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Adding contingency management intervention to vocational rehabilitation: Outcomes for dually diagnosed veterans

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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.
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851
JRRD
JRRD
Volume 44, Number 6, 2007
Pages 851–866
Journal of Rehabilitation Research & Development
Adding contingency management intervention to vocational rehabilitation:
Outcomes for dually diagnosed veterans
Charles E. Drebing, PhD;
1
*
E. Alice Van Ormer, PhD;
1
Lisa Mueller, MA;
1
Marcie Hebert, PsyD;
1
Walter E.
Penk, PhD, ABPP;
1
Nancy M. Petry, PhD;
2
Robert Rosenheck, MD;
3
Bruce Rounsaville, MD
3
1
Bedford Department of Veterans Affairs Medical Center, Bedford, MA;
2
University of Connecticut Health Center,
Farmington, CT;
3
Yale University School of Medicine, New Haven, CT
Abstract—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. Partici-
pants 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 ten-
ure, 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 dif-
ferent 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 cur-
rent programming or by restructuring traditional work-for-pay
contingencies to include direct financial rewards for achieve-
ment of clinical goals.
Key words: compensated work therapy, contingency manage-
ment, dual diagnosis, employment, job search, job tenure, psy-
chiatric rehabilitation, sobriety, vocational rehabilitation, work.
INTRODUCTION
Helping adults with psychiatric disabilities find and
maintain employment is a national priority [1]. To address
this issue, the Veterans Health Administration (VHA) has
invested heavily in vocational rehabilitation (VR) pro-
grams, particularly Compensated Work Therapy (CWT),
which is the Department of Veterans Affairs’ (VA) largest
clinical VR program. In less than 10 years, the number of
veterans served annually by VA VR services has grown to
more than 22,000 [2–3] and the amount of money paid
annually to veterans through work-for-pay activities has
grown to more than $34 million [4]. The outcome for VA
VR participants in terms of percentage employed in com-
petitive jobs at discharge has increased almost every year
since 1993 [5]. Despite this investment of effort and
resources, the highest rate of competitive employment at
discharge, achieved in fiscal year 2004, was 41.7 percent
[5]. Dropout rates in some programs range as high as
70 percent, and as many as 40 percent of participants drop
out before 4 weeks of participation [4]. Similar findings
are noted among non-VA VR programs [6].
Abbreviations: CM = contingency management, CWT = Com-
pensated Work Therapy, DSM-IV = Diagnostic and Statistical
Manual of Mental Disorders-Fourth Edition, HR = hazard rate,
JSBI = Job Search Behaviors Index, VA = Department of Veter-
ans Affairs, VHA = Veterans Health Administration, VR =
vocational rehabilitation, VRS = VR specialist.
*
Address all correspondence to Charles E. Drebing, PhD;
Bedford VA Medical Center, Psychology Service, 200
Springs Road, 116B, Bedford, MA 01730; 781-687-2462;
fax: 781-687-2169. Email: Charles.Drebing@med.va.gov
DOI: 10.1682/JRRD.2006.09.0123
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JRRD, Volume 44, Number 6, 2007
In prior work [4,7–8], we identified factors contribut-
ing to the modest outcomes for VA VR participants with
psychiatric disorders: poor program compliance, early
drop out, frequent substance abuse relapse, low rates of
transition to competitive employment, inadequate sup-
port to sustain competitive employment, and financial
and emotional disincentives for employment. Of veterans
with psychiatric disorders who enter VR, 75 percent have
comorbid substance use disorders [8], and the proportion
of VR entrants who are dually diagnosed has grown
steadily since 1995 [5]. Substance abuse among persons
with severe mental illness substantially increases the risk
of treatment noncompliance, premature termination,
relapse, and rehospitalization [9–10]. For improved VA
VR outcomes, the needs of clients with dual diagnoses
must be more fully addressed [11–12].
If we look to the field of substance abuse treatment,
we see that similar problems of poor compliance and
modest outcomes have been addressed successfully by
adding incentive-based contingency management (CM)
techniques [13–14]. By using behavioral principles to
enhance participants’ incentives for completing treatment
and meeting clinical goals, substance abuse programs
have increased completion rates from 30 to 80 percent
and sobriety rates from 15 to 70 percent [15–16]. The effi-
cacy of these approaches is now well documented in more
than 24 clinical trials [13–14,17–18].
Despite the empirical evidence of the efficacy of CM
techniques, they have not yet been adapted widely for
other clinical settings such as VR [14]. In two initial
studies, vouchers were an effective reward for sustained
abstinence in a work setting [19–21]. In two additional
studies, activities related to returning to work were
rewarded directly. Silverman and associates found that
job-training attendance significantly improved with an
incentive regimen that rewarded attendance with vouch-
ers [22]. Petry and associates allowed participants in sub-
stance abuse treatment to select work-related goals for
their CM program [23]. Fifty-nine percent of the sample
chose at least one work-related goal to be rewarded. Suc-
cess rates varied between behaviors (e.g., working on a
résumé was successfully completed 50% of the time,
identifying potential jobs 66%, submitting job applica-
tions 87%, and attending work 69%), while all work-
related goals were successfully accomplished in 79 per-
cent of the cases.
We recently published the results of an initial applica-
tion of CM principals to enhance outcomes in a VA VR
program [24]. In this study, 19 dually diagnosed veterans
entering VR were randomly assigned to VR only (n = 8)
or VR + CM (n = 11). Over the first 16 weeks of rehabili-
tation, those in the VR + CM group could earn cash
incentives for meeting two sets of clinical goals:
(1) abstaining from drugs and alcohol and (2) taking steps
to obtain and maintain competitive employment. We
offered an escalating schedule of incentives for negative
urine and Breathalyzer screens biweekly over the
16 weeks and for steps toward obtaining and maintaining
employment, such as creating a résumé, completing a job
interview, and working at a competitive job. Primary out-
come variables were (1) placement into competitive
employment and the time (in days) to placement,
(2) hours of paid work and earnings, (3) substance abuse,
and (4) program retention.
Results documented that participants in the VR + CM
condition fared better on all outcome measures relative to
those in VR only. The VR + CM group, compared with
the VR-only group, was more likely to have created a
résumé (81% vs 13%, respectively), have completed a job
interview (81% vs 25%, respectively), and be working in
a competitive job (45% vs 25%, respectively). Also, a
larger percentage of the VR + CM group remained absti-
nent during the study (64% vs 25%, respectively).
The current study built on this initial pilot study to
determine whether a revised version of this CM interven-
tion applied to a larger sample of VR participants could
improve treatment outcomes in terms of the number of
participants obtaining and maintaining their own jobs. The
incentive structure is a revised version of the pilot study
intervention [24]. The specific behavioral targets for the
incentives were selected based on the “pathways to reem-
ployment” model [25]. In the pilot study, the number and
value of incentives offered for work goals were less than
those offered for sobriety goals ($270 of total incentives
for work goals vs $736 for sobriety goals). Although the
incentive group in that study completed work goals more
often than the comparison group, further room for
improvement existed in terms of rate of placement into
competitive employment for the incentive group. We
therefore increased the number and total value of incen-
tives available for work goals and extended the availability
period for employment incentives.
In a random-assignment trial of VR versus VR + CM,
we examined whether VR + CM produced better employ-
ment outcomes than VR only. The primary hypotheses
were that participants in the VR + CM condition would
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DREBING et al. Contingency management and rehabilitation
more rapidly transition to competitive employment and
that those in the VR + CM condition who transitioned to
competitive employment would have greater job tenure.
Secondary analyses evaluated whether the VR + CM
intervention effectively helped participants meet “interme-
diate” goals related to enhanced job-search intensity and
sustained sobriety.
