Development and evaluation of an online vocational program for veterans with legal convictions and psychiatric illness

PURPOSE

We describe the development and pilot evaluation of an online vocational rehabilitation program, the About Face Online System (AFOS), for veterans with a history of felony convictions and either mental illness and/or substance use disorders.

METHOD

Phase One was the development and acceptability testing of the online system. Phase Two was a small, randomized trial comparing the likelihood of obtaining employment among people using the AFOS, compared to people receiving a self-directed hardcopy manual, after 6 months.

RESULTS

In Phase One, 17 veterans provided feedback as the system was being developed. The final system allows veterans to receive education on vocational reintegration skills, watch short videos describing the techniques, and communicate with a vocational staff member via chat features. Veterans found the AFOS to be as acceptable as a hardcopy manual that covered similar material. In Phase Two, 38 veterans with a history of felony convictions and either mental illness or substance use disorder were randomized to receive the AFOS or a hardcopy manual. After 6 months, people randomized to the AFOS were more likely to obtain employment than people randomized to the hardcopy manual.

CONCLUSION

An online vocational program may help veterans who cannot attend traditional in-person vocational services to successfully obtain employment.

The association between time incarcerated and employment success: Comparing traditional vocational services with a hybrid supported employment program for veterans

Objective : This study evaluates the effects of time incarcerated on employment outcomes between a manualized vocational program, the About Face Vocational Program (AFVP), and a hybrid program of the AFVP and Individualized Placement and Support, Supported Employment (AFVP + IPS-SE). Method : Eighty-four veterans with the histories of felony convictions and a mental illness or a substance use disorder were randomly assigned to the AFVP or AFVP + IPS-SE conditions and followed for 6 months. The associations between time to employment and months incarcerated were evaluated using nonparametric tests. Findings : The number of months incarcerated was positively associated with time to employment in the hybrid AFVP + IPS-SE condition but not the AFVP condition. In addition, significant differences were found between employment rates of the groups at lower number of months incarcerated, with higher rates of employment in the hybrid AFVP + IPS-SE condition, becoming similar as months incarcerated increased. Conclusion and Implications for Practice : Number of months incarcerated may have a deleterious effect on employment rates when using IPS-SE. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Substance Use Rates of Veterans with Depression Leaving Incarceration: A Matched Sample Comparison with General Veterans

Formerly incarcerated military veterans—comprising approximately 8% of the prison population—experience significant barriers to reentry including homelessness, mental illness, and mortality. One of the most consequential barriers is relapsing into substance use. Most justice-involved veterans (JIV) possess histories of substance abuse before imprisonment, and this rate continues upon release. Mental illness—depression in particular—is often comorbid with substance abuse. With high rates of depression and substance use in a JIV population, it is important to determine to what extent release from prison contributes to predicting substance use and negative clinical outcomes. This study compares rates of substance use and negative outcomes between two matched samples of JIV and general veterans, both with depression and a substance use disorder. It is hypothesized that JIV will have a higher rate of substance use and that use will be associated with higher negative outcomes in the JIV condition. Rates of use of veterans released from prison and general veterans were collected during six-year follow-up periods. Use was defined as the use of an illicit substance or alcohol, if an alcohol use disorder was present, and determined by urine drug tests or self-report recorded in medical notes. Results indicate that JIV used substances at a higher rate compared to those not recently incarcerated, and that such use is predictive of several other negative outcomes including homelessness, use of inpatient substance treatment, and reincarceration. Structured drug treatment programs and other interventions should cater to veterans recently released from prison to offer help in these areas.

Blending Traditional Vocational Services and Individualized Placement and Support for Formerly Incarcerated Veterans

OBJECTIVE

This study compared two vocational programs: the About Face Vocational Program (AFVP), a traditional group-based vocational program created for formerly incarcerated veterans, and a hybrid program combining the AFVP with principles of individual placement and support-supported employment.

METHODS

The study evaluated 111 veterans with at least one felony conviction who had a mental illness, substance use disorder, or both. Veterans were randomly assigned to either vocational condition.

RESULTS

Veterans in the hybrid condition, compared with the AFVP alone, were more likely to find employment, had higher rates of full-time employment, and earned significantly more money over the course of the study. A comparison of only participants who found employment showed higher rates of full-time employment for veterans in the hybrid condition but similarities between the two groups in other measures of employment success.

CONCLUSIONS

Blended models of vocational services for veterans with mental illness, substance use disorders, or both are effective at returning formerly incarcerated veterans to competitive employment.

