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This article presents the argument that all veterans engaged in substance use treatment, regardless of current or recent use, should be allowed access to vocational services through Veterans Affairs (VA). This argument is presented as a commentary to Cosottile and DeFulio (2020), who argue for the VA to restrict veteran's access to work and Compensated Work Therapy (CWT) transitional work (TW) services to those who have demonstrated abstinence from substances.Our commentary provides an overview of relevant literature and programmatic considerations.The VA previously had common practice of restricting access to CWT TW services based on demonstrated sobriety and now has explicit policies and guidance against this practice. Research demonstrates that employment is an important recovery goal, that employment and substance use influence one another (both positively and negatively), and that substance use does not detract from employment outcomes of individuals participating in vocational rehabilitation services.Work activity is not simply a means or incentive for achieving sobriety. Employment is a critical component of recovery that supports a healthy sober lifestyle. Vocational services can be successfully integrated into substance use treatment without restricting access to those who have demonstrated sobriety. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

BACKGROUND In the veteran community, chronic pain is particularly prevalent and often debilitating. Until recently, veterans with chronic pain were offered primarily pharmacological intervention options, which rarely suffice and can also have negative health consequences. To better address chronic pain in veterans, the Veterans Health Administration has invested in novel, nonpharmacological behavior interventions that target both pain management and chronic pain–related functional issues. One approach, acceptance and commitment therapy (ACT) for chronic pain, is supported by decades of efficacy evidence for improving pain outcomes; however, ACT can be difficult to obtain owing to issues such as a lack of trained therapists or veterans having difficulty committing to the time and resources needed for the full clinician-led ACT protocol. Given the strong ACT evidence base combined with access limitations, we set out to develop and evaluate Veteran ACT for Chronic Pain (VACT-CP), an online program guided by an embodied conversational agent to improve pain management and functioning. OBJECTIVE The aims of this study are to develop, iteratively refine, and then conduct a pilot feasibility randomized controlled trial (RCT) of a VACT-CP group (n=20) versus a waitlist and treatment-as-usual control group (n=20). METHODS This research project includes 3 phases. In phase 1, our research team consulted with pain and virtual care experts, developed the preliminary VACT-CP online program, and conducted interviews with providers to obtain their feedback on the intervention. In phase 2, we incorporated feedback from phase 1 into the VACT-CP program and completed initial usability testing with veterans with chronic pain. In phase 3, we are conducting a small pilot feasibility RCT, with the primary outcome being assessment of usability of the VACT-CP system. RESULTS This study is currently in phase 3; recruitment for the RCT began in April 2022 and is expected to continue through April 2023. Data collection is expected to be completed by October 2023, with full data analysis completed by late 2023. CONCLUSIONS The findings from this research project will provide information on the usability of the VACT-CP intervention, as well as secondary outcomes related to treatment satisfaction, pain outcomes (pain-related daily functioning and pain severity), ACT processes (pain acceptance, behavioral avoidance, and valued living), and mental and physical functioning. CLINICALTRIAL ClinicalTrials.gov NCT03655132; https://clinicaltrials.gov/ct2/show/NCT03655132 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/45887

Compared to their civilian counterparts, Veterans have higher rates of mental health difficulties but are less likely to utilize health services. Since 2009, more than 1.4 million Veterans, service members, and their families have used the Post 9/11 GI Bill to fund their education, suggesting that college campuses are potential environments to reach Veterans with unmet health care needs. The Veterans Integration to Academic Leadership-Supported Education (VITAL-SEd) program was developed using psychiatric rehabilitation principles to provide in-person access to academic interventions, mental health programming, and access to additional services for unmet needs. The cases of three student Veterans are reported to demonstrate the implementation process and impact of VITAL-SEd in facilitating healthcare access and utilization among student Veterans. An outline of the VITAL-SEd model utilized is offered, and analyses of these three cases provided reveal the following practical implication themes: (1) responding to expressed educational needs helped build rapport and trust, thereby facilitating identification of unmet healthcare needs, (2) promoting Veteran choice and self-direction can shift student Veterans from a deficit to empowerment model of their own academic role, (3) using an integrated-health care lens within the context of SEd can help Veterans obtain both academic and health-management skills. Overall, results provide preliminary evidence of the usefulness and feasibility of the VITAL-SEd model.