METHODS
Participants
For this study, we recruited 100 dually diagnosed
veterans from among veterans entering the CWT pro-
gram at the Bedford VA Medical Center (Bedford, Mas-
sachusetts). “Dually diagnosed veterans” were defined as
those meeting Diagnostic and Statistical Manual of Men-
tal Disorders-Fourth Edition (DSM-IV) criteria for a cur-
rent diagnosis of (1) schizophrenia, bipolar disorder,
major depression, posttraumatic stress disorder, or other
anxiety disorder and (2) current drug or alcohol depen-
dence or abuse, as well as active substance use within
90 days of enrollment. Because prior studies suggest that
CM approaches to increasing abstinence are most effec-
tive when a relatively small number of substances are tar-
geted [23,26], we required participants to have substance
dependence or abuse for alcohol, cocaine, or opiates and
targeted those substances in the CM intervention.
Participants also had to have the potential for return
to competitive supported employment within 6 months,
as evidenced by a history of at least some participation in
competitive employment during the prior 3 years and
acceptance of the stated goal of returning to competitive
employment within 8 months. They had to be clinically
stable, defined as having no suicidal or homicidal ide-
ation in the prior 12 weeks and abstaining from drugs or
alcohol for at least 1 week. Veterans who were older than
55, had a chronic medical problem that would make
obtaining and sustaining a competitive job within
8 months unlikely, or did not intend to stay in VR for at
least 4 months or live in the local region for 12 months
were considered less likely to be seeking VR participa-
tion to gain competitive employment and were excluded
[27]. Candidates enrolled in other research studies that
would affect their participation were also excluded.
Because of the complexity of the incentives, we sought to
exclude veterans who would have difficulty understand-
ing the CM program. We therefore excluded any veteran
who had less than 10 years of formal education, had a
history of significant head trauma (loss of consciousness
for >1 hour) or another disorder resulting in significant
cognitive impairment, or failed to pass a 10-item quiz
about the incentives.
Veterans meeting all other criteria were given an
overview and a paper summary of the intervention. To
screen for potential participants who would have diffi-
culty comprehending the intervention, we then asked
them to complete the 10-item quiz covering the content
of the intervention. All potential subjects correctly com-
pleted the quiz. Potential participants were then invited to
sign informed consent at the time of CWT admission.
A total of 101 veterans signed consent, completed the
baseline evaluation, and completed random assignment.
One participant was found to be ineligible for VA
services because of a dishonorable discharge and so was
excluded from the study. Of the remaining 100 partici-
pants (Table 1), the majority were non-Hispanic white,
middle-aged males who had at least 12 years of formal
education. Most had affective disorders (major
depression = 79%, bipolar disorder I or II = 21%) or anx-
iety disorders (posttraumatic stress disorder = 53%, other
anxiety disorder = 50%). Nine percent had a psychotic
disorder. All met criteria for dependence on at least one of
the three target substances, with 88 percent dependent on
alcohol, 43 percent on cocaine, 26 percent on opiates,
29 percent on cannabis, 13 percent on sedatives, 5 per-
cent on stimulants, and 3 percent on hallucinogens. Most
were polysubstance dependent, with 33 percent of the
sample dependent on two or more substances and 30 per-
cent on three or more substances. Regarding employ-
ment, the average length of unemployment was
16.2 months and 46 percent stated that they lost their last
job primarily because of substance abuse or psychiatric
problems. On the Meaning of Work scale [28], most of
the sample ranked work as very important, with
28 percent rating work as more important than all other
life domains (family, religion, community, leisure) and
44 percent rating it only below family in importance.
Financially, most were in substantial debt that out-
weighed their financial reserves, 26 percent were receiv-
ing some form of disability income, and 61 percent were
receiving some form of public assistance.
Two subjects, both assigned to the VR-only condition,
dropped out of the study during week 7 of the 16-week
follow-up period. The follow-up rate was 94 percent for
the 3-month follow-up, 90 percent for the 6-month follow-
up, and 88 percent for the 9-month follow-up.
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JRRD, Volume 44, Number 6, 2007
Design and Procedures
Approximately 1,136 veterans were screened for the
study. Detailed data were collected on the first 318
screened. Of those, 77 percent did not meet at least one
screening criteria, 14 percent met criteria but did not enter,
and 9 percent met criteria and entered the study. Of those
who did not meet criteria, 20 percent did not have a psychi-
atric diagnosis, 9 percent did not have a substance abuse or
dependence diagnosis, and 20 percent had a target sub-
stance use diagnosis but had been abstinent too long.
Regarding employment, 18 percent of those not meeting
the criteria had not worked competitively in 3 years,
15 percent were not seeking competitive employment
within 8 months, and 9 percent were enrolled in treatment
programs that limited their ability to participate fully in
VR. Moreover, 8 percent were older than 55, 6 percent had
recent suicidal or homicidal ideation, 2 percent had used
substances in the prior 7 days, 2 percent had evidence of
significant cognitive impairment, and 3 percent were
already in another research study that would affect their
participation. Of those who met criteria but declined par-
ticipation, the stated reasons for declining included lacking
confidence in their ability to obtain or maintain a competi-
tive job (22%), not wanting the obligation or investment of
time required for participating (18%), feeling that the inter-
vention would overwhelm them (16%), not wanting to
complete job-search tasks (9%), not wanting to undergo
drug screening (4%), and wanting to enter education
instead of employment (13%). Finally, 22 percent said they
would consider participating but never returned and did not
give a reason for not participating.
Those candidates who signed consent completed a
baseline evaluation that included basic demographics,
clinical assessment, and work history data collected with a
demographics questionnaire and the CWT Work History
Questionnaire [7]. Financial functioning was documented
by a self-report questionnaire. Current psychiatric and sub-
stance use diagnoses were determined with the Structured
Clinical Interview for DSM-IV [29]. A measure of role-
limitation due to either medical or emotional factors was
administered (Medical Outcomes Study 36-item Short
Form) [30]. Job-search intensity was assessed with an
adapted form of the Job Search Behaviors Index (JSBI)
[31], a brief 15-item checklist of job-search activities
Table 1.
Demographics and baseline variables of participants with comorbid psychiatric and substance use disorders who completed vocational
rehabilitation (VR) only (n = 50) or VR plus contingency management (CM) (n = 50).
Variable Total Sample VR Only VR + CM t-Test /
χ
2
p-Value
Ethnicity, n (%)
2.11 0.64
Hispanic 5 (5) 2 (4) 3 (6)
Non-Hispanic 95 (95) 48 (96) 47 (94)
Race, n (%) 2.00 0.57
White 78 (78) 39 (78) 39 (78)
African American 20 (20) 10 (20) 10 (20)
American Indian or Alaskan 1 (1) 0 (0) 1 (2)
Asian or Pacific Islander 1 (1) 1 (1) 0 (0)
Age, Mean ± SD (yr) 46.3 ± 8.0 47.2 ± 6.7 45.4 ± 9.0 1.11 0.27
Education, Mean ± SD (yr) 12.9 ± 1.9 12.7 ± 1.7 13.1 ± 2.1 1.25 0.21
Female, n (%) 1 (1) 1 (2) 0 (0) 1.01 0.31
MOS SF-36: Role Limitation, Mean ± SD
Medical 71.2 ± 23.3 67.9 ± 26.3 74.6 ± 19.3 1.44 0.15
Emotional 67.0 ± 41.6 61.3 ± 42.8 72.8 ± 40.1 1.40 0.17
Receiving Disability Income, n (%) 26 (26) 14 (28) 12 (24) 0.08 0.78
Receiving Any Public Support, n (%) 61 (61) 28 (56) 33 (66) 0.84 0.35
Unemployment Before Evaluation, Mean ± SD (mo) 16.2 ± 19.0 15.1 ± 16.1 17.4 ± 21.5 0.59 0.55
Meaning of Work Scale, Mean ± SD 6.0 ± 1.2 6.0 ± 1.3 6.0 ± 1.1 0.17 0.87
Baseline Job Search Behavior Index, Mean ± SD 11.3 ± 8.4 10.1 ± 7.9 12.6 ± 8.9 1.50 0.14
Financial Questionnaire, Mean ± SD ($)
Current Debt 15,993 ± 28,671 14,521 ± 29, 423 17,523 ± 28,089 0.52 0.60
Current Cash Reserves 5,937 ± 27,616 6,927 ± 31,082 4,910 ± 23,760 0.36 0.72
Net Worth –10,054 ± 40,435 –7,595 ± 44,095 –12,614 ± 36,517 0.62 0.54
MOS SF-36 = Medical Outcomes Study 36-Item Short Form, SD = standard deviation.
