Evaluating the Efficacy of a Vocational Counseling Intervention to Improve Occupational Functioning and Employment Quality Among Veterans With Mental Health and Substance Use Disorders

The investigators will conduct a multi-site efficacy RCT comparing Purposeful Pathways + transitional work (TW) (n=127) to TW alone (n=127) with sites at VA Bedford (Bedford, MA), VA Hines (Chicago, IL), and VA North Texas (Dallas, TX). The proposed project will allow us to evaluate the efficacy of Purposeful Pathways as an augmentation to TW for improving the primary outcome of occupational functioning, as well as downstream improvements in secondary outcomes of quality of life, mental health, and substance use. The investigators will also explore whether occupational functioning outcomes in the Purposeful Pathways + TW group are mediated by the factors proposed by the underlying theoretical model for Purposeful Pathways.

Aim 1: Evaluate the efficacy of Purposeful Pathways for improving occupational functioning (primary outcomes) Hypothesis 1a-e: Purposeful Pathways + TW, compared to TW only, will improve occupational functioning at a 12-month follow-up as evidenced by (1a) rates of competitive employment, (1b) hours worked, (1c) income earned, (1d) career adaptabilities (Career Adapt-Abilities Scale), and (1e) meaningful employment (Work as Meaning Inventory-Positive Meaning Subscale).

Aim 2: Evaluate the efficacy of Purposeful Pathways for improving quality of life, and reducing mental health symptoms and substance use (secondary outcomes) Hypothesis 2a-c: Purposeful Pathways + TW, compared to TW only, will improve (2a) quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form), and reduce (2b) mental health symptoms (Patient Health Questionnaire) and (2c) substance use (Tobacco, Alcohol, Prescription medications, and other Substance tool) at a 12-month follow-up

Aim 3 (Exploratory): Explore whether occupational functioning (competitive employment attainment) in the Purposeful Pathways + TW group is mediated by vocational identity, work hope, self-regulation, and/or employment motivation, key factors central to the Purposeful Pathways intervention.

The study intervention is a behavioral intervention. Purposeful Pathways is a manualized, vocational counseling intervention based on a Veteran-centered, recovery-oriented approach. The overarching target of the intervention is to increase motivation to pursue meaningful employment goals by enhancing vocational identity/positive vocational self-appraisals, increasing work hope (goals, pathways, and self-efficacy), and promoting employment-related self-regulation skills. The table below provides an overview of the specific treatment elements associated with each of the four core components: 1) career/identity exploration, 2) goal setting/planning, 3) job-search skill building, and 4) self-regulation skill building. The Purposeful Pathways intervention will be provided over 12 weeks by a master's level clinician affiliated with their respective (Bedford, Hines, of North Texas) vocational rehabilitation program. Sessions will be provided in person or through the VHA telehealth services platform (VVC).

All participants will complete the following surveys/questionnaires.

Demographics. The investigators will gather basic demographic information including age, gender, race, level of education, service-connected percentage, service connected condition, receipt of disability pensions, housing stability, and history of substance abuse and mental health diagnoses.

Competitive employment. The investigators will ask whether a Veteran has been competitively employed at any point over the previous month. In line with other RCT research, the investigators define competitive employment as "a non-sheltered job earning salary, wages, or commission, excluding military drill and transient cash-based jobs, such as yard work, babysitting, and manual day labor." (p. 318). For those employed, the investigators will also ask for job title, industry, and company names.

Weeks/hours worked. Among those who have worked in a competitive job, we will ask about the number of days/weeks worked over the past month, as well as the number of hours worked.

Income earned. Among those who have worked in a competitive job, the investigators will ask for the participants' hourly wage.

Career-related adaptability skills. The Career Adapt-Abilities Scale (CAAS) will be utilized to measure one's level of career adaptability, a commonly used measure of ability and skill for navigating long-term career advancement. This is a 24-item measure that is grouped into four different subscales that capture total adaptability along with four dimensions: concern, control, curiosity, and confidence. Respondents are asked to rate how strongly they have developed each of these strengths using a 5-point Likert type scale. Responses range from 5 ("Strongest") to 1 ("Not strong").

Meaningful employment. The Positive Meaning Scale of the Work as Meaning Inventory (WAMI) will be used to measure the degree to which someone perceives their work as meaningful. The Positive Meaning scale consists of 4 items answered on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores represent higher levels of meaningful work. This scale has been used extensively in the vocational literature and has demonstrated consistent reliability and validity, including with Veterans with co-occurring conditions.