Objective: This study sought to identify key ingredients of motivational interviewing (MI) associated with taking a step in the direction of competitive employment (CE) for unemployed veterans with serious mental illness (SMI). Method: Data were analyzed from 195 audiotaped MI sessions targeted to employment conducted with 39 veterans with SMI. Sessions were coded and analyzed to identify components of MI practice predictive of taking any step in the direction of CE (e.g., asking for a referral to supported employment or conducting a job search). Predictor variables were (a) counselor MI talk behaviors and adherence to MI technical and relational principles and (b) client intensity and frequency of change talk and sustain talk. Covariates were age, gender, race, duration of unemployment, receipt of disability income, health status, work importance, work confidence, mental health diagnosis, and session number. Generalized estimating equations were used to create multivariate models. Results: After controlling for session number, work importance, work confidence and duration of unemployment, variables significant in the adjusted multivariate model were intensity of client change talk and sustain talk and counselor adherence to MI technical principles of cultivating change talk and softening sustain talk. Conclusions and Implications for Practice: Findings suggest that change talk and sustain talk during counseling sessions are associated with taking a step toward employment and that counseling focused on cultivating change talk and softening sustain talk increases the likelihood that unemployed veterans with SMI will take steps toward becoming competitively employed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Military personnel transitioning to civilian life have reported significant challenges in reintegrating into civilian culture. Filmmaking has been used as a therapeutic intervention to enhance the community reintegration of veterans, but there are no published quantitative data documenting its impact. The present study provides outcome data on 40 veterans who participated in the I Was There (IWT) filmmaking workshop. This 3-day (20-hr) group intervention involved veterans working in small teams with a film coach, making short films designed to communicate some aspect of their experience during or after military service, and then creating a screening event to show their films to community members. The sample consisted of community-dwelling veterans who reported at least some mental health symptoms and who were not engaged in mental health treatment for those symptoms. Targeted outcomes included engagement in mental health care, symptoms of posttraumatic stress disorder (PTSD) and depression, and reported perception of community interest in their experience as veterans. Fifty-six percent of participants entered treatment within 4 months of participation. Significant decreases were noted in symptoms of PTSD at 1-month follow-up but not at the 4-month follow-up, while changes in depression were not statistically significant. Participation was related to increased perception of community interest in veterans' experience, and increased interest among community members who viewed the films. These data provide initial support for the conclusion that the IWT film workshop is a potentially effective tool for treatment engagement and for community reintegration among veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background: Unhealthy drug use is a concern in many settings, including military and veteran populations. In 2013, the Veterans Health Administration (VHA) medical center in Bedford, Massachusetts, started requiring routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. Methods: This study used descriptive and multivariable analyses of VHA electronic records for patients eligible for the screening program ( N = 16,118). The study assessed first-year rates and predictors of screening and of positive screens, both for drug use and for unhealthy alcohol use, for which screening was already required. Results: During the first year, 70% of patients were screened for unhealthy drug use and 84% were screened for unhealthy alcohol use. In multivariable analyses, screening for drug use was more likely for patients who had 8 or more days with VHA visits or were aged 40 or over. Patients with a prior drug use disorder diagnosis were much less likely to be screened. Three percent of patients screened for unhealthy drug use had a positive screen, and 14% of those screened for unhealthy alcohol use had a positive screen. Strong predictors of a positive drug use screen included a prior-year diagnosis of drug use disorder, any mental health clinic visits, younger age, or being unmarried. Conclusions: The drug screening initiative was relatively successful in its first-year implementation, having screened 70% of eligible subjects. However, it failed to screen many of those most likely to screen positive, thereby missing many opportunities to address unhealthy drug use. Future refinements should include better training clinicians in how to ask sensitive questions and how to address positive screens.

Supporting returning veterans' job-seeking, hiring, and retention issues has become an essential goal for effective community reintegration. Given both the particular strengths and challenges associated with veterans transitioning from military to civilian life, multiple models for supported employment have become integrated into Veterans Affairs health care facilities across the nation. In this article, we review the state of vocational rehabilitation for veterans, with a particular focus on individual placement and support-supported employment (IPS-SE), the current vocational services model that is considered the gold standard of vocational rehabilitation. Various modifications to the IPS-SE model are presented, including additions such as cognitive rehabilitation, contingency management, motivational interviewing, supported self-employment, and transitional work. Finally, recommendations are made about future directions and strategies to expand access to IPS-SE-based programs and to effectively meet the needs of returning veterans for employment in jobs of their choice. (PsycINFO Database Record