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DREBING et al. Contingency management and rehabilitation
performed over the prior 3 months. The degree to which
participants valued work was assessed with the Meaning
of Work scale [28]. After the baseline evaluation, partici-
pants were randomly assigned to either VR only or VR +
CM.
Vocational Rehabilitation Only
Both groups participated in VHAs CWT program
and all CWT services were available to them. The Bed-
ford CWT program is the largest in the country, with 700
unique veterans admitted each year and 250 participating
on an average day [5,7]. Like other CWT programs, the
Bedford CWT program is a multicomponent work-for-
pay VR program. Veterans are placed in structured work
settings, usually in private companies in the metropolitan
area, and compensated for their work. They are typically
paid by CWT, which contracts with the company for their
labor. While the veterans are working, the CWT staff
help them negotiate and resolve difficulties on the job
and prepare for obtaining their own competitive job. Like
a growing number of CWT programs, the Bedford CWT
program includes a supported employment component
that helps participants maintain employment in their own
competitive jobs through structured support and manage-
ment [32–33]. Participants are encouraged to perform
job-search tasks, abstain from drugs and/or alcohol, and
obtain and then maintain competitive employment. The
Bedford CWT program is similar in structure and out-
come rates to other CWT programs around the country
[5]. The mean hourly wage is $7.28 [34]. For dually diag-
nosed participants, the average length of stay is 17 weeks
and the transition to competitive employment for those
who transition typically occurs after 22 weeks [7]. The
only random-assignment evaluation of CWT found that
participation was associated with reduced drug and alco-
hol abuse, fewer episodes of homelessness and incarcera-
tion, and protection from declined physical health
relative to a control group [35].
Vocational Rehabilitation Plus Contingency Management
In addition to the usual CWT program just described,
veterans assigned to the VR + CM group received addi-
tional incentives for taking steps toward obtaining and
maintaining competitive employment and for abstinence
from substance use.
Incentives for Abstaining from Substance Use
Of the possible clinical symptoms to target, we chose
abstinence because of its direct tie to dropout [7] and
demonstrated responsiveness to CM [14]. The “incen-
tive” regimen for encouraging abstinence was modeled
closely after approaches developed and validated by Hig-
gins and colleagues [15,26]. A series of increasing cash
incentives was offered for drug and alcohol screens nega-
tive for alcohol, cocaine, or opiates. We conducted onsite
urine screening using the OnTrak TESTCUP 5 and
the OnSite Alcohol Assay (Roche Diagnostics Inc, India-
napolis, Indiana). Screens were conducted twice weekly
at unannounced times over the initial 16 weeks of the
intervention. Screening results had to indicate no evi-
dence of alcohol, cocaine, or opiate use to be considered
negative or “clean.” The incentive for the initial clean
screen was worth $2.50 and the value of each consecutive
negative screen increased by $1.00, such that the second
consecutive negative screen was worth $3.50, the third
$4.50, and so on. No payments were given if the screen
was positive or if the participant did not produce a urine
screen for any reason. Additionally, a positive screen or
failure to provide a scheduled specimen reset the value of
the incentives to their original level of $2.50, from which
they could increase again with consecutive negative
screens. Four consecutive clean screens following a reset
returned the incentive value to where it was before the
reset. In total, participants could earn up to $560.00 if all
32 samples tested clean during the 16 weeks.
Incentives for Obtaining and Maintaining Competitive
Employment
Employment incentives were available in two phases.
Phase I incentives targeted job-search tasks and were
available for the first 16 weeks of the intervention. Phase
II incentives targeted employment itself and were avail-
able for the first 32 weeks. To help participants meet the
goal of obtaining a competitive job, we chose to reward
the following job-search behaviors: conducting a job
search, creating a résumé, completing a job application,
networking, completing a job-relevant course, completing
an informational interview, completing a mock interview,
and completing a job interview. To help participants meet
the goal of maintaining a competitive job, we chose to
reward the following target behaviors: obtaining a com-
petitive job and maintaining it for up to 4 months. Guide-
lines for these incentives were as follows:
1. As part of the study, participants were expected to
participate in the Supported Employment track of the
CWT program. Through this track, CWT staff were
available to assist participants with each step in
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JRRD, Volume 44, Number 6, 2007
getting a job and support them in maintaining that job
as long as the participants desired the support. If par-
ticipants lost their job for any reason, CWT staff were
available to help them find another job.
2. The job-search incentives were flexible to be more
relevant to all participants. Participants could earn
one incentive in each of the first 16 weeks by com-
pleting at least one target behavior. They could
choose the behavior to complete, within some limits.
For example, they could earn an unlimited number of
incentives for completing job interviews but no more
than one incentive for completing a résumé. Com-
pleting one target behavior during the first week
resulted in payment of a $5 incentive. The value of
the subsequent incentives increased by $2 for each
consecutive week that the incentive was earned, such
that the second incentive was worth $7, the third $9,
and so on. Because we felt that consecutive weeks of
job-search activities were less critical than consecu-
tive weeks of sobriety, we did not reset the value of
the job search incentives if the participant did not
earn an incentive during a week.
3. Because participants could take several weeks to be
ready to seek competitive employment, the availability
of incentives for work was more flexible. Specifically,
while the Phase I job-search incentives were available
for the first 16 weeks of the study, the Phase II incen-
tives were available for up to 32 weeks. Like maintain-
ing sobriety, job-search activities were intermediate
goals of the intervention and particularly important in
the first 16 weeks of VR participation. Our pilot data
suggest that job-search activities often are not com-
pleted in the first few months of CWT participation,
reducing the likelihood of a timely transition to a com-
petitive job. In contrast, the ultimate goals of obtaining
and maintaining competitive employment typically
occur only after the intermediate goals are accom-
plished. To ensure that most participants could achieve
the Phase II target behaviors, these incentives were
available for up to 32 weeks after the participant
entered the study.
4. Participants could earn a job-search incentive for
meeting with their CWT VR specialist (VRS) to learn
or review how to conduct a job search. The VRS
could show participants useful Web sites and other
resources that list available jobs. These meetings
were located at the VA and used computers available
to participants for job searches. Participants needed
to produce a printed computer job listing signed by
their VRS to receive this incentive. To earn the incen-
tive for a second job search, they needed to produce a
printed computer job listing of jobs for which they
were interested in applying or a written list of credi-
ble employers to whom they wished to apply. A
“credible employer” was defined as any employer
known to have an available job for which the partici-
pant may qualify. The listing had to have the date
printed on it or be signed and dated by a computer
laboratory or CWT staff member. For the third and
fourth job searches, participants needed to produce a
printed computer job listing and a fax machine print-
out showing that they had faxed their résumé to a
potential employer. Computers and fax machines
were available in the CWT facility. We did not limit
the number of incentives that could be earned for
completing job searches.
5. Participants could also earn a job-search incentive for
having or creating a résumé that could be used to
obtain a job. CWT staff were available to help partic-
ipants develop a résumé. To earn an incentive, the
résumé had to meet the following criteria, as judged
by study staff:
a. Provided relevant information—name, address,
telephone number, educational background, work
history.
b. Was organized similar to résumés in résumé work-
books. Study or CWT staff members supplied par-
ticipants with examples if necessary.
c. Looked professional—neatly printed on clean paper.
An incentive could be earned only once for creating a
résumé.
6. Participants could earn a job-search incentive for
conducting informational interviews at potential
places of employment and providing written docu-
mentation of the interview. Up to four incentives
could be earned for informational interviews.
7. Participants could earn a job-search incentive for net-
working. To earn this incentive, participants needed
to write a description of who they talked with, when
they talked with them, what they talked about, and
how the discussion was related to a targeted job.
Study staff had to agree that the contact was clearly
linked to a targeted job for the incentive to be earned.
Up to two incentives could be earned for networking.
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DREBING et al. Contingency management and rehabilitation
8. Participants could earn a job-search incentive for
completing a mock job interview. CWT staff were
available to conduct these mock interviews. To earn
this incentive, participants needed a signed note from
a VRS that stated that they had completed a mock
interview. Up to two incentives could be earned for
mock interviews.
