A major mental health problem is the extremely low labor force participation of veterans with severe mental illness coupled with their overrepresentation on federal disability rolls. Reviews of the literature indicate that approximately 65% to 90% of veterans with severe mental illness are chronically unemployed. These figures are particularly discouraging given the importance of employment to personal and clinical well-being. To gain traction on this problem, it will likely be necessary to find treatments that address key determinants of work outcome. Evidence indicates that neurocognitive and social cognitive deficits are among the key determinants of functional outcome for persons with schizophrenia, a finding that underscores the basis for the current proposal. The proposed project includes two behavioral training interventions: (a) errorless learning, and (b) social cognition training. Errorless learning is a method of training that compensates for neurocognitive impairments that impede or restrict skill acquisition such as those involved in learning a new job. Social cognition training addresses impairments in neurocognitive processes associated with the perception, understanding, and response to social situations such as those involving interactions with co-workers and supervisors on the job. The efficacy of the combined use of these interventions will be examined within the context of an Individual Placement and Support (IPS) model of supported employment, the leading evidence- based approach to supported employment for persons with severe mental illness. The study has two primary aims: (a) to test the efficacy of the combined training methods on job placement and work outcome, and (b) examine determinants of job placement and work outcome. The study will recruit 108 veterans with schizophrenia or schizoaffective disorder who are interested in attaining competitive employment. Study participants will be matched on level of neurocognitive and social cognitive functioning, and randomized to one of two training groups: (a) errorless learning plus social cognition training plus IPS supported employment (EL+SCT+IPS), or (b) supported employment plus control conditions to match the experimental group on duration and frequency of training contact (IPS+). Baseline assessment will include measurement of neurocognition, social cognition, clinical symptoms, motivation, life events, alcohol and substance use, medication adherence, and personal well-being. Veterans randomized to EL+SCT+IPS will receive 12 sessions of social cognition training during the period of job search. After job placement, veterans assigned to EL+SCT+IPS will receive errorless learning training on their primary job assignment and then a second phase of social cognition training to address social difficulties on the job. Veterans randomized to IPS+ will receive symptom management training and one-on-one support matched for duration, frequency, and type of training contact in the EL+SCT+IPS group. A second baseline assessment will be conducted two weeks after job placement using the same measures administered at the first baseline plus measures of work performance, work outcome, and work-related personal well-being (e.g., job satisfaction, work stress). Veterans will then be followed for 12 months with assessments conducted every three months to examine short- and longer-term training effects. Outcome assessments will include measures of work performance, job tenure, work outcome, and work-related personal well-being. The primary analyses will examine: (a) the overall efficacy of errorless learning plus social cognition training on job placement and work outcome, and (b) predictors of job placement and work outcome.
Veterans with schizophrenia have exceedingly high rates of unemployment, which is a major public health issue. These rates are particularly unfortunate given the value placed on work by many veterans with schizophrenia and other forms of severe mental illness (SMI). It is clear that there are many hurdles to overcome to successfully return SMI veterans to the workplace (e.g., stigma, rules governing disability benefits, cognitive deficits). This proposal addresses one of those hurdles by introducing an innovative training approach that includes two behavioral interventions to address neurocognitive and social cognitive impairments that act as impediments to successful employment. The results of this project may serve to guide future research efforts in this area. Training procedures may need to be modified, obstacles within the workplace may need to be addressed, or individual differences may need to be addressed to better suit the needs of veterans with severe mental illness.