A randomized controlled pilot of supported education services was conducted with 33 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF, OIF, OND, respectively) veterans with posttraumatic stress disorder (PTSD) who had higher education goals. Veteran peers delivered supported education services to an intervention group; for the control group, peers provided "matched attention" of generalized support without supporting educational goals. The intervention was based on a manualized veteran-centric program of supported education using principles of supported employment for individuals living with mental illness and components of civilian models of supported education. The attrition rate was high, with 30% lost to services between the baseline screening and the first peer session, although this drop-out rate is comparable to other rehabilitation studies. Despite a small sample and a matched attention control that could have diluted possible effects, significant positive differences were found, with the intervention group spending greater amounts of time on educational activities than did the control group. Effect sizes for the impact of the intervention were large between Time 1 and Time 2, and moderately large between Time 2 and Time 3. PTSD-symptom severity and recovery attitudes did not predict the impact of the supported education intervention. Implementation of the veteran supported education program using veteran peers appears feasible, although assertive outreach may be necessary to recruit and engage veterans with PTSD. Findings suggest that supported education services can have a measurable effect on time spent attaining an educational goal. Future studies will need to be longitudinal, as well as attend to the attrition issue and capture the impact on other education outcomes, such as successful program completion. (PsycINFO Database Record

Background and objectives Gambling Disorder (GD) is characterized by recurrent gambling behavior that is associated with significant impairment and distress, high psychiatric comorbidities, and high functional disability. The military veteran population appears particularly susceptible to developing the disorder, but relatively little has been studied among this population. The purpose of the present study is to investigate the clinical psychopathologies and comorbidities of veterans seeking treatment for problem gambling and how problem gambling may impact functioning. Methods Treatment-seeking veterans meeting criteria for GD (N = 61) underwent a structured clinical interview and completed the South Oaks Gambling Screen (SOGS), the Gambling Symptom Assessment Scale (G-SAS), the Yale-Brown Obsessive-Compulsive Scale for Gambling Disorder (PG-YBOCS), the Gambling Belief Questionnaire (GBQ), the Barratt Impulsiveness Scale (BIS-11), and the Sheehan Disability Scale (SDS). Results Veterans seeking treatment for GD had high rates of psychiatric and addiction disorder comorbidities. Few veterans had previously sought treatment and most reported substantive challenges in social and occupational functioning. When determining how gambling-related characteristics (ie, severity and cognitive distortions) impact function, severity of cognitive distortions was the strongest statistical predictor of overall functional disability. Conclusions and scientific significance The findings from this study indicate that there is high comorbidity between GD and other psychiatric and addictive disorders, as well as social and occupational functioning. In addition, cognitive distortions related to gambling relate importantly to overall functioning and should be considered in the development of interventions for veterans with GD. (Am J Addict 2018;27:108-115).

Peer support is an important component in the promotion of recovery for people with serious mental illness. The Veterans Health Administration (VHA) has implemented peer support services nationally. This study used a series of questions about the perceived acceptance of peer services at VA facilities and the Recovery Self-Assessment (RSA), a standard measure of recovery attitudes, to evaluate and compare responses of a convenience sample of peer support specialists (PSS) and local peer supervisors (LPS). The authors hypothesized that level of receptivity of program among PSS and LPS will be high and that the scores on the five RSA domains will be comparable. The level of perceived receptivity was quite high for PSS and LPS and it was strongly correlated with recovery attitudes. Moreover, PSS scored significantly higher than LPS, on the Receptivity measure and on several domains of the RSA. RSA scores in this study were slightly higher than, or similar to, those observed in other VHA and non-VHA sa...

Military personnel transitioning to civilian life commonly report difficulty with establishing friendships, reconnecting with family, and a greater sense that they do not "fit in." Personal narrative interventions have the potential to increase the community's interest and understanding of Veterans' experience. This study examines the impact of a narrative intervention in which Veterans used film or verbal storytelling to describe their experience of being a Veteran to civilian audiences. A total 12 Veterans participated in at least one performance, and 88 community audience members attended one of six performances of the Veterans' narratives. Survey data indicate increase in positive attitudes towards Veterans, as well as a shift in the Veterans' perspective of civilians as receptive and supportive. These preliminary findings suggest that narrative interventions appear to have a positive impact on civilians' interest in Veterans and therefore, may be a valuable community reintegration intervention.

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.

Despite the availability of effective treatments for coping with traumatic experiences, a large percentage of military veterans in need do not seek help. The “I Was There” model is a new filmmaking program which is a creative-expressive tool, developed to enable veterans to reflect on their experiences and jointly create short artistic films. These artistic films articulate, often metaphorically, aspects of the veterans’ service experiences, traumatic events, and reintegration challenges. The current study employed a qualitative methodology to explore participants’ subjective experience of the program. We interviewed 50 participants following the intervention, focusing specifically on their perceptions of the filmmaking process, the aspects they viewed as meaningful, and whether and how the process affected them. Most participants reported their experience as positive and empowering. Three overarching themes emerged as significant in describing the benefits of participation: Gaining a new sense of agency, regaining a sense of affiliation, and processing the trauma. The findings are illustrated and discussed within the context of narrative therapy, as is the potential of video-based therapy, especially regarding non-articulated, sensory traumatic memories, and for the process of (re)construction of the trauma narrative.