9. Participants could also earn an incentive for applying
for jobs. To earn the incentive, the participant had to
send their résumé and/or completed job application to
at least three potential employers and provide fax
confirmation or other written documentation to study
staff. We did not limit the number of incentives that
could be earned for applying for jobs.
10. Participants could also earn an incentive for complet-
ing a real job interview. Participants needed to pro-
duce written evidence of an interview, similar to that
used by the State Unemployment Office. We did not
limit the number of incentives that could be earned
for completing job interviews.
11. Because sustaining employment can be more difficult
that obtaining employment and is the ultimate goal of
VR, we designed the Phase II incentives to encourage
consecutive weeks of employment. The value of the
incentives increased with consecutive weeks of
employment. Participants had to produce pay stubs or
other written documentation of their work hours to
receive the incentive. Participants could only earn
incentives for the 16 weeks after beginning their first
competitive job. During that time, they could change
jobs or miss work, but they would not be paid incen-
tives for times that they worked <20 hours a week.
12. The value of the incentive was $10 for the first week
of work, $15 for the second week, $20 for the third
week, and $25 for the fourth week. After 4 weeks of
consecutive incentives, we diminished the frequency
of incentives to facilitate the transition to naturally
existing incentives. Participants could earn an incen-
tive of $80 for working a second consecutive month.
This incentive was paid at the end of the month if
participants provided pay stubs showing at least
20 hours of work a week for each of the 4 weeks in
that month. The incentive value was $85 for a third
consecutive month of work and $90 for a fourth con-
secutive month. If participants failed to work consec-
utive weeks, the value of the next incentive that could
be earned was reset to $10 for the first week of
employment. Once participants began working, they
could only earn incentives for working during the
subsequent 16-week period.
13. To avoid creating a disincentive for participants to
enter employment while the job-search incentives
were available, participants entering employment
during the first 16 weeks of the study also received
incentive payments for completing Phase I tasks as
long as they continued to be employed up to week 16.
14. Participants could only earn incentives if they were
enrolled in CWT. If they were discharged from CWT
for any reason, they could not earn incentives. If they
did not maintain contact with staff members or
stopped participating in their psychiatric care or any
other care that VR requires, they could be discharged
and unable to earn incentives.
15. All participants understood that if any question
existed about whether an incentive had been earned,
the research associate, in consultation with the
project director, made the final determination.
In total, participants could earn up to $610 if they suc-
cessfully completed all work-related activities. Over the
36 weeks of the intervention, participants could earn
incentives up to $1,170. Participants were paid with either
cash or a voucher for cash immediately redeemable at the
hospital cashier, depending on whether going to the hospi-
tal cashier was reasonably convenient for the participant.
Because the incentive schedule is complex, we
reviewed the intervention guidelines with all participants
and gave three case examples. The participants then
signed a summary agreement stating that they understood
the intervention. They were given two copies of the
signed contract, along with summary tables of the poten-
tial incentives and a summary of the incentives printed on
a card to carry in their wallet. During meetings with
study staff, participants were also encouraged to ask
questions about the incentives.
Data collected during the first 16 weeks of study par-
ticipation included measures of completed job-search
tasks (assessed by weekly check-ins with the 15 JSBI
items) and abstinence from alcohol, cocaine, and/or opi-
ates (assessed by biweekly urine screens). Missing drug-
screen data were considered positive, breaking the string
of continuous abstinence. Missing income and employ-
ment data were assumed to reflect no income or no
employment.
To ensure rapid and accurate onsite urine screening, we
used the OnTrak TESTCUP 5 and OnSite Alcohol Assay.
The OnTrak TESTCUP 5 provides a simultaneous screen
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JRRD, Volume 44, Number 6, 2007
for a panel of the five drugs that CWT participants
most commonly abuse: cocaine, marijuana (THC),
amphetamines, PCP, and morphine (300 ng/mL) [7]. Sepa-
rate results were provided for each substance. Performance
data supplied by the manufacturer indicated a >99 percent
accuracy of the OnTrak TESTCUP 5 for all five target sub-
stances and a >95 percent precision [36]. Similar manufac-
turers’ data indicated a 98 percent accuracy of the OnSite
Alcohol Assay and good sensitivity and specificity [37].
During the study, all assays were conducted discreetly in a
public restroom. The screenings provided results in
<3 minutes, and staff gave immediate feedback and pay-
ment of incentives for those in the VR + CM group.
Participants in the VR-only group were paid $5 per
biweekly screen, for a total of $160 over the initial
16 weeks, regardless of the test results. Clinicians and
CWT staff could not access the urine-screen results for
either group, and urine-screen results were not provided
to participants in the VR-only group. The CWT program
staff occasionally collected urine screens on their own,
but the frequency of these was approximately once every
3 months except in unusual circumstances.
At the 3-, 6-, and 9-month follow-ups, we assessed
job search and competitive employment variables using
the CWT Work History and the JSBI. We assessed sub-
stance use using the time line follow-back method [38].
Since participants in the VR + CM group could earn
more, we added an additional payment of $30 for com-
pleting the final interview for those in the VR-only
group. Participants in the VR-only group could receive
up to $135 for completing all data collection, and partici-
pants in the VR + CM group could receive up to $105.
Data Analysis
We compared the two treatment groups on baseline
characteristics that may be related to job-search and job-
acquisition outcomes, including demographic variables,
work history, financial resources and liabilities, disability
income and other public support, limitations due to phys-
ical and mental illness, and job-search intensity, using t-
tests for ordinal variables and chi-square tests for nomi-
nal variables. Some research hypotheses were also tested
with t-tests for ordinal variables and chi-square tests for
nominal variables.
All analyses were based on an intention-to-treat
approach with
α
= 0.05. All tests of the primary hypothe-
ses (A and B) were one-tailed. This meets Cohen’s crite-
ria for the appropriate use of a one-tailed test, given that
the intervention is costly and would only be used if found
to positively affect target variables [39]. Because the
analyses for the remaining hypotheses (C and D) did not
meet these criteria, these tests were two-tailed.
Hypothesis A
For hypothesis A, the primary outcome variable was
number of weeks between intake and transition to compet-
itive employment. Competitive employment was defined
as the participant working at least 20 hours a week in an
ongoing community-based job for which he or she was
paid at least minimum wage. Because the goal of the inter-
vention was sustained community-based employment,
agency-contracted community employment, paid work
activity at a business owned and run by a rehabilitation
agency, and “casual” labor including day labor and tempo-
rary jobs were excluded from the outcome of competitive
employment. We used a time-to-employment survival
analysis with right-censored survival data to determine
whether the hazard rate (HR) for transitioning to competi-
tive employment was greater for the VR + CM group. The
log-rank test compared time-to-employment between
groups. We also compared the percentage of participants
engaged in competitive employment during each month
and the percentage that participated in competitive
employment at any point during the study.
Hypothesis B
For hypothesis B, the primary outcome variable was
tenure of the first competitive job obtained, as indicated
by the reported total number of days worked at that job.
This variable was obtained through the CWT Work His-
tory, which was completed at the 3-, 6-, and 9-month fol-
low-ups. Because job tenure was limited by the point in
the follow-up when the job was obtained and jobs could
potentially continue past the final follow-up, we again
used a time-to-event analysis with right-censored sur-
vival data, with the target event being termination of the
first job obtained. We used the log-rank test to compare
time-to-end-of-first-job analyses between groups.
Hypothesis C
We evaluated hypothesis C in two ways. First, we
compared the two groups with respect to the total number
of activities completed during each week and over the
entire 16-week period when incentives were available
and the frequency of each of the behaviors measured on
the JSBI during the VR + CM intervention. Second, time-
859
DREBING et al. Contingency management and rehabilitation
to-event survival analyses with use of right-censored
survival data were used to determine whether the HR for
three key job-search steps (creating a résumé, applying
for a job, completing a job interview) during the
16 weeks that incentives were available was greater for
the VR + CM group. Log-rank tests were again used to
compare time-to-event analyses between groups.