Predictors of dropout from a randomized clinical trial of cognitive processing therapy for female veterans with military sexual trauma-related PTSD

Many veterans do not complete evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD). Veterans with military sexual trauma (MST)-related PTSD were shown to have higher than average rates of dropout from PTSD treatment in a national study of EBT implementation. Although predictors of dropout from EBTs have been identified, these factors are largely unmodifiable (e.g., age, service era). The purpose of the present study was to identify dynamic psychosocial predictors of dropout among female veterans from cognitive processing therapy (CPT). Data were utilized from 56 female veterans who participated in a randomized clinical trial investigating the effectiveness of CPT for MST-related PTSD. Dropout was defined continuously (i.e., number of sessions attended) and dichotomously (i.e., attending six or more sessions). Potential predictors included sociodemographic factors, psychotherapist fidelity, PTSD-related service connection, psychiatric symptom severity (i.e., PTSD, depression), trauma-related negative cognitions (about self, self-blame, world), and treatment expectations. Higher trauma-related negative cognitions about self-blame and lower trauma-related negative cognitions about self were protective against dropout. The current study generated testable hypotheses for further research on dynamic predictors of dropout from CPT in female veterans with MST-related PTSD. With replication, results may assist with identifying pre-treatment strategies to reduce dropout in this clinical population.

The association between time incarcerated and the search for employment in a veteran sample with substance use disorders

OBJECTIVE

Incarceration and substance use disorders/mental illness can have a significant negative impact on finding employment. However, it is unclear in what phase of the search for employment, that is, applying for jobs, obtaining interviews, being offered employment, does time incarcerated have the most effect. This study will determine how time incarcerated in the past 10 years is associated with negative job search process outcomes.

METHOD

This study evaluates 84 (81 men and 3 women) veterans with substance use disorders and histories of felony convictions. Four path analyses were conducted to evaluate models that incorporated time incarcerated at the different phases.

RESULTS

The superior model incorporated time incarcerated negatively affecting the number of interviews obtained. Models that assessed the association between time incarcerated with applications submitted and likelihood of being offered employment did not demonstrate adequate goodness-of-fit.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Overall, the findings demonstrate the ex-offenders enrolled exhibited similar effort in searching for employment across time incarcerated. Also, employers are equally likely to hire those with felony histories, regardless of the time incarcerated, once the applicant has been met and interviewed. The results highlight the need for services focusing on breaking down stigma and reducing barriers that screen out ex-offenders from being interviewed by employers. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Vocational rehabilitation for veterans with felony histories and mental illness: 12-month outcomes

Lack of employment is an important barrier to successful reintegration encountered by those released from prison with mental illnesses and/or substance use disorders. This study compares 3 different vocational reintegration modalities for a veteran population: (a) basic services; (b) self-study using the About Face Vocational Manual; and (c) the About Face Vocational Program, a standardized group program focused on the About Face Vocational Manual. One-hundred eleven veterans with a history of at least one felony conviction and a mental illness and/or substance use disorder were recruited from a large urban Veterans Affairs (VA) medical center. Veterans were assigned to 1 of the 3 conditions and followed for 12 months. At the end of the 1-year follow-up period, veterans in the group condition had superior competitive and stable employment rates, as well as faster times to employment compared with both the basic and self-study conditions. The self-study condition was generally indistinguishable from the basic services condition. Overall, new employment during the last 6 months of the follow-up period was relatively low. The findings support the use of standardized group vocational reintegration programs such as the About Face Vocational Program. Limitations and implications are discussed. (PsycINFO Database Record

Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes

OBJECTIVE

To determine the effects of a 24-month program of Individual Placement and Support (IPS) supported employment (SE) on employment outcomes for veterans with spinal cord injury (SCI).

DESIGN

Longitudinal, observational multisite study of a single-arm, nonrandomized cohort.

SETTING

SCI centers in the Veterans Health Administration (n=7).

PARTICIPANTS

Veterans with SCI (N=213) enrolled during an episode of either inpatient hospital care (24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of traumatic brain injury (TBI).

INTERVENTION

IPS SE for 24 months.

MAIN OUTCOME MEASURE

Competitive employment.

RESULTS

Over the 24-month period, 92 of 213 IPS participants obtained competitive jobs for an overall employment rate of 43.2%. For the subsample of participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for an overall employment rate of 52.2%. Overall, employed participants averaged 38.2±29.7 weeks of employment, with an average time to first employment of 348.3±220.0 days. Nearly 25% of first jobs occurred within 4 to 6 months of beginning the program. Similar employment characteristics were observed in the subsample without TBI history enrolled as outpatients.