Peer support groups, also known as "self-help groups," provide a unique tool for helping veterans working through the military-to-civilian transition to achieve higher levels of social support and community integration. The number and variety of community-based peer support groups has grown to the point that there are now more visits to these groups each year than to mental health professionals. The focus of these groups on the provision of social support, the number and variety of groups, the lack of cost, and their availability in the community make them a natural transition tool for building community-based social support. A growing literature suggests that these groups are associated with measurable improvements in social support, clinical symptoms, self-efficacy and coping. For clinical populations, the combination of peer support groups and clinical care results in better outcomes than either alone. Given this evidence, we suggest clinical services use active referral strategies to help veterans engage in peer support groups as a means of improving community reintegration and clinical outcomes. Finally, suggestions for identifying appropriate peer support groups and assisting with active referrals are provided. (PsycINFO Database Record

Gambling Disorder (GD) is characterized by recurrent gambling behavior that is associated with significant impairment and distress, high psychiatric comorbidities, and high functional disability. The military veteran population appears particularly susceptible to developing the disorder, but relatively little has been studied among this population. The purpose of the present study is to investigate the clinical psychopathologies and comorbidities of veterans seeking treatment for problem gambling and how problem gambling may impact functioning.Treatment-seeking veterans meeting criteria for GD (N = 61) underwent a structured clinical interview and completed the South Oaks Gambling Screen (SOGS), the Gambling Symptom Assessment Scale (G-SAS), the Yale-Brown Obsessive-Compulsive Scale for Gambling Disorder (PG-YBOCS), the Gambling Belief Questionnaire (GBQ), the Barratt Impulsiveness Scale (BIS-11), and the Sheehan Disability Scale (SDS).Veterans seeking treatment for GD had high rates of psychiatric and addiction disorder comorbidities. Few veterans had previously sought treatment and most reported substantive challenges in social and occupational functioning. When determining how gambling-related characteristics (ie, severity and cognitive distortions) impact function, severity of cognitive distortions was the strongest statistical predictor of overall functional disability.The findings from this study indicate that there is high comorbidity between GD and other psychiatric and addictive disorders, as well as social and occupational functioning. In addition, cognitive distortions related to gambling relate importantly to overall functioning and should be considered in the development of interventions for veterans with GD. (Am J Addict 2018;27:108-115).

Veterans transitioning from military to civilian life are vulnerable to a loss of social support and an increase in isolation from their communities, which can exacerbate other difficulties they may be experiencing, such as physical or mental health problems. Veteran Coffee Socials are an innovative community-building pilot intervention designed to foster social support and community between veterans. In seven target communities, certified peer specialists initiated and facilitated weekly "Veteran Coffee Socials"-open peer support groups for veterans, held in local coffee shop or restaurants. Over a 9-month period, an average of 8.5 veterans attended each meeting, for a total of 2236 veteran engagements across seven towns. A range of activities were identified as commonly occurring during these Veteran Coffee Socials. Veteran attendees routinely formed relationships with each other, representatives from community organizations, and staff from local and VA healthcare resources. One of the most common activities involved veterans receiving information and directions for enrollment into needed healthcare supports and to local community resources. Case descriptions are provided illustrate the potential positive impact of this intervention to build community and expand social support for returning veterans through the examination of three individual and three group examples.

Background: Technology-assisted clinical interventions are increasingly common in the health care field, often with the proposed aim to improve access to and cost-effectiveness of care. Current technology platforms delivering interventions are largely mobile apps and online websites, although efforts have been made to create more personalized and embodied technology experiences. To extend and improve on these platforms, the field of robotics has been increasingly included in conversations of how to deliver technology-assisted, interactive, and responsive mental health and psychological well-being interventions. Socially assistive robots (SARs) are robotic technology platforms with audio, visual, and movement capabilities that are being developed to interact with individuals socially while also assisting them with management of their physical and psychological well-being. However, little is known about the empirical evidence or utility of using SARs in mental health interventions. Objective: The review synthesizes and describes the nascent empirical literature of SARs in mental health research and identifies strengths, weaknesses, and opportunities for improvement in future research and practice. Methods: Searches in Medline, PsycINFO, PsycARTICLES, PubMed, and IEEE Xplore yielded 12 studies included in the final review after applying inclusion and exclusion criteria. Abstract and full-text reviews were conducted by two authors independently. Results: This systematic review of the literature found 5 distinct SARs used in research to investigate the potential for this technology to address mental health and psychological well-being outcomes. Research on mental health applications of SARs focuses largely on elderly dementia patients and relies on usability pilot data with methodological limitations. Conclusions: The current SARs research in mental health use is limited in generalizability, scope, and measurement of psychological outcomes. Opportunities for expansion of research in this area include diversifying populations studied, SARs used, clinical applications, measures used, and settings for those applications.