Hypothesis D
Hypothesis D was evaluated in several ways. First, we
used a time-to-relapse survival analysis with right-
censored survival data to determine whether the HR for
relapse during the initial 16 weeks, when incentives for
abstinence were available, was lower for the VR +
CM group. An additional survival analysis determined
whether the HR for relapse over the entire course of the
study was lower for the VR + CM group. Log-rank tests
were used to compare time-to-relapse between groups.
Second, the percentages of participants in each group using
targeted substances each week and over the entire 16-week
period when incentives were available were compared by a
series of chi-square tests. A simple t-test compared the
longest period of sustained sobriety during the interven-
tion. Substance use was measured with results from the
biweekly screenings for weeks 1–16, and self-report data
from the time line follow-back between the 16-week point
when the urine screens ended and the 9-month point.
RESULTS
Comparisons between the groups on baseline demo-
graphic characteristics indicated no significant differ-
ences at baseline (Table 1). No differences were found in
diagnosis.
When the time-to-first-employment analysis was
completed, participation in the VR + CM condition was
associated with a significantly shorter time to entry into
competitive employment (HR = 1.88, log-rank statistic =
2.23, p < 0.05). As shown in Figure 1(a), 50 percent
of the VR + CM group and 28 percent of the VR-only
group had entered competitive employment by the end of
the 9-month follow-up (
χ
2
(1, n = 100) = 5.09, p < 0.05).
We also compared the percentage of participants
employed during each month (Figure 1(b)). While a
greater percentage of the VR + CM group was employed
at each month, the differences were statistically signifi-
cant only for months 2, 7, and 9.
When job tenure was examined, participation in VR +
CM was not associated with statistically significantly
longer tenure in competitive employment (HR = 1.63, log-
rank statistic = 1.18, p = 0.29). Note that this analysis was
limited by the fact that only 39 study participants entered
employment, 16 entering in the last 4 months of follow-
up. Half of those who entered were still working in that
position by the end of the follow-up period, further limit-
ing information about tenure. Given that the incentive
program rewarded job tenure of at least 4 months, we
examined the subset of 18 participants (7 in the VR-only
group and 11 in the VR + CM group) who entered work
and had at least 4 months of follow-up data available for
that position. No significant differences were noted in job
tenure in this subgroup, as assessed with a simple t-test
(t (16) = 0.14, p = 0.90)
Comparison between the groups with respect to job-
search intensity fairly strongly supports hypothesis C.
During the intervention, participants in the VR + CM
group completed 39 percent more job-search tasks than
those in the VR-only group (Table 2). When compared
weekly during the intervention, the VR + CM group
completed a greater number of tasks each week, though
the differences were statistically significant only for
weeks 1, 6, 7, 9, 11, and 13. When the frequency of com-
pleting specific job-search tasks was compared, the VR +
CM group had a statistically significant higher comple-
tion rate on 5 of the 15 tasks (Table 2).
Figure 1.
Vocational rehabilitation (VR) only versus VR plus contingency man-
agement (CM) during 36 weeks of follow-up (n = 100, 50 each
group): (a) time to competitive employment (CE) and (b) percentage
engaged in CE.
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JRRD, Volume 44, Number 6, 2007
We used time to job-search task completion to deter-
mine whether the intervention also resulted in earlier com-
pletion of tasks. We examined three key tasks identified in
prior studies [24]: résumé creation, first job application,
and first job interview. As shown in Figure 2(a), 86 per-
cent of the VR + CM group had completed a résumé by
the end of the 16-week period compared with 68 percent
of the VR-only group (HR = 1.77, log-rank statistic = 2.48,
p < 0.05). Similarly, 78 percent of the VR + CM group had
submitted their first job application by week 16 as opposed
to 50 percent of the VR-only group (HR = 2.13, log-rank
statistic = 2.61, p < 0.01) (Figure 2(b)). The difference in
time to first job interview was smaller (Figure 2(c)), with
48 percent of the VR + CM group participating in at least
one job interview by the end of the 16-week period com-
pared with 32 percent of the VR-only group (HR = 1.60,
log-rank statistic = 0.94, p = 0.35). This difference was not
statistically significant.
When time to first relapse was analyzed for weeks 1–
16, participation in the VR-only condition was associated
with significantly shorter sobriety (HR = 1.74, log-rank
statistic = 2.02, p < 0.05). As shown in Figure 3, 50 per-
cent of the VR + CM group had relapsed by week 16 in
comparison with 72 percent of the VR-only group. If we
examine the full 9-month follow-up period, the difference
in relapse rate narrows, with 67 percent of the VR + CM
group relapsing by the end of the 9-month follow-up com-
pared with 75 percent of the VR-only group (HR = 1.25,
log-rank statistic = 1.34, p = 0.18). The difference between
the groups is no longer statistically significant. The rates of
abstinence for the VR + CM group were higher than those
of the VR-only group for 14 of the 16 weeks, but the
differences were statistically significant only during weeks
2, 4, and 5. When we compared the longest period of sus-
tained sobriety during weeks 1–16, the VR + CM group
achieved a mean ± SD of 11.8 ± 4.7 weeks versus 9.4 ±
5.3 weeks for the VR-only group, a statistically significant
difference (t (98) = 2.37, p < 0.05).
We conducted additional analyses to examine the
relationship between relapse and employment outcomes.
Those participants who relapsed during weeks 1–16 were
not significantly different from those who remained absti-
nent in terms of whether they entered competitive
employment (
χ
2
(1, n = 100) = 0.13, p = 0.90) or how
quickly they entered employment (HR = 1.03, log-rank
statistic = 0.01, p = 0.91). Similarly, those participants
who relapsed at any point during the study were not sig-
nificantly different from those who remained abstinent in
terms of whether they entered competitive employment
(
χ
2
(1, n = 100) = 1.66, p = 0.56) or how quickly they
entered employment (HR = 1.65, log-rank statistic =
0.36, p = 0.23).
Table 2.
Job-search activity by group: Vocational rehabilitation (VR) only versus VR plus contingency management (CM) (n = 100, 50 each group). Data
shown as mean ± standard deviation.
Variable Total Sample VR Only VR + CM t-Test p-Value
Total Job-Search Tasks Completed 39.4 ± 30.7 33.0 ± 28.5 46.1 ± 31.8 2.13 0.04
Individual Job-Search Behaviors
Looked in Newspaper
8.8 ± 5.8 7.8 ± 5.8 9.9 ± 5.8 1.76 0.08
Checked with Employment Agencies
1.8 ± 2.9 1.6 ± 2.9 1.9 ± 3.0 0.53 0.59
Talked with Friends/Family About Jobs
7.3 ± 5.7 6.6 ± 5.7 8.0 ± 5.7 1.20 0.23
Worked on Résumé
3.0 ± 3.4 2.7 ± 3.3 3.3 ± 3.5 0.86 0.39
Submitted Résumé
1.9 ± 3.1 1.7 ± 2.9 2.2 ± 3.4 0.77 0.44
Completed Job Application
1.9 ± 2.7 1.4 ± 2.2 2.5 ± 3.1 2.01 0.05
Telephoned or Visited Employer
3.0 ± 3.3 2.2 ± 2.6 3.8 ± 3.8 2.49 0.01
Attended Job Interview
0.8 ± 1.4 0.6 ± 1.1 1.1 ± 1.7 1.55 0.12
Took Steps to Improve Impression
4.6 ± 5.0 3.4 ± 4.6 6.0 ± 5.3 2.58 0.01
Checked with Public Employment Agency
0.9 ± 2.2 0.8 ± 1.9 1.0 ± 2.5 0.54 0.59
Attended Informational Interview
1.3 ± 2.4 0.8 ± 1.5 1.7 ± 2.9 2.10 0.05
Attended Job/Vocational Training
1.1 ± 2.9 1.3 ± 3.5 1.0 ± 2.0 0.56 0.58
Read Book About Job Search
0.6 ± 1.7 0.3 ± 1.2 1.0 ± 2.1 1.80 0.07
Studied/Took Course
0.6 ± 2.0 0.6 ± 2.5 0.6 ± 1.2 0.14 0.89
Other Job-Search Steps
1.3 ± 2.6 1.0 ± 3.0 1.6 ± 2.2 1.00 0.32
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DREBING et al. Contingency management and rehabilitation
DISCUSSION
These results support the efficacy of adding CM
intervention to VR to enhance entry into competitive
employment, with entry rates being very similar to those
achieved in the pilot study [24]. The VR + CM partici-
pants completed more job-search tasks and completed
two of three target job-search tasks more quickly than the
VR-only participants. Most importantly, they were more
likely to transition to competitive employment and to
transition more quickly than the VR-only participants.
