answers ranged from 2 to 7). For instance, students said:

I am very skilled in self-analysis: because of this I did not get really much new information, but it was good to see this confirmed (Male student of Electrical Engineering, 22 years, Asperger syndrome, answer score of 2).

In fact, it was already clear to me that I had to be open to some extent (Male student of Applied Mathematics, 26 years, bipolar disorder/psychosis, answer score of 4).

The meetings gave me a clear picture of the advantages and disadvantages associated with the different choices. I have a clear picture of how I will be open. I now also know what I am going to tell and to whom (Female student of Applied Psychology, 20 years, bulimia nervosa, answer score of 7).

In general, the students were ‘satisfied’ about the ‘To tell or not to tell?’-sessions (M = 6.11, SD = .67; answers ranged from 5-7).

It was nice and clarifying to talk to someone about this in a focused and detailed way. This also made me think in new and even deeper ways (Female student of Social Legal Services, 24 years, anxiety disorder, answer score of 5).

Although I was quite chaotic myself, I was well supervised and the supervisor responded with patience (Male student of Laws, 23 years, ADHD, answer score of 7).

Also, the contents of the sessions and of the worksheets were rated to be ‘sufficient to good’ (M = 5.63, SD = 0.88, range 4 to 7; M = 5.37, SD = .91, range 3 to 7; respectively). For example, regarding the sessions, students said:

To my opinion, the mechanics of the problems could have been discussed more deeply. Why do we feel the shame and what can be changed about that subjective experience? (Male student of Information, Communication and Technology, 29 years, anxiety disorder, answer score of 4).

The right questions were asked that contribute to making a choice about disclosure. The structure was also good (Male student of Social Work, 28 years, ADD, answer score of 7).

With respect to the worksheets, students responded:

Some of the questions could be interpreted in several ways (Female student of Ocean Technology, 17 years, depression/ADHD/Asperger syndrome, answer score of 3).

Very good topics on the worksheets, it were exactly the things that I had doubts about and about which I had difficulty making a decision. The questions were clear (Female student of Applied Psychology, 19 years old, anxiety disorder/PTSD, answer score of 6).

They were quite extensive. I haven’t missed anything myself. Pretty much everything that is necessary to make this choice is discussed step-by-step (Female student of Animal Management, ADD/depression, 25 years old, answer score of 7).

None of the students reported elements missing in the worksheets or sessions, nor that certain elements were redundant. A few students mentioned that it would be helpful to have a digital version of the worksheets and to have more space for writing down their answers.

With respect to the support the students received from the educational professionals, they indicated it to be ‘very good’ (M = 6.57, SD = .56; scores ranged from 5 to 7).

She was a nice woman who herself had some experience in her former work with difficult events (Female student of Social Work, 19 years old, Borderline personality disorder/PTSD/Anxiety disorder, answer score of 5).

I had the feeling that I could safely discuss the subject and I was well guided through the possibilities and she also gave suggestions which helped me to gain more insight into it (Male student of Laws, 23 years old, ADHD, answer score of 7).

Finally, to the question whether the students would recommend the ‘To or not to tell?’-intervention to other students experiencing the disclosure-dilemma they all responded that they would recommend it.

Prior to the intervention, 70.5% of the students stated that they wanted to disclose their mental health problems at school. After the intervention, the percentage of students that decided to disclose their mental health problems changed to 77.8%. It appeared that 11 students changed their decision after receiving the intervention: four students first indicated that they wanted to disclose their mental health problems, but after the intervention, they decided not to disclose anymore; and seven students first indicated that they did not want to disclose, but afterwards indicated that they did want to disclose.

During the group meeting at the end of the project, the educational professionals answered four evaluative questions which were discussed later on. Just like the students, the professionals were positive about working with the ‘To tell or not to tell?’-intervention and they appreciated the clear structure:

It provides a good basis for researching whether or not to tell with the student (Female study advisor at university A).

In this way everything is discussed in a structured way. At the same time, it provides space to conduct the conversation in your own way and you can use the method as a checklist (Female student career counsellor 1 at university B).

It is a nice method. The student is free in the choice of the worksheets and he has space to make his own assessment (Male study advisor at university C).

Moreover, the worksheets were also regarded as useful. Some of the educational professionals used the worksheets in a strict order; other professionals let the students choose the worksheet they wanted to discuss.

The worksheets supported the students well in their search for an answer to the question of whether or not to disclose (Female study advisor at university A).

Fixed worksheets are useful; I have always followed the fixed order because I find it logical myself (Female student career counsellor 2 at university B).

