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Work plays a significant role in how people identify themselves, and successful return to work is associated with significant psychological and rehabilitative benefits. Unfortunately, despite the many benefits of employment, Veterans who experience mild traumatic brain injury and have mental health issues often have significant difficulty getting their vocational needs met. Considering that a consistent relationship between cognitive dysfunction and difficulties with employability has been firmly established, cognitive rehabilitation may enhance engagement in vocational rehabilitation and return to work outcomes. In this pilot study, we evaluated a 12 wk cognitive rehabilitation intervention embedded within vocational rehabilitation services. Eighteen Veterans were randomly assigned to receive either the embedded cognitive rehabilitation intervention (n = 10) or a control condition offering supportive client-centered therapy that did not focus on employment or cognitive rehabilitation (n = 8); all Veterans (intervention and control groups) received vocational rehabilitation services. This pilot feasibility study demonstrated efficient implementation of an embedded cognitive rehabilitation intervention within vocational rehabilitation. The current pilot data revealed small to moderate effect sizes on employment outcomes. Given these preliminary findings, a larger outcome study is warranted.

INTRODUCTION Scientific efforts to advance the practice of vocational rehabilitation (VR) for adults with the full range of disabilities have made remarkable progress over the past two decades. The number of published evaluations of vocational interventions has grown at an encouraging pace, and though the number of clinical trials has been fairly small, it is steadily increasing. Moreover, the level of methodological and statistical sophistication has improved substantially. To a significant extent, these trends have been driven by research studies seeking to carefully evaluate the use of the Individual Placement and Support model of supported employment (IPS SE) for adults with psychiatric disorders. There have been more than 20 clinical trials of IPS SE over the past 20 years, and more than 25 percent of all empirical evaluations of vocational services (VS) published in 2009 represent evaluations of IPS SE. These efforts have coincided with growing agreement among policymakers, clinicians, and researchers that clinical programming should be guided by principles of evidence-based practice (EBP) [1-2]. While IPS SE is one of the practices with a sufficient evidence base to be included on the list of EBPs, relatively few of the range of common vocational interventions have been the focus of controlled trials. Of those that have been, the populations studied have typically been a subset of the disability groups using VS. As VS research matures, it is necessary for the field to review its progress and identify any important gaps in measurement and methodology that may hamper its ability to answer key questions. Moreover, articulating larger strategic issues may help direct future research toward particularly relevant and compelling concerns. To encourage progress, we have identified (1) ways to increase consistency in measurement of employment outcomes, (2) emerging patterns and lingering gaps in the range of variables and measures commonly used in VS research, (3) broader methodological patterns and needs in the area of study design and sampling, (4) interventions that warrant additional study, and (5) broad strategies to increase the overall amount and quality of VS research. We make recommendations in each of these five areas. These recommendations vary in terms of the audience they are relevant to and the potential benefit they may produce. Given these variations in focus, audience, and potential benefit, we have not tried to prioritize them in terms of importance but instead offer them all as potential ways to enhance different aspects of current research. Note that this article is not intended to be a comprehensive review of the literature, measures, or methodology in VS research. Instead, we have tried to highlight trends in the literature and make recommendations for the field as it moves forward. In particular, the final section of this article focusing on broad strategies for enhancing research could easily include extensive discussion of each strategy--an approach that is beyond the scope of this article. COMPETITIVE EMPLOYMENT OUTCOMES AND MEASURES As a field, VS profits from the relative luxury of having a single primary outcome: competitive employment. Competitive employment is defined by the Department of Labor (DOL) as work in the competitive labor market that is performed on a full-time or part-time basis in an integrated setting and for which an individual is compensated at or above the minimum wage [3]. While the stated goals of vocational interventions may be framed in a range of ways, the overall objective for most is to help participants obtain and maintain their own competitive job in the community. The singular focus on competitive employment as the primary outcome of VS and as a key outcome for rehabilitation should continue for a number of reasons. Deterioration in functioning in competitive employment is a central element in the definition of disability (see the World Health Organization's International Classification of Functioning, Disability, and Health [4]), as evidenced by its central use in the compensation determination processes. …

Vocational services (VS), particularly supported employment models, have clear advantages for assisting adults with severe mental illness (SMI) in returning to the workplace, but a majority of eligible individuals with SMI do not receive any type of VS. The reasons for nonparticipation in VS remain poorly understood, and the potential contribution of cognitive impairment as a barrier to entry has not been explored. The present study uses a pathways-to-care design to examine the specific contribution of cognitive functioning to entry into VS among veterans with SMI. We examined 179 veterans with both SMI and un- or underemployment who completed a work history, the Pathways To Care Inventory, and the Trail-Making Test, Part B. Analysis revealed that veterans with SMI and moderate to severe cognitive impairment took significantly longer to progress through pathways-to-care than those with SMI and mild or no cognitive impairment. These results suggest that identifying veterans with SMI and cognitive impairment early and providing them with integrated and adjunct services may help them navigate VS.

In this random-assignment trial, we evaluated the efficacy of using a contingency management (CM) intervention to enhance job acquisition and tenure among participants of a vocational rehabilitation (VR) program. The CM intervention offered participants cash incentives up to $1,170 for completing tasks related to sobriety and job search and maintenance. Participants were 100 veterans with comorbid psychiatric disorders and substance dependence who were randomly assigned either to VR only or VR + CM. Relative to participants in the VR-only group, those in the VR + CM group showed more intense job searches and transitioned to competitive employment faster and at higher rates. No significant difference was found in job tenure, though this may be due to the limited follow-up period. Abstinence rates were significantly better in the VR + CM group during the first 16 weeks of follow-up but not significantly different in subsequent follow-ups. No relationship was found between relapse and employment. These results suggest that rehabilitation outcomes may be enhanced by adding CM to current programming or by restructuring traditional work-for-pay contingencies to include direct financial rewards for achievement of clinical goals.