Less clear is whether the intervention had a lasting bene-
fit for the intermediate goal of sustained sobriety. Also
less clear is whether CM helped extend job tenure,
though this may well be an artifact of the limited length
of the follow-up and the number of participants who
obtained jobs.
Regarding job-search activities, the incentives were
associated not only with faster completion of two of three
targeted tasks but also with more job-search activity
overall. While the VR + CM participants were rewarded
for completing up to one job task a week, on average they
completed 3.1 tasks a week compared with the 2.2 com-
pleted by the VR-only participants. A comparison of
individual items on the JSBI indicates that the VR + CM
participants more frequently completed tasks that were
not specifically rewarded than the VR-only participants.
For example, they were more likely than the VR-only
participants to report talking with friends, family, and
others to get information about jobs (54% vs 43%,
respectively) and more likely to report improving their
appearance to be more marketable to potential employers
(40% vs 22%, respectively). Interestingly, the differences
in job-search intensity did not continue past the period in
which the incentives were available, although this effect
may have been a function of the fact that only the indi-
viduals least likely to be employed were still looking for
employment by the time incentives for job-related activi-
ties were discontinued.
Of the targeted job-search tasks, the VR + CM group
achieved a job interview more rapidly than the VR-only
group, but the difference was not statistically significant.
The percentage of the VR + CM group completing an
interview (48%) is lower than in the pilot study (82%)
[24]. Possibly, with the wider range of job-search behav-
iors that could earn an incentive in the revised intervention,
participants did not choose the more anxiety-producing
or more difficult-to-arrange tasks, like completing a job
interview. In the pilot study, only four target behaviors
could be rewarded and the reward for completing a job
interview was among the highest in value, possibly result-
ing in the higher interview rate noted in that study. This
change in interview rates is unfortunate, since completing
a job interview is typically a crucial step in job acquisition
and was closely related to employment entry in this study.
The intervention should be further refined to ensure that,
while adequate choice in job-search behaviors is available,
Figure 2.
Percentage of participants completing key job-search tasks during
weeks 1–16; vocational rehabilitation (VR) only versus VR plus
contingency management (CM): (a) résumé, (b) job application, and
(c) job interview.
Figure 3.
Time to relapse during 9 months of follow-up; vocational rehabilita-
tion (VR) only versus VR plus contingency management (CM). Note:
Sobriety incentives were available weeks 1–16 only.
862
JRRD, Volume 44, Number 6, 2007
that choice is structured so that the most critical behaviors
are reinforced with the greatest magnitude to guarantee
their completion.
The mixed substance abuse outcome of the CM inter-
vention also differs from the findings of the pilot study
and suggests that the relatively lower magnitude of
incentives for sobriety in the current study may have
reduced the impact on substance abuse, particularly after
the incentives were no longer available. The finding that
relapse was not significantly related to employment out-
comes is somewhat surprising and likely reflects the
complex relationship between relapse and employment
for VR participants, at least during the initial period of
VR participation. During the baseline evaluation, most
study participants reported long histories of working
competitively while using substances, suggesting that the
negative impact of relapse on employment may not have
been immediate enough to be documented in the follow-
up period. Several participants reported that they actually
moved to competitive employment after relapsing
because they no longer felt confident that they could con-
tinue working in the CWT program without being
“caught” and subsequently discharged. So in the short
term, substance abuse may impel some VR participants
to move to competitive jobs and may not be a large
impediment to employment for others. This finding does
raise questions about the necessity of incentives for absti-
nence in the intervention, particularly given their dimin-
ished effect in this protocol by the end of the follow-up
period. It also suggests that the enhanced employment
outcomes noted are most directly related to the incentives
for employment and job search, as opposed to the incen-
tives for sobriety.
Another important question is whether the VR + CM
intervention results in more people entering competitive
employment or simply encourages those who would
enter to do so more rapidly. While the current study can-
not fully answer this question, it is noteworthy that with a
9-month follow-up time, the difference in entry rates into
employment continued to grow over the last 4 months of
follow-up. If the VR + CM condition were simply
encouraging a speedier entry into work by those who
would simply enter later, one would expect the difference
in the entry rates into employment to diminish over time.
Future evaluation of CM interventions for work-related
activities should examine effects over longer periods.
This study, along with the previous pilot study, docu-
ments the efficacy of a different application of CM tech-
niques. Prior research focused almost exclusively on
interventions that enhanced substance abuse treatment.
While some studies focused on employment outcomes
within substance abuse treatment settings, ours is the first
to focus specifically on a VR setting. These results sup-
port the possibility of a wider range of clinical applica-
tions of CM techniques. CM techniques are often used to
achieve repetition of targeted behaviors in order for par-
ticipants to unlearn negative habits and increase learning
of positive behavior patterns or increase compliance with
treatment so that they receive a sufficient dose and
achieve a clinical outcome. In this intervention, we iden-
tified key barriers to the positive goal of employment,
identified behavioral targets that overcame those barriers,
and then rewarded those targets. This different approach
to CM incentives apparently facilitates the chain of
behaviors required to successfully acquire employment.
A similar approach would likely be well suited for
improving outcomes for other rehabilitation services and
goals.
Supported employment and motivational interview-
ing are two interventions that emphasize participants’
intrinsic motivation to achieve rehabilitation goals like
employment. Using extrinsic rewards to encourage
employment in this CM intervention raises questions
about whether CM has any effect on intrinsic motivation
to work. Certainly, employment is a complex behavior
governed by a wide range of intrinsic and extrinsic fac-
tors. Further study will be needed to better understand the
effect of this CM intervention on this array of factors and
to clarify whether combining interventions like motiva-
tional interviewing and CM would have an additive posi-
tive effect.
The current study has a number of limitations. First, the
sample used in the study was clearly a select subgroup of
VR participants and so findings cannot be generalized to
the larger population of VR participants. A full 77 percent
of candidates screened were excluded, and another
14 percent declined participation. Of note, many candidates
who were excluded were actually insufficiently complex
clinically. Still, many common VR participants have less
clear “potential” for competitive employment in terms of
poorer work history, lower commitment to employment,
and greater clinical instability and so are not represented by
the sample used here. Second, the intervention is fairly
complex, raising the concern that potential problems with
comprehension may limit its applicability in some VR set-
tings. While study staff noted some evidence of difficulty
863
DREBING et al. Contingency management and rehabilitation
understanding the incentives, it was fairly limited and eas-
ily addressed by the staff. Also worth noting is that only
4 percent of potential candidates were excluded because of
cognitive limitations, and of the candidates who met the ini-
tial study criteria, all passed the 10-item screening quiz.
Third, the study is also limited by its reliance on self-report
data for key outcome variables, including job-search activi-
ties, employment, and substance use during the extended
follow-up. While the self-report measures used have been
validated, additional means of collecting follow-up data are
recommended. Fourth, the 9-month follow-up period was
too short to provide sufficient data regarding job tenure.
Future studies should consider using a 2-year follow-up
period to allow more documentation of whether job tenure
was clearly impacted. Finally, cost is a major concern about
this type of intervention. An additional cost of $1,000 in
payments would almost double the cost of care per VR par-
ticipant [3]. Further study is needed to determine (1) the
relationship between the total cost of payments and out-
come, (2) whether the payments result in secondary costs or
savings in changes in other health service use, and
(3) whether funding payments out of employer contracts is
feasible and effective.