Purpose The influx of young adult veterans with mental health challenges from recent wars combined with newly expanded veteran education benefits has highlighted the need for a supported education service within the Veterans Administration. However, it is unknown how such a service should be designed to best respond to these needs. This study undertook a qualitative needs assessment for education supports among veterans with post-9/11 service with self-reported PTSD symptoms. Methods Focus groups were held with 31 veterans, 54% of whom were under age 30. Transcripts were analyzed and interpreted using a thematic approach and a Participatory Action Research team. Results Findings indicate a need for age relevant services that assist with: education planning and access, counseling for the G.I. Bill, accommodations for PTSD symptoms, community and family re-integration, and outreach and support. Conclusions and implications for practice The veterans recommended that supported education be integrated with the delivery of mental health services, that services have varied intensity, and there be linkages between colleges and the Veterans Health Administration.

The current study provides naturalistic data documenting the pathways to care to vocational services (VS) for 80 adults who were receiving some form of mental health care through a New Hampshire state mental health service and who had an unmet vocational need but were not currently enrolled in VS. Of the participants, 81.2% had recognized their vocational need, 55.3% reported that they or someone else had sought help to alleviate the need, and 52.6% had participated in some form of VS to address the need. The mean length of the participants' unmet vocational need was 4.4 years, and for those who had previously entered VS the mean length of time until services were first received was more than 2.8 years. The largest portion of the total delay to VS entry was associated with the failure to recognize the need. The results are discussed with respect to possible interventions that could increase access and reduce delays to treatment entry.

The original version of this article unfortunately contained a mistake in co-author name and his affiliation. The author name should be Anthony Russo instead it was published as Antony Russo and his affiliation has been corrected.

Using a scenario format, this study examined whether behavioral economic concepts are useful for understanding vocational rehabilitation and job search decision-making. It was also designed to determine factors most likely to motivate participants to engage in job search activities. Results document the relative salience of specific cost/benefit factors associated with likelihood of seeking employment. The most salient factors include intrinsic factors such as interest or sense of accomplishment in the job, extrinsic factors such as pay, discounting factors such as length of time until the job starts, and factors related to income effects such as housing costs. The data also suggest that altering the unit price of specific job characteristics leads to predictable changes in the probability of job search behaviors consistent with classic behavioral economic demand curves. These findings suggest that a behavioral economic perspective is useful for understanding decision making for veterans within a vocation...

The social environment of service programs—the context for treatment delivery rather than the treatment itself—is often neglected in evaluations of treatment outcomes. This research paper uses Moos's [Moos, R. H. (1997). Evaluating treatment environments: The quality of psychiatric and substance abuse programs (2nd ed.). New Brunswick, NJ: Transaction] measure of level of program involvement to identify variation in the social environment of a multi-site transitional program for homeless veterans that included both work and residential components. The transitional program, the Veterans Health Administration Compensated Work Therapy/Transitional Residence program (CWT/TR) provides a unique opportunity to test the simultaneous influence of the social environment in work and housing. Three hypotheses were tested concerning the impact of the social environment on three health outcomes and three functional outcomes. We find that programs with higher average involvement levels tended to produce more improvement among participants, particularly for those who were more impaired at baseline. Identifying the influence of the social environment within this program required assessment of both the work and residential environments and tests for their conjoint influence, as well multiple tests of person–environment fit with multiple outcomes.

Research into vocational rehabilitation (VR) consumer service preferences has been limited. The current study describes the self-reported goals of 228 applicants to a VR program sponsored by the Veterans Administration (VA) and documents the relationship of those goals to participant background variables and outcomes. Participants endorsed a wide variety of goals for participation, including clinical and practical goals. Competitive employment was a goal of only 53% and was the primary goal of only 5%. The apparent contrast between the diversity of VA participant goals and the growing focus by VA rehabilitation professionals on competitive employment suggests that greater dialogue is needed between providers and consumers.