CONCLUSIONS

Almost half of the veterans with SCI participating in the 24-month IPS program as part of their ongoing SCI care achieved competitive employment, consistent with their expressed preferences at the start of the study. Among a subsample of veterans without TBI history enrolled as outpatients, employment rates were >50%. Time to first employment was highly variable, but quite long in many instances. These findings support offering continued IPS services as part of ongoing SCI care to achieve positive employment outcomes.

The Emotional Impact of Chosen and Imposed Thoughts

Two studies tested the idea that perceptions of choice can alter the self-relevance and emotional impact of thoughts. Participants who were initially in either a positive or negative mood engaged in a thought exercise that involved either positive or negative thinking. Half of the participants received information stressing the optional nature of the task, thereby fostering a sense of choice and personal determination. The results indicate that under high-choice, mood-incongruent thinking was especially self-relevant, memorable, and produced the most mood change. The findings raise new considerations for self-perception and cognitive dissonance theories and offer insights into the relationship between cognition and emotion.

Incorporating Individualized Placement and Support Principles Into Vocational Rehabilitation for Formerly Incarcerated Veterans

OBJECTIVE

This study evaluated the six-month outcomes of incorporating the principles of supported employment, specifically Individual Placement and Support (IPS), into the About Face program, an existing standardized group-based vocational program for previously incarcerated veterans.

METHODS

Participants (N=84) with a history of at least one felony conviction and a substance use disorder (88%) or mental illness or combination (59%) were recruited from a large urban veterans hospital. Veterans were randomly assigned to either the About Face program (AF) or to that program plus a modification of IPS (AF+IPS). Veterans were followed for six months. Employment outcomes, including time to employment, hours worked, and income earned, were evaluated with survival analyses and nonparametric tests.

RESULTS

Rates of employment over the follow-up period were significantly higher for those receiving AF+IPS, with 21 of 46 (46%) finding employment, compared with only eight of 38 (21%) who received AF alone. As a group, those receiving AF+IPS worked more hours and earned more wages than those receiving AF alone.

CONCLUSIONS

Incorporating many of the principles and techniques of IPS into an existing vocational program was associated with improved employment outcomes over the six-month follow-up period and should be considered a viable rehabilitation option when working with this vulnerable population.

Redesign of a Screening Process for VA Homeless Housing

Standardizing the screening processes for homeless housing among VA facilities can make programs more accessible to veterans experiencing homelessness and improve provider knowledge of existing and available services.

Effects of structured vocational services in ex-offender veterans with mental illness: 6-month follow-up

With more than 200,000 veterans incarcerated, a significant need exists for the development of technologies that help veterans with felony histories return to employment. This study evaluated the effect of three methods of vocational assistance on competitive employment over a 6 mo follow-up period: (1) basic vocational services, (2) self-study using a vocational manual designed for formerly incarcerated veterans, and (3) a group led by vocational staff using the vocational manual. We evaluated 111 veterans for time to obtain and total time of competitive employment. The group format was expected to be superior to the self-study and the self-study superior to basic services. Findings indicated that the group format was associated with quicker employment and more total employment than the basic and self-study conditions. Limitations and directions for future refinement are discussed.

Lifestyle coaching's effect on 6-month follow-up in recently homeless substance dependent veterans: a randomized study

OBJECTIVE

Behaviors and activities consistent with "healthy" lifestyles (i.e., leisure and recreational activities, social and family interactions, coping behaviors) have been shown to be related to prolonged substance dependence recovery. However, there has been little focus on systematically capitalizing on this association in treatment to improve relapse rates. The goal of this study was to determine if the inclusion of healthy lifestyle coaching, that is the encouragement of specific behaviors in a therapeutic setting, could impact time to relapse.

METHODS

Fifty-six veterans who were recently discharged from a Veterans Administration (VA) homeless Domiciliary Residential Rehabilitation and Treatment Program and were substance dependent were evaluated over a 6-month follow-up period. Using a partially randomized design, three groups were evaluated: 1) those followed by a therapist and coached to increase healthy behaviors, 2) those followed by a therapist and receiving only emotional support, and 3) those not followed by a therapist. Survival analyses and nonparametric evaluations were performed.

RESULTS

Coached consumers had longer latency to relapse than noncoached and relapsed at a lower rate than those not followed by a therapist.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Therapeutic interventions which focus on increasing healthy behaviors chosen by the consumer can be an important component of sustained recovery from substance dependence.

