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

Significance to VA: Hundreds of thousands of Veterans are affected by unemployment each year, and those with mental health and/or substance use conditions are at highest risk. Unemployment has consequences across all areas of life and functioning including economic insecurity, homelessness, worsening mental health and physical health, increased substance use, disability, and suicide. The Veterans Health Administration (VHA) has sought to address the critical problem of Veteran unemployment through vocational rehabilitation (VR) programming. Unfortunately, existing programming appears inadequate, with national data indicating that the most commonly utilized VHA VR program – transitional work (TW) – leads to an average employment rate of only 38.6%. TW aims to rapidly restore functioning by providing Veterans with a temporary, paid work-role. In its current form, TW does not target intrinsic motivation and other psychological factors/skills (e.g., attitudes, self-efficacy, self-regulation) known to impact quality employment. We assert that failing to address intrinsic psychological motivators/skills associated with quality employment outcomes has contributed to TW’s subpar performance, and is a critical gap to address. Our team empirically developed, refined, and piloted a vocational counseling intervention, Purposeful Pathways, to address this gap. Innovation and Impact: The Purposeful Pathways intervention is a career development intervention designed specifically for Veterans with psychiatric conditions that targets psychological processes and skills that contribute to occupational functioning outcomes. By combining the strengths of TW (access to functional role) with Purposeful Pathways (addressing psychological motivators and skills), there is an opportunity to improve Veterans’ employment outcomes and downstream effects on quality of life, mental health, and substance use through this innovative VR pairing. Specific Aims: Aim 1: Evaluate the efficacy of Purposeful Pathways for improving occupational functioning (primary outcome). Hypothesis: Purposeful Pathways + TW, compared to TW only, will improve occupational functioning. Aim 2: Evaluate the efficacy of Purposeful Pathways for improving quality of life, and reducing mental health symptoms and substance use (secondary outcomes). Hypothesis: Purposeful Pathways + TW, compared to TW only, will improve quality of life, and reduce mental health symptoms and substance use. Aim 3 (Exploratory): Explore whether occupational functioning (competitive employment attainment) in the Purposeful Pathways + TW group is mediated by vocational identity, work hope, self-regulation, and/or employment motivation, key factors central to the Purposeful Pathways intervention. Methodology: We will conduct a phase II, multi-site, RCT comparing Purposeful Pathways + TW (n=127) to TW alone (n=127) among Veterans participating in TW at VA Bedford, VA Hines, and VA North Texas. Occupational functioning is the primary outcome (as measured by): rates of competitive employment, hours worked, income earned, career adaptabilities (Career Adaptabilities Scale), and meaningful employment (Positive Meaning Scale of the Work as Meaning Inventory). Secondary outcomes include: quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form), mental health symptoms (Patient Health Questionnaire), and substance use (Tobacco, Alcohol, Prestation medications, and other Substance tool). Candidate mediators include: vocational identity (Vocational Identity Scaled), work hope (Work Beliefs Scale), self-regulation (Short Self-Regulation Questionnaire), and employment motivation (Importance of Obtaining Preferred Position scale). Path to Translation/Implementation: Our study will set the stage for clinical dissemination and future studies on the effectiveness and implementation of Purposeful Pathways nationally through a subsequent effectiveness-implementation hybrid type 1 trial. Project Number: 1I01RD000383-01 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Brian Stevenson | Institution: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL, BEDFORD, MA | Activity Code: I01 | Study Section: Behavioral Health & Social Reintegration[RRD4] View on NIH RePORTER: https://reporter.nih.gov/project-details/11241268