The worksheets helped to ‘step-by-step analyse a big, vague problem’ (female study advisor 1 at university B). For one professional (female study advisor 2 at university B), using the worksheets felt artificial at first, but soon they became a well-integrated part of the conversations with the students. Some educational professionals mentioned that it was an eye-opener for students that they did not need to mention their diagnosis on the worksheet ‘What to tell?’ but that it was sufficient to mention the hindrances they experience with studying because of their mental health problems. One professional (female student career counsellor 1 at university B) pointed out that the worksheets are focusing on disclosure at school; she advised to add ‘during your internship’ to the worksheets as some of the students that she was supporting were interns. The other professionals agreed with this addition.

To the question ‘What are the critical elements of the “To tell or not to tell?”-intervention for you?’, the professionals mentioned: the clear structure; the five aspects; the practicality; awareness and the time to discuss all the aspects well.

The clear structure that somewhat deprived the subject of its emotion. My student indicated that this gave him new insights (Female study advisor 1 at university B).

Finally, all educational professionals stated that they certainly would continue working with the ‘To tell or not to tell’-intervention with their students.

Level of concern

Another aim of the present study was to examine whether the degree to which the students are concerned about disclosing or not declined after using the ‘To tell or not to tell?’-intervention. In order to answer this question the mean scores on experienced level of concern were calculated and compared using the Wilcoxon signed ranks test (see Table 2). This non-parametric test was chosen as the data were not normally distributed. It appeared that directly after the final session (t1) students are less concerned about disclosing or not than prior to the first session (t0). Three months after the final session (t2) the students received an email containing the question about the level of concern regarding disclosing or not, to which 20 students responded.² It appeared that their level of concern was still lower than prior to the first session.

Table 2. Means, standard deviations and Wilcoxon Signed ranks tests for level of concern, and the decisional conflict (sub)scales

	t0	t1	t2
	M (SD)	M (SD)	M (SD)	Z (t0-t1)	Z (t0-t2)
Level of concern	6.00 (0.67)	3.75 (1.61)	3.45 (1.15)	−4.88*	−3.87*
Level of decisional conflicts in general	2.64 (.48)	3.91^a (0.47)		−5.13*
Uncertainty subscale	1.93 (.60)	3.29 (.70)		−4.71*
Informed subscale	3.02 (62)	4.18 (.54)		−4.47*
Values clarity subscale	2.99 (.65)	4.23 (.65)		−4.62*
Support subscale	2.62 (.80)	3.91 (.61)		−4.85*

* p < .001; ^a A higher score on the decisional conflict scale indicates a lower level of decisional conflict.

Level of decisional conflicts

Finally, the level of experienced decisional conflicts prior to and directly after the last session has been examined (see Table 2). A Wilcoxon signed ranks test showed that directly after the last session (t1), students experienced less decisional conflicts in general than prior to the start of the sessions (t0). The students felt less uncertain about their decision, they also felt better informed about the different aspects of their choice, knew better what is most important to them concerning benefits and risks of their decision, and experienced more support with making a decision than before the start of the ‘To tell or not to tell?’-sessions. Finally, the students indicated that they thought that they made an effective decision with respect to their current personal situation (M = 3.85, SD = .68).

Discussion

The aim of the present study was to evaluate the experiences of both students with mental health problems and educational professionals with the ‘To tell or not to tell?’-intervention using a mixed-method approach as well as to study some preliminary quantitative outcomes. The qualitative and quantitative findings were in line with each other and also the perspective of the students corresponds with the perspective of the educational professionals. The intervention seems to be a user-friendly and useful tool to support students in higher education with mental health problems in making a well-informed decision regarding whether or not to disclose their mental health problems in an educational context. Both students and professionals were positive about working with the intervention and appreciated the content, the structured worksheets and the sessions. All of the students would recommend the intervention to other students experiencing the disclosure dilemma, and all professionals plan to continue working with the ‘To tell or not to tell?’-intervention. Furthermore, after working with the intervention, students felt less concerned about whether or not to disclose their mental health problems in an educational context, and they experienced less decisional conflicts about it. These results correspond with the findings of (recent) research into the other disclosure interventions in which was found that disclosure-related distress decreased after being supported (Mulfinger et al. 2018; Rüsch et al. 2014), and that the level of experienced decisional conflicts was lower than prior to the intervention (Brohan et al. 2014; Henderson et al. 2013).

With a few adjustments, this intervention may also be used to come to a well-informed decision about whether or not to disclose other issues about which stigma exists in society, for example, learning disabilities (Shifrer 2013), sexual orientation (Hatzenbuehler and Pachankis 2016), epilepsy (De Boer, Mula, and Sander 2008) or HIV (Herek, Capitanio, and Widaman 2002). In addition, as the disclosure-dilemma is experienced by students with mental health problems worldwide and our ‘To tell or not to tell?’-intervention is context-free, the intervention can be used in other languages and in other countries as well. The questions on the worksheets are generally formulated, but the answers can be obviously country-specific, as for instance the structure of educational programmes can differ per country.