Archival data from 17,929 homeless adults entering the Veterans Health Administration's Healthcare for Homeless Veterans program were analyzed to identify whether the rate of referral and admission to vocational rehabilitation differed between adults with psychiatric disorders alone and those with psychiatric disorders with a coexisting substance-use disorder (SUD). Participants with an SUD had an 11% greater chance of being referred to vocational rehabilitation than did those with a psychiatric disorder alone. Of the participants referred to vocational rehabilitation, those with an SUD were almost twice as likely to participate. Those with an SUD also had a higher rate of employment prior to evaluation than did those with a psychiatric disorder alone. These advantages were significant after covarying for demographic variables, specific psychiatric diagnosis, and Addiction Severity Index (McLellan, Luborsky, & Woody, 1980) psychiatric composite score. These findings fail to support the hypothesis that there is a bias in the process of referral or admission into vocational rehabilitation and suggest that work and participation in work rehabilitation are not negatively affected by a coexisting SUD.

The purpose of this study is to identify what factors predict job and career commitment among professional caregivers working with patients with dementia. A secondary analysis was completed using data collected from 77 professional caregivers working in residential dementia special care programs. The findings suggest that professional caregivers’ commitment to their jobs and careers is most closely related to their level of involvement in the interpersonal aspects of the work, the degree to which they feel personal growth or benefit, and the level of burden that their work generates. Strategies are suggested for improving job and career longevity among professional caregivers by enhancing attachment to patients and families, fostering professional identity and personal growth, and monitoring and managing professional caregiver burden.

Two hypotheses were tested: (1) in a sample of religiously-committed evangelical adults, past experience of abuse is related to more frequent (a) religious behaviour such as prayer, church attendance and Bible reading, and (b) religious experiences, such as religious visions, healings and speaking in tongues; (2) abuse is also associated with evidence of alienation from God, as noted in more frequent reports of God as distant and more frequent religious doubting. Survey data from 3424 adults attending one of four new evangelical movement churches were analysed. Controlling for socio-economic and religious socialization variables, a series of regression equations were calculated looking at the relationship between the experience of abuse and the dependent variables of three factor scores representing conventional religious behaviour, transcendent religious experience and feelings of distance from God. Self-report of the frequency of abuse was positively associated with frequency of reported transcendent re...

Archival data from 25,480 adults entering the Compensated Work Therapy (CWT) program of the Veterans Health Administration were analyzed to identify differences in work functioning and vocational rehabilitation among participants with psychiatric disorders alone, substance use disorders (SUD) alone, and psychiatric disorders with coexisting SUD. The co-existence of psychiatric disorders and SUD was associated with better work functioning, more participation in vocational rehabilitation, and a better outcome, compared to psychiatric disorders alone. Poorer functioning was seen on all variables relative to participants with SUD alone. These findings are due in part to correlates of substance abuse, but they may suggest that clinicians should focus on work and vocational goals to support other clinical efforts for clients with dual diagnoses.

The objective of this study was to establish the validity and reliability of the Professional Caregivers' Burden Index (PCBI), a new measure of burden for professionals who work with patients with Alzheimer's disease. In phase 1, content validity was examined; in phase 2, the 24-item instrument was administered to professional caregivers on specialty dementia care units at a long-term care facility in New England. In phase 3, mean staff PCBI scores were found to increase significantly at 3 and 9 months following a reduction of approximately 5% in staffing levels at a dementia care program. These initial data on the PCBI suggest that it may be used as a valid and reliable measure of burden among professional caregivers of patients with Alzheimer's disease.

The authors sought to determine the relationship between receipt of disability compensation and participants' success in a vocational rehabilitation program.Administrative data for 22,515 individuals who participated in the Veterans Health Administration compensated work therapy program between 1993 and 1998 were analyzed. Six dependent variables were compared between participants who were receiving disability compensation and those who were not: duration of participation in compensated work therapy, number of hours worked per week, mean hourly earnings, total income from compensated work therapy, dropout rate, and competitive employment status at discharge. Regression equations were determined for each dependent variable to assess associations with the degree of disability, the amount of disability compensation, and the type of compensation program.Participants who were receiving disability benefits worked fewer hours in compensated work therapy each week, earned less income, had a higher dropout rate, and were less likely to be competitively employed at discharge. The amount of compensation and the type of program were modestly but significantly associated with participation in compensated work therapy and with outcome.Unintended effects of disability compensation programs discourage full participation in vocational rehabilitation and result in poorer rehabilitation outcomes.