CONCLUSIONS
Overall, these findings are promising and suggest
that the addition of CM techniques to VR programs
increases participants’ efforts to find employment and
their resulting rate of entry into employment. In one
sense, this finding should not be surprising. Employers
and economists have developed a wide variety of pay-
ment incentives to shape employees’ behavior. What is
surprising is that clinicians working in VR programs,
who focus on helping adults with disabilities return to
work, apparently fail to recognize the potential of using
financial incentives directly tied to the achievement of
clinical goals to enhance their clinical programs. Like
employers, many VR programs use financial incentives
like pay and bonuses to reward work performance [24],
but little evidence exists that they have applied these
same incentives to directly reward job acquisition. While
the current study directly supports the addition of CM
interventions to enhance VR outcomes, it also suggests
that VR programs should consider restructuring existing
financial payments to include explicit links to these clini-
cal goals.
In summary, this study demonstrates that adding a
CM intervention to a VR program can positively affect
program outcomes for dually diagnosed participants,
increasing their overall rate of employment and job-
search intensity. Further study must address the amount
and structure of the reinforcement schedule, the general-
izability to the broader population of VR participants, the
effectiveness of adding CM interventions to other VR
models such as supported employment and interventions
like motivational interviewing, and the long-term effect
of payments on VR participants’ job tenure and sobriety.
ACKNOWLEDGMENTS
We thank Marylee Losardo, who assisted with sub-
ject recruitment, and John Clary, who assisted with cleri-
cal support.
Dr. Penk is now with Texas A&M Health Science
Center College of Medicine, College Station, Texas, and
Dr. Hebert is now with Framingham State College,
Framingham, Massachusetts.
This material was based on work supported by the
VA Rehabilitation Research and Development Service
(grant D2944R) and with resources of the New England
Mental Illness Research, Education, and Clinical Center.
The authors have declared that no competing interests
exist.
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... However, adherence was not maintained after reinforcement contingencies were discontinued. Consistent with other studies, findings suggest that sustained abstinence through contingent work schemes fail to produce longer-term, post treatment change (Defulio et al 2011; Drebing et al 2007; Petry et al 2014; Prendergast et al 2008; Silverman et al 2002). Further when making entry into a therapeutic workplace contingent on abstinence, Silverman et al (2007) found that participants in the work-only group attended on 79% of the days, while participants in the abstinence-and-work group only attended on 39% (OR 3.77, CI 2.25–6.33, ...
... Quality Of Life was also improved for treatment group. This study in, conjunction with previous reports (Drebing et al., 2005Drebing et al., , 2007), suggest that reinforcing work-related activities using behavioural approaches has a strong potential for improving employment outcomes, as well as related areas of functioning. ...
... The remaining two included studies were focused on two different interventions, were designed for very specific population groups and were assessed as having unclear 40 or high risk of bias. 45 These studies investigated an intervention focused on 'activation' 45 and an incentive-based contingency management programme. ...
... 45 These studies investigated an intervention focused on 'activation' 45 and an incentive-based contingency management programme. 40 A summary of these studies is presented in table 5. ...
Article
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... MSMVs may experience a range of mental health diagnoses and disabilities (Haynie & Shepherd, 2011) that present higher education and professional adjustment difficulties (Glover-Graf, Miller, & Freeman, 2010). Therefore, access to vocational rehabilitation (Bellotti, Laffaye, Weingardt, Fischer, & Schumacher, 2011), contingency management interventions (Drebing et al., 2007), community-based entrepreneurship training (Kerrick, Cumberland, Church-Nally, & Kemelgor, 2014), and other employment services may be critical to their reintegration. ...
... In general, the literature suggests vocational rehabilitation may improve social function and ability to perform daily tasks (Bellotti et al., 2011) and may improve chances of reintegration to civilian employment (Drebing et al., 2007). However, VA employment services have reached few veterans with psychiatric diagnoses, and the type of services offered have varied by specific psychiatric diagnosis (Abraham, Ganoczy, Yosef, Resnick, & Zivin, 2014). ...
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Returning military service members and veterans (MSMVs) experience a wide range of stress-related disorders in addition to social and occupational difficulties when reintegrating to the community. Facilitating reintegration of MSMVs following deployment is a societal priority. With an objective of identifying challenges and facilitators for reintegration of MSMVs of the current war era, we critically review and identify gaps in the literature. We searched eight electronic databases and identified 1,764 articles. Screening of abstracts and full text review based on our inclusion/ exclusion criteria, yielded 186 articles for review. Two investigators evaluating relevant articles independently found a lack of clear definition or comprehensive theorizing about MSMV reintegration. To address these gaps, we linked the findings from the literature to provide a unified definition of reintegration and adapt a social ecological systems theory to guide research and practice aimed at MSMV reintegration. Furthermore, we identified individual, interpersonal, community, and societal challenges related to reintegration. The 186 studies published from 2001 (the start of the current war era) to 2015 included six experimental studies or clinical trials. Most studies do not adequately account for context or more than a narrow set of potential influences on MSMV reintegration. Little evidence was found that evaluated interventions for health conditions, rehabilitation, and employment or effective models of integrated delivery systems. We recommend an ecological model of MSMV reintegration to advance research and practice processes and outcomes at four levels (individual, organizational, interpersonal, societal).
... Although evidence suggests that many service members and veterans experience transition difficulty, the majority of transitionfocused interventions target relatively small groups of veterans and service members who are at particularly high risk of poor transition outcomes, such as homeless veterans (Kasprow & Rosenheck, 2007;Smelson et al., 2013;Weissman, Covell, Kushner, Irwin, & Essock, 2005) and veterans dually diagnosed with substance-use disorder and behavioral health issues (Drebing et al., 2007;Smelson et al., 2007). Although these types of intervention are valuable, they are unlikely to help the much larger proportion of veterans having difficulty navigating the benefits system and finding satisfying employment. ...
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Mobile technologies may be able to provide service members and veterans with the knowledge necessary to transition to civilian life successfully in a cost-effective and accessible manner. Although a number of transition applications (apps) currently exist in the marketplace, to our knowledge, none of them has been evaluated for quality or effectiveness. For this study, 6 experts used the Mobile App Rating Scale (MARS; Stoyanov et al., 2015) to evaluate the quality of 16 transition apps. The majority of these apps focused on providing service members with resource lists, employment assistance, or assistance with disability applications. Only 2 apps had been downloaded more than 10,000 times on GooglePlay, with the majority being downloaded between 100 and 1,000 times. Only 1 app received an above-average overall quality rating, and half received below-average overall quality ratings. Based on these findings, the authors recommend that researchers and developers create more high-quality apps by focusing on education and health-care transition issues, as well as work to better disseminate their products.
... Reintegration and related terms describe a time period, process, or outcome that MSMVs may experience following military service. Figure 2 shows that both reintegration and community integration place primary emphasis on participation in life's many roles-as an employee at work (Drebing et al., 2007;Brown, 2008), a student at school (Ackerman and DiRamio, 2009;Bauman, 2009;DiRamio and Spires, 2009;Baechtold and Danielle, 2011), or a spouse (Cohan et al., 2005) or parent within one's family (Grantz, 2007;Chandra et al., 2010). Readjustment and transition also describe participation in life roles; however, they tend to highlight specific phenomena. ...
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Returning military service members and veterans (MSMVs) may experience a variety of stress-related disorders and challenges when reintegrating from the military to the community. Facilitating the reintegration, transition, readjustment and coping, and community integration, of MSMVs is a societal priority. To date, research addressing MSMV reintegration has not identified a comprehensive definition of the term or defined the broader context within which the process of reintegration occurs although both are needed to promote valid and reliable measurement of reintegration and clarify related challenges, processes, and their impact on outcomes. Therefore, this principle-based concept analysis sought to review existing empirical reintegration measurement instruments and identify the problems and needs of MSMV reintegration to provide a unified definition of reintegration to guide future research, clinical practice, and related services. We identified 1,459 articles in the health and social sciences literature, published between 1990 and 2015, by searching multiple electronic databases. Screening of abstracts and full text review based on our inclusion/exclusion criteria, yielded 117 articles for review. Two investigators used constant conceptual comparison to evaluate relevant articles independently. We examined the term reintegration and related terms (i.e., transition, readjustment, community integration) identifying trends in their use over time, analyzed the eight reintegration survey instruments, and synthesized service member and veteran self-reported challenges and needs for reintegration. More reintegration research was published during the last 5 years (n = 373) than in the previous 10 years combined (n = 130). The research suggests coping with life stresses plays an integral role in military service member and veteran post-deployment reintegration. Key domains of reintegration include individual, interpersonal, community organizations, and societal factors that may facilitate or challenge successful reintegration, and results suggest that successful coping with life stressors plays an integral role in post-deployment reintegration. Overall, the literature does not provide a comprehensive representation of reintegration among MSMVs. Although, previous research describes military service member and veteran reintegration challenges, this concept analysis provides a unified definition of the phenomenon and identifies key domains of reintegration that may broaden our understanding and guide reintegration research and practice.