As this was an exploratory study -the first experiences of students and professionals working with the intervention were examined -using both quantitative and qualitative methods, the number of participants was sufficient. However, the quantitative findings should be interpreted with caution and cannot be generalised to the overall population. Research into the effects of using this intervention on for instance school functioning should include more students.

Because of the sample size and also the heterogeneity of the sample regarding mental health problems, analyses could not be performed separately for students with specific mental health problems. Research has shown that the (perceived) stigma and self-stigma differ for people with different mental health problems. For example, there is a more severe stigma in society about people with schizophrenia and personality disorders than about people with other psychiatric diagnoses (Catthoor et al. 2015; Magallon-Neri et al. 2013). This could possibly be of influence on the decision whether or not to disclose these mental health problems. This aspect was not included in the present study, follow-up research could look more into that aspect.

Furthermore, although it appeared that the positive effect on level of concern of the support by the ‘To tell or not to tell?’-intervention was still there after three months, it is not clear whether this effect remains after a longer period. Longitudinal research is needed to study this.

Finally, the effect of the support using the ‘To tell or not to tell?’-intervention on school performance of students with mental health problems could be studied in future research. This was not the scope of the current study, but with our findings in mind, it could be speculated that students who have been supported with their disclosure-dilemma will function better at school. Experiencing a disclosure-dilemma can be stressful. Stress negatively influences academic performance among students (Sharp and Theiler 2018; Travis et al. 2020). The ‘To tell or not to tell?’-intervention contributes to a decrease in the level of stress among students, as we found that the level of concern and level of experienced decisional conflicts were significantly lower after using the intervention. Therefore, we expect that students who have been supported with the ‘To tell or not to tell?’-intervention will function better at school. An RCT with an intervention versus control group should be conducted in the future to examine the effect of this intervention in a broader group.

Conclusion

The present study showed that the ‘To tell or not to tell?’-intervention can contribute to the decision-making process of students with mental health problems to come to the decision whether or not they want to disclose their mental health problems at the university or at an internship, and to who, what, when and how to disclose. The ‘To tell or not to tell?’-intervention meets the needs of students with mental health problems in higher education as well as of educational professionals regarding support with the disclosure-dilemma. Promising results were found regarding students’ level of concern about disclosure and experienced decisional conflicts. The ‘To tell or not to tell?’-intervention is therefore a valuable addition to the existing interventions regarding disclosure. Educational organisations could relatively easy offer the support with the disclosure-dilemma to their students, as the support using the ‘To tell or not to tell?’-intervention can be given at universities by educational professionals who have been trained in the use of it. Follow-up research is needed to further explore the (longitudinal) effects of the ‘To tell or not to tell?’-intervention on for instance school functioning.

Acknowledgments

We thank all the participants (students and professionals) in the study and the student with lived experience for her contribution to the two-day training for the educational professionals in the ‘To tell or not to tell’- intervention.

Disclosure statement

The authors have no conflict of interest to disclose.

Data availability statement

The data that support the findings of this study are available from the corresponding author, Jacomijn Hofstra, upon reasonable request.

Additional information

Funding

This work was partly supported by the Agis Innovation Fund under Grant number 2016-06; and the Triodos Foundation under Grant number 4306.

Notes on contributors

Jacomijn Hofstra

Jacomijn Hofstra is an associate professor at the Research and Innovation centre for Rehabilitation and at the department of Applied Psychology at the Hanze University of Applied Sciences Groningen. The main topic of her research is Supported Education: supporting students with mental health problems to choose, get and keep regular education.

Nynke Boonstra

Nynke Boonstra is professor of Care and Innovation in Psychiatry at NHL Stenden University of Applied Science. The main topic of her research is prevention and recovery of psychiatric disorders in young people.

Lies Korevaar

Lies Korevaar is professor of Rehabilitation at the Research and Innovation centre for Rehabilitation at the Hanze University of Applied Sciences Groningen, the Netherlands. For more than twenty years he is involved in national and international Supported Education research and innovation projects for (young) people with mental health problems.

Notes

1. For more detailed information about the disclosure intervention and a manual for professionals see Hofstra and Korevaar (2016) or www.supportededucation.eu.

2. A dropout analysis using the Mann-Whitney test for non-parametric data showed that the students who did not respond to the t2 question, did not differ in their scores on level of concern at t0 and t1 from the students who did answer the question at t2 (t0: U = 146, p = .62; t1: U = 150.6, p = .76). Furthermore, the group of students who did not respond to the t2 question did not differ in age and gender from the group of students who did answer the question at t2 (M = 23, SD = 2.9 versus M = 23.35, SD = 4.17, t (34) = −.29, p = .77 and χ² (1) = 0.21; p = .65, respectively).