Problem gambling is a common, highly destructive disorder which is often overlooked by clinicians. Levels of clinical training, clinical experience, and professional competence for providing clinical services for problem gambling were examined in a survey of 181 clinical psychologists working in the Veterans Healthcare Administration (VHA). The results suggest that the majority of clinical psychologists have little or no formal training and little or no past or current clinical experience in the treatment of disordered gambling, nor do they see themselves as competent to evaluate or treat patients with disordered gambling. Most have not referred patients for treatment of problem gambling and do not know of a competent provider to whom they can refer. There is an identifiable subgroup, representing 9% of respondents, who do have more training, provide services, and see themselves as competent to provide care for patients with problem gambling. The amount of formal training is positively correlated with care provided and self-ratings of competence. Despite the lack of training and experience, most respondents expressed interest in receiving additional training. These data suggest that to improve rates of diagnosis and treatment of patients with problem gambling in mental health settings, additional training needs to be made available for mental health providers as a group, with specialized training for clinicians interested in specializing in this area.

This study represents the first attempt to cross validate and report on the Neuropsychology Behavior and Affect Profile (NBAP) using closed head injury (CHI) participants. The NBAP is designed to measure emotional functioning before and following a brain event. Two CHI samples, differing primarily by method of ascertainment, were compared to a group of normal controls. Results provided support for concurrent and predictive validity of the NBAP across both CHI samples. Significantly higher levels of postinjury emotional functioning in clinic-referred CHI patients compared to CHI individuals not seeking treatment (strictly research participants) was demonstrated. A surprising finding was that pre-injury emotional levels of clinic-referred subjects were rated as less severe than that of controls. Based on this finding, the possibility of a gradient effect was discussed in which raters appeared to place selectively greater weight on current condition, while simultaneously making premorbid levels less severe than they really were. Results were discussed in the context of study limitations and directions for further research.

Objective: Two hypotheses were tested: (1) In a sample of adult men, past experience of child abuse (sexual, physical, or emotional) will be related to higher levels of reported alienation from religion and God as shown in lower rates of current religious behavior, higher frequency of spiritual “injury,” and lower stability of religious behavior and experiences; (2) More “severe” forms of abuse will be associated with higher indicators of alienation. Method: Data were collected from 1,207 male veterans, 527 (43.7%) of whom reported being abused as a child. Each subject completed the Spiritual Issues Assessment, a large survey which includes data about: (1) KASL Religiosity Index; (2) The Spiritual Injury Scale; and (3) Religious items from the Westberg Personal Health Inventory. Results: A history of sexual abuse was related to significantly greater spiritual injury and lower stability of spiritual behaviors and experiences, but not to overall rate of current religious behavior. Surprisingly, abuse was related to increased frequency of prayer and of “spiritual experience.” Multivariate analyses indicate that the effect size is relatively small and the type of abuse was less important than the presence of any form of abuse. Conclusions: The findings suggest that the impact of childhood abuse is more complex than initially hypothesized. While abuse seems to be related to continuing spiritual injury and distress, it is also related to higher levels of some spiritual activities and experiences which are usually associated with positive spirituality.

The Neuropsychology Behavior and Affect Profile (NBAP) is a peer-rated inventory of behavioral and affective changes in brain injured individuals and consists of five Clinical Scales that have demonstrated strong external validity. A potential confound is the NBAP's susceptibility to rater bias. In the present investigation, four validity scales were developed and external validity and psychometric properties were examined through a dissembling paradigm. Study I describes item selection and construction of the validity scales. Study 2 demonstrates that various combinations of both the clinical and validity scales effectively differentiated dissemblers from informants of two groups of traumatic brain injury patients. Although results differed somewhat when dissemblers were grouped according to their level of neuropsychological training, highly trained dissemblers (licensed clinical neuropsychologists) could be detected.

The current study provides naturalistic data documenting the pathways-to-care to vocational services for 155 veterans who were receiving some form of mental health care from the Veterans Health Administration and had a vocational need but were not currently enrolled in vocational services. Of the participants, 94.2% had recognized their vocational need, 80.6% reported that they or someone else had sought help to alleviate the need, and 77.4% had previously received some form of vocational services. The median length of the participants' vocational need was more than 4.2 years. Delays associated with recognition, help-seeking, and treatment entry all contributed to the overall delay in entering appropriate care. Filtering factors associated with quicker recognition, seeking help, and receiving services included diagnosis, level of disability, type of vocational need, and support from primary providers, family, and friends. The results provide information for designing interventions to improve service entry by adults with mental health problems and vocational needs.