Effects of structured vocational services on job-search success in ex-offender veterans with mental illness: 3-month follow-up

With the high number of incarcerated veterans with mental illness and substance dependence returning to the community annually, a significant need exists for technologies that will help them return to employment. This study evaluates three methods of assistance: (1) basic vocational services, (2) self-study of a vocational manual designed for formerly incarcerated veterans, and (3) a group led by vocational staff using the vocational manual. We evaluated 69 veterans to determine the number finding employment within 3 months after enrollment in the study. The group format was expected to be superior to self-study, and self-study was expected to be superior to basic services. Though the group format was found to be superior to both self-study and basic services, the results for self-study and basic services were statistically similar. Limitations and directions for future refinement are discussed.

Detecting random responding using the Assessment of Depression Inventory: a brief screening measure of depression

BACKGROUND

Traditionally, the assessment of random responding in psychological assessment tools has been the primary domain of large multi-scale inventories. However, the ability of clinicians to assess random responding when using short symptom inventories is also an important facet of reliably assessing psychopathology and psychological distress.

METHODS

This study assesses the effectiveness of a short symptom inventory, the Assessment of Depression Inventory (ADI), to assess random responding.

RESULTS

The responses of 335 clinical patients, 150 responses from a feigning population, and 1,000 generated random profiles were compared to determine if the Random and Reliability scales of the ADI could detect adequately random responses.

CONCLUSIONS

Findings indicate that even scales as short as four items can be used to detect random responses in symptom inventories at levels equivalent to or better than longer multi-scale inventories.

Reliability and validity of World Health Organization Quality of Life-100 in homeless substance-dependent veteran population

The number of homeless individuals and specifically homeless veterans is increasing. Accurate assessment of quality of life is an important need in working with this population because of the myriad problems encountered. However, the reliability and validity of quality-of-life instruments have not been assessed in this population. This study evaluated the psychometric properties of the U.S. version of the World Health Organization Quality of Life-100 in a homeless veteran population. Results found adequate internal consistency for all domain and most facet scores, while test-retest stability varied for the facet scores. We confirmed validity by using subsamples with physical, emotional, and social problems and by comparing scores from populations that returned to the community with employment and housing. Limitations and directions for future study are discussed.

Effects of hemodialysis on profound memory deficits in renal insufficiency due to multiple myeloma: a case study

Multiple myeloma, a rare cancer for individuals less than 65 years of age, and its pathophysiological effects have a profound impact on neurocognitive function. Specific transient deficits in patients with renal failure secondary to multiple myeloma have been noted to improve with hemodialysis. We present a complex case of an individual with multiple myeloma, renal insufficiency, treated seizure disorder, and schizophrenia, paranoid type, who experienced functional improvements in memory and visuospatial function with short- and long-term administration of hemodialysis. Within weeks of treatment, memory impairments resolved. With continued hemodialysis, some areas of neurocognitive function were in the superior range, indicating an overall improvement of more than three standard deviations. Implications and recommendations for clinicians treating individuals with similar challenges are offered.

Evaluating risk factors for violence at the inpatient unit level: combining young adult patients and those with mental retardation

The current study demonstrates the use of patient case mix to evaluate the probability of aggression occurring on an inpatient psychiatric unit. The impact of combining young adult psychiatric patients with patients classified with mental retardation on the overall negative events and injuries on an inpatient psychiatric unit was evaluated. Results suggest when the combined number of young adults and patients classified with mental retardation exceeds 10 the unit is at high risk for aggressive behavior occurring. Recommendations for evaluating violence at a unit level using case mix are provided.

Line staff use of the behavioral observation system: assessment of depression scale validity and cut scores

The Behavioral Observation System (BOS) is an objective behavioral tool used by non-degreed line staff to assess depression, mania, psychosis, and acting out in psychiatric inpatients. The current study uses the Beck Depression Inventory (BDI)-1A to provide evidence for convergent validity for the BOS Depression Scale and to determine effective cut-scores to assist in BOS interpretation. Findings support substantial correlational agreement between the BOS Depression Scale and the BDI. A discriminant function analysis established a "hit rate" of 82% using a Depression Scale score of 7 or greater to identify those with at least moderate levels of depression. The study data lend further credibility to the use of non-degreed line staff as a source of data that can aid in treatment decisions.

A brief behavioral activation treatment for depression. A randomized pilot trial within an inpatient psychiatric hospital

The brief behavioral activation treatment for depression (BATD) is a relatively uncomplicated, time-efficient, and cost-effective method for treating depression. Because of these features, BATD may represent a practical intervention within managed care-driven, inpatient psychiatric hospitals. Based on basic behavioral theory and empirical evidence supporting activation strategies, we designed a treatment to increase systematically exposure to positive activities and thereby help to alleviate depressive affect. This study represents a pilot study that extends research on this treatment into the context of an inpatient psychiatric unit. Results demonstrate effectiveness and superiority of BATD as compared with the standard supportive treatment provided within the hospital. A large effect size was demonstrated, despite a limited sample size. The authors discuss the limitations of the study and future directions.