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Background: Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. Objectives: To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. Search methods: The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases. Selection criteria: We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. Data collection and analysis: Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. Main results: Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence). Authors' conclusions: We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
Chapter
Employment and vocational difficulties are often overlooked within many mental health treatment settings and yet are often central to what clients are seeking to resolve during treatment. Among the various clinical interventions available to adults with a mental health condition, Individual Placement and Support (IPS) Supported Employment is one of the most well-established evidence-based practices across any mental health area. There are a growing number of interventions that appear to positively enhance employment outcomes when they are added to interventions like IPS Supported Employment, including motivational interviewing, contingency management, cognitive rehabilitation, social skills training, and supported education. Mental health providers should routinely screen for vocational problems and refer appropriate clients to the model of care that is most likely to meet their goals of obtaining employment, stabilizing employment, or improving their vocational situation. New models of care are being piloted and evaluated, and expanded research funding is supporting the search for effective interventions to help veterans deal with vocational problems. All of these developments point to a larger trend in the expansion of services targeting veterans and the greater investment by the US Department of Veterans Affairs, by the Department of Labor, by state and local governments, and by the community in helping veterans meet their goals of returning to productive lives.
Chapter
The terms “dual diagnosis” and “co-occurring” are used to refer to patients with both psychiatric and substance use disorders, but recent research has broadened the concept to identify patients with the presence of any two or more medical conditions as well as numerous related psychosocial conditions that derive, to varying degrees, from the medical diagnoses. Traditionally, medical care for the dually diagnosed patient has focused treatment on the individual diseases and has had unintended consequences in patients with dual diagnoses, namely, the potential for high treatment burden (e.g., polypharmacy, frequent appointments, multiple procedures) or worsening of one disease by treatment of another. Within the mental health care system, this siloing (i.e., operating in isolation) of healthcare delivery approach has led to fragmented and stymied mental health care delivery. This chapter reviews the evolution of treatment for the dually diagnosed individual and veteran from the sequential approach to parallel and finally integrated approach that affords the most benefits with the least harm.
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Despite availability of treatments for gamblers, few at-risk and pathological gamblers seek help. Self-help treatments offer a private and personalized alternative that may appeal to gamblers who need help. Objective: This study examines the impact of the self-help treatment JEu me questionne (JMQ) on gambling behavior and severity, and reports participants' satisfaction. Method: Forty-seven at-risk and pathological gamblers entered the program that involved a self-help treatment workbook and two motivational phone interviews. Results: Among the 32 gamblers who completed the program, results indicated a significant reduction in the number of pathological gambling diagnostic criteria. This gain was maintained at the one- and six-month follow-ups. Time gambling and money spent were also significantly lower post-treatment, but only a reduction in time spent gambling was maintained at follow-up. Participants reported high satisfaction with the program. The discussion raises clinical and theoretical implications of these findings.
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Background: People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions. Objectives: To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness. Search methods: In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials. Selection criteria: We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only. Data collection and analysis: Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE. Main results: We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions. Authors' conclusions: Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.
Article
Full-text available
Empirical evaluations of treatments for abuse of substances other than alcohol are reviewed and critiqued. Methodological strengths and deficits of treatment-outcome studies are delineated, and interpretation of reported results is considered in light of these factors. In large part, intervention strategies for which controlled outcome evaluations exist can be divided into those conceptualized along classical conditioning lines (e.g., extinction and stimulus avoidance) and those derived from operant learning principles (e.g., contingency contracting and community reinforcement). Whereas stimulus avoidance techniques appear to be relatively more effective than pure extinction trials in reducing drug use, the efficacy of operant methods has been most strongly supported. Moreover, componential treatment packages in which contingent reinforcement is applied to both reductions in drug use and increases in stimulus-avoidance behaviors evince the most dramatic effects. Additional research that addresses the methodological shortcomings of contemporary studies is needed.
Article
Full-text available
A 15-item fidelity scale was developed to assess the extent to which vocational programs for people with severe mental illness followed the Individual Placement and Support (IPS) model of supported employment (SE). It was piloted with staff at 27 sites, including 9 IPS programs, 11 other SE programs, and 7 other vocational rehabilitation (VR) programs. Both interrater reliability and internal consistency were adequate.The scale discriminated between IPS and the other VR programs. IPS and the other SE programs differed on items relating to integration with mental health services and zero exclusion admission criteria. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This special issue of the journal is devoted to the Individual Placement and Support (IPS) model of supported employment, LPS is a standardized community mental health center-based approach to supported employment for persons with severe mental illness. Although IPS emerged in mental health centers less than 10 years ago, the approach has already produced good empirical outcomes in several research studies and is spreading rapidly.
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Archival data from 27,799 adults entering the Veterans Health Administration's (VHA) Compensated Work Therapy (CWT) program, were analyzed to identify differences in vocational rehabilitation participation and outcome as a function of participants' age. Nine percent of participants were over the age of 55 and the annual percentage of participants over the age of 55 increased steadily from 1994 to 1999. Significant age-related differences were noted with respect to amount of non-work related income, clinical problems at the time of admission, participant goals, length of stay in rehabilitation, earnings, work placements, and treatment outcome. The results suggest that participants over the age of 55 are very different than their younger counterparts in a range of variables relevant to rehabilitation, indicating that programmatic efforts are needed to adequately address their differing needs.
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Examined job tenure among 85 individuals with psychiatric disabilities. Surveyed clients' demographic, clinical, and vocational histories, their initial reactions to specific jobs, and aspects of the work environment. The average job lasted 70 days. Longer tenure was predicted by previous work history, early satisfaction with the job, lower autonomy, and higher innovation. (RJM)
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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 vocational rehabilitation context. They also provide specific ways to increase job search activity among vocational rehabilitation participants with dual diagnosis.
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The Structured Clinical Interview for DSM-III-R [Diagnostic and Statistical Manual, Revised] (SCID) is a semistructured interview for making the major Axis I and Axis II diagnoses. It is administered by a clinician or trained mental health professional who is familiar with the DSM-III-R classification and diagnostic criteria (1). The subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as subjects in a community survey of mental illness or family members of psychiatric patients. The language and diagnostic coverage make the SCID most appropriate for use with adults (age 18 or over), but with slight modification, it may be used with adolescents. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Addressed the development and early studies of the Individual Placement and Support (IPS) model of supported employment. IPS is a standardized, community mental health center-based approach to supported employment for persons with severe mental illness. Although IPS emerged in mental health centers less than 10 yrs ago, the approach has already produced good empirical outcomes in several research studies and is growing rapidly. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This one-year follow-up study focused on the impact of labour market interventions (i.e. guidance courses, vocational training and subsidized employment) on re-employment, job-seeking activity and psychological distress of the unemployed. Another aim was to investigate how individual factors, especially one's financial situation, are related to re-employment, job-seeking activity and psychological distress. The results show that participation in guidance courses predicted re-employment, whereas vocational training and subsidized employment did not have any effect on re-employment. Of the individual factors, job-seeking activity, and being married or co-habiting in a steady relationship, predicted reemployment. None of the studied interventions increased job-seeking activity. Deterioration of one's financial situation between the two measurement points was related to an increase in job-seeking activity. Vocational training decreased temporarily psychological distress and a deterioration of one's financial situation was related to an increase in distress. Guidance, which focuses on job-seekers' skills, job-search process and labour market knowledge, should be emphasized more.