This study explored the relationship between three indices of intersubtest scatter and level of cognitive deterioration in a sample of 104 patients with dementia of Alzheimer's type, who ranged in age between 52 and 84 years. Scatter was highly related to education and premorbid level of functioning. Advancement of dementia was shown to be associated with decrease in scatter, which suggests caution in interpretation of high magnitude of inter-subtest scatter as an indication of brain dysfunction. Easy-to-calculate range of scatter proved to be adequate measure of scatter. Calculation of more complex indices, such as PVI, provides only minimal incremental gain.

The study explored differential patterns of deficits in different memory components as a function of dementia severity. Three groups of 58 subjects each were used: (1) highly functioning elderly who are free of neurological or psychiatric symptoms; (2) individuals with early signs of memory disturbance, whose MMSE scores were > or = 24; and (3) individuals with MMSE scores below 24, who meet criteria for DAT. Performance on the tests that assess different memory components was compared for the three groups. Results suggest pronounced change in acquisition component of memory at the onset of dementia, whereas retrieval from remote memory discriminates well between the mild and the more advanced phases of the disease. Retrieval from recent memory deteriorates more gradually. Based on these results, efficiency of different memory mechanisms was discussed.

The study explored encoding, storage, and retrieval components of memory functioning in four groups of subjects: (1) normal elderly; (2) elderly subjects in the early prestages of DAT; (3) elderly subjects with a more advanced DAT; (4) younger subjects in the early prestages of AIDS dementia. Each group consisted of 26 subjects, who were administered the Rey Auditory-Verbal Learning Test. The results suggest impaired encoding and retrieval in the DAT groups. The AIDS group demonstrated deficient storage and retrieval. Their pattern of memory deficits was similar to that seen in normal aging. The results speak in favor of the hypothesis of subcortical nature of neurological changes in normal aging.

Our study investigates the nature of elevated depression scores on the MMPI-168 in human-immunodeficiency-virus- (HIV-)infected individuals. Comparison of MMPI scales, factor scores, and individual depression item endorsement rates were made between three groups of homosexual/bisexual men: asymptomatic HIV-1 seropositives (n = 156), symptomatic HIV-1 seropositives (n = 156), and a comparison group of HIV-1 seronegatives (n = 117). Elevated scores were found on the MMPI depression scale for all three groups, with HIV infection and the presence of symptoms being associated with significant elevations in depression. Analyses of these elevated scores through the use of factor scores and individual item analyses strongly suggest that endorsement of items related to physical symptoms and neuropsychological complaints accounted for much of the difference in overall depression scores between samples. Implications are discussed for measurement and diagnosis of depression in HIV populations.

Objective This study seeks to compare the effectiveness of Veterans Health Administration's (VHA) transitional work experience (TWE) services and a minimal but common intervention-job placement (JP) services, for veterans with co-morbid substance and psychiatric disorders. Methods We conducted a random clinical trial comparing work outcomes for 89 veterans with co-morbid psychiatric and substance use disorders (SUD) who were randomly assigned to participate in VHA TWE services with those assigned to simple JP services provided by state vocational rehabilitation professionals. Participants were enrolled at the time of application to VHA TWE services and then randomly assigned to the two treatment groups and followed for 12 months. Results VHA TWE participants were more likely to engage in paid activity, to work more total hours, to work more weeks and to earn more in total wages. The groups were not significantly different with respect to competitive employment, in terms of the percentage acquiring competitive jobs, the number of hours worked, or wages earned. Conclusions These data suggest that the primary benefit of VHA TWE services is in rapidly engaging participants in paid activity and that these services are not effective at helping dually diagnosed veterans obtain competitive employment.

Supported housing is a service model that couples provision of independent housing with provision of community-based supports for individuals with psychiatric disabilities at risk of homelessness. Despite its promise as an alternative to traditional sequential residential rehabilitation programs, supported housing has not been evaluated to an extent that supports firm conclusions concerning the efficacy of specific program elements. We conducted a comprehensive review of the literature on supported housing and similarly labeled programs, to determine the degree of clarity in the supported housing model and the degree of fidelity to that model within the empirical literature, and to determine whether lack of clarity or fidelity are barriers to widespread, systematic program implementation and evaluation. We encountered a number of limitations in the literature, including conflicting use of program labels, inconsistent definitions of supported housing and its elements, and use of inadequate measurement indices in assessing adherence to program elements. Our findings suggest that greater model clarity, better specification of model elements, and greater standardization in measurement of program dimensions would aid in supported housing program implementation and evaluation. We present a number of recommendations for the field and suggestions for future research.