Five-year outcomes following psychiatric consultation to a tertiary care emergency room

OBJECTIVE

The authors prospectively examined inpatient psychiatric hospitalization and mortality rates of psychiatric patients seen in the emergency room of a large Department of Veterans Affairs medical center.

METHOD

Charts of 504 patients receiving evening psychiatric consultation during a 13-month period were assessed 5 years after the consultation to determine rates of psychiatric hospitalization and mortality.

RESULTS

Patients with multiple psychiatric diagnoses, including comorbid addiction disorders, had significantly higher rates of psychiatric hospitalization 5 years after an emergency room visit. Comorbid psychiatric disorders increased the rate of inpatient psychiatric hospitalization across diagnoses. Seventy-eight patients died during the study period.

CONCLUSIONS

These findings reveal relationships between diagnostic profiles and future psychiatric hospitalization and mortality rates. This information could focus psychiatric and medical interventions for high-risk patients.

The comparison of the behavioral observation system and the brief psychiatric rating scale-expanded

The construct validity of the Behavioral Observation System (BOS), an observational instrument used by line staff to rate psychopathological behaviors, was studied using comparisons with the Brief Psychiatric Rating Scale-Expanded version (BPRS-E). A sample of 100 inpatient participants was rated using the BPRS-E on the same day they were rated by line staff using the BOS. Pearson product-moment correlations were performed, supporting good convergence and divergence. Principle component analysis on the six BPRS-E scales and the four BOS scales resulted in a three-factor finding. This analysis was supportive of construct validity. Uses of the BOS in light of these findings were discussed.

The Behavioral Observation System (BOS): a line staff assessment instrument of psychopathology

This study examined the initial reliability and validity of the Behavioral Observation System (BOS). The BOS, which consists of 34 items rating inpatient behaviors and is completed by psychiatric aids, was developed to assess the domains of Psychosis, Mania, Depression, and Behavioral Dyscontrol. Three studies are described. Results of the reliability study suggest adequate intraclass correlations and coefficient alphas. Analyses of the interscale correlations demonstrated appropriate initial discrimination between the scales. A comparison of diagnoses with ratings yielded expected convergent validity. The overall results suggest the BOS is likely to provide reliable and useful information to treatment teams. Directions of future studies also are discussed.

Validity rates of the MMPI-2 and PAI in a rural inpatient psychiatric facility

This study examines the validity rates of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Personality Assessment Inventory (PAI) profiles in a rural inpatient population. The validity scales of 90 MMPI-2 and 90 PAI profiles were analyzed using published criteria for determining validity. Random responding, positive impression management, and negative impression management were also evaluated. The PAI had a higher number of valid profiles compared with the MMPI-2. Evidence suggests the primary source of the invalid profiles within the MMPI-2 is a higher level of endorsement of relatively rare statements. The substitution of the Infrequency-Psychopathology scale (Fp) for the Infrequency scale (F) on the MMPI-2 substantially reduced the number of invalid profiles. Contrary to expectations, the PAI did not demonstrate lower levels of invalid profiles due to random responding. Rates of invalid profiles for each scale are provided.

The impact of a token economy on injuries and negative events on an acute psychiatric unit

OBJECTIVE

Although the use of token economies has been shown to facilitate patient change and improve program functioning in numerous settings, token economies have received little attention in acute psychiatric settings. A token economy was introduced on an acute care unit in a rural hospital, and rates of negative events were compared before and after implementation.

METHODS

Negative events were defined as patient and employee injuries that were not accidents. Unauthorized absences and use of emergency medications were also counted as negative events. Rates of negative events were calculated over two four-month periods, before and after the token economy was introduced on a 24-bed acute care unit that housed the hospital's neo-adult program for patients between the ages of 18 and 20. The unit also served as an admitting unit for patients over age 20.

RESULTS

When the analysis controlled for unit census and the number of neo-adults, an analysis of covariance indicated that the number of negative events fell significantly after the token economy was introduced, from 129 in the four months before implementation to 73 after implementation, a 43 percent reduction. Both staff and patient injuries were significantly reduced. A small increase in use of emergency medications was noted, but it was not statistically significant.

CONCLUSIONS

Findings support the use of the token economy in acute settings to improve the unit milieu by reducing negative events.