Job-Searching Behavior. The Job-Search Intensity Scale (JSIS) will be utilized to assess the level of time one spent on various job-search activities. This nine-item measure asks respondents about the following job-search activities: preparing/revising resume, reading classified/help. wanted advertisements, looking for jobs on the Internet, talking with friends/relatives about job leads, speaking with previous employers or business acquaintances about job leads, contacting employment agencies, making inquiries to prospective employers, sending out application letters, and preparing and going on job interviews. Responses to each activity are measured on a 5-point, Likert-type scale to assess the amount of time spent on each activity. Possible scores for each item range from 1 ("No time at all") to 5 ("Very much time").

Quality of life. The Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q - SF) will be used as a measure of general psychiatric functioning. The Q-LES-Q - SF is a 16 item self-report measure of perceived functioning and is one of the most widely used outcomes measures in psychiatric research.

Mental health: The Patient Health Questionnaire-9 (PHQ-9) is a 9-item measure of common mental health symptoms associated with depression. It is a widely used and available inventory in VHA with good validity and reliability.

Substance use. Substance use outcomes include frequency, quantity, and severity of substance use, and will be measured with the Tobacco, Alcohol, Prescription medications, and other Substance (TAPS) tool, which is used within the National Institute on Drug Abuse (NIDA) clinical trials network.

Vocational identity. The Vocational Identity Scale (VIS) will measure the extent to which an individual possesses a clear and stable understanding of his or her goals, interests, and talents as related to vocational decisions. The VIS consists of 18 true or false items that asks respondents to identify whether the statement is mostly "True" or mostly "False." Higher scores indicate more crystallized vocational identity. The VIS is extensively used in vocational psychology literature and has undergone psychometric analysis demonstrating validity and reliability, and has been used in studies with Veterans and those with psychiatric disorders.

Work hope. The Work Beliefs Scale (WBS) will be utilized to measure work hope. This is a 24-item measure on a seven-point scale ranging from "Strongly disagree" to "strongly agree." Respondents are asked to rate their level of agreement on various items empirically related to work hope (having a goal, having a plan to reach goal, and having self-efficacy to pursue one's goal). Validity and reliability among individuals with significant psychosocial barriers have been established.

Self-regulation. The Short Self-Regulation Questionnaire (SSRQ) will be used to measure self-regulation skills. This 31-item self-report measures asks respondents to respond to items on a 5 point Likert type scale ranging from strongly disagree to strongly agree. The measure demonstrated construct validity and demonstrated high internal consistency among Veterans with co-occurring conditions.

Employment motivation. The Importance of Obtaining Preferred Position (IOPP) will be used to measure motivational attitudes to attain preferred employment. This is a 5-item measure on a five-point scale ranging from "Not important" to "Very Important." This scale has been validated and has been used widely in vocational literatures as an measure of motivational commitment to employment among individuals who are unemployed.

Client satisfaction. The Client Satisfaction Questionnaire-8 (CSQ-8) will be used to measure satisfaction, perceived quality, and effectiveness of treatment. This self-report questionnaire consists of eight items, scored 1 to 4, with higher scores indicating higher satisfaction with treatment. The CSQ-8 has been used in mental health and other health centers and has acceptable internal consistency.

Exit interviews. The investigators will randomly ask 30 Veterans participating in the intervention arm to complete a brief qualitative exit interview (15-minutes) at 12-week treatment end. These semi-structured, open-ended interviews will take place via phone, VVC, or in-person depending on Veteran's preference. Questions will assess barriers and facilitators of treatment engagement (e.g., Describe how the timing of the intervention fit into your day/week and overall recovery. Would you recommend the intervention earlier or later in your recovery? Would you recommend the intervention as in-person or virtual? Were there issues being able to attend your appointments? Did you received any feedback from your TW counselor or workplace supervisor about attending appointments?). Interviews will be recorded via VA-approved recording technologies and will be transcribed by a VA-approved transcription service.

Inclusion criteria

• enrolled in VHA TW at one of the three VA recruitment sites
• be unemployed
• report interest/intention to return to paid work within the upcoming three years
• presence of a psychiatric disorder as indicated by documented ICD-10 diagnosis (mental health disorder and/or substance use disorder) addressed in an encounter at VHA within the 24 months preceding study enrollment
• willing to participate in weekly vocational counseling sessions

Exclusion criteria

• report a plan to remain unemployed during the upcoming 12 months
• report plans to retire within the next 12 months
• be currently retired
• be a full-time student
• enrolled in Supported Employment
• experiencing significantly elevated mental health symptoms as indicated by a score greater than 26 on the Symptom Checklist-6 (SCL-648)
• have a guardian or conservator