Employment and Vocational Rehabilitation Experiences among Veterans with Polytrauma/Traumatic Brain Injury History

Abstract

Evidence suggests that Iraq and Afghanistan war veterans with polytrauma/traumatic brain injury (TBI) history and neurobehavioral symptoms may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in Department of Veterans Affairs (VA) vocational rehabilitation programs. This study utilized qualitative interviews and focus groups with veterans with documented polytrauma/TBI history to explore veterans’ perceived barriers to employment and vocational rehabilitation program participation, as well as to solicit thoughts regarding interest in an evidence-based vocational rehabilitation program, the Individual Placement and Support model of Supported Employment (IPS-SE). Veterans identified physical, emotional, cognitive, and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and sequelae. Communication and logistical issues were described as the primary barriers to vocational rehabilitation program access, while barriers to program utilization included eligibility characteristics, fear of losing financial benefits, and a military-cultural belief of self-sufficiency that made help-seeking difficult. Finally, veterans endorsed key aspects of IPS-SE, such as staff serving as translators, advocates, and navigators of the job search and maintenance process. Policy recommendations are addressed.

Traumatic Brain Injury (TBI) is not unique to modern warfare, but the increased use of improvised explosive devices (IEDs) coupled with falling rates of injury-related death has led to a rise in the prevalence of TBI among United States military service members returning from deployments to the Iraq and Afghanistan Wars (Tanielian et al., 2008). TBI is defined as “a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force,” which is followed by loss of consciousness, memory loss, altered mental state, neurological deficits and/or intracranial lesion (The Management of Concussion-mild Traumatic Brain Injury Working, 2016). Injuries are classified from mild to severe, with 75–80% of cases of TBI among both Veterans and civilians classified as mild (CDC, 2003; DoD Worldwide TBI Numbers, 2018). For veterans, such events may result from blast exposure, motor vehicle crashes, falls, or other head trauma and frequently co-occur with mental health diagnoses such as post-traumatic stress disorder (PTSD) (Tanielian et al., 2008). Among Veterans, TBI also often occurs in the context of polytrauma, defined as two or more injuries that affect multiple organ systems, and results in impairment and disability (Department of Veterans Affairs, 2015). In a study examining Iraq and Afghanistan war veterans accessing services within VA, 9.6% had been diagnosed with a TBI; of these, the majority had also been diagnosed with a mental health disorder, and roughly half had both PTSD and pain (Cifu, Taylor, William, Bidelspach, Sayer, 2013). In response to the influx of post-9/11 veterans seeking care for complex symptoms and sequelae related to TBI and its common comorbidities, the VA implemented a nationwide Polytrauma/TBI System of Care in 2005 in which veterans with any level of TBI severity may receive coordinated, interdisciplinary rehabilitation services (Department of Veterans Affairs, 2013).

Deployment-related polytrauma/TBI can have important implications for neurobehavioral health and functioning (Sayer, 2012). Physical symptoms of TBI may include headaches, sleep disorders, blurred vision, dizziness and loss of hearing (Vanderploeg, Belanger, & Curtiss, 2009). Emotional symptoms may include increases in anxiety, depression, and decreased ability to tolerate frustration (Sayer, 2012). Cognitive complaints, whether perceived or objective, may include problems with memory, attention, learning and executive function (Donnelly, Donnelly, Warner, Kittleson, & King, 2017; Meterko et al., 2012; Tanielian et al., 2008). While some symptoms of TBI – particularly mild TBI (mTBI) – may be indistinguishable from symptoms of frequently co-occurring disorders (e.g., PTSD or depression), together they may lead to increased functional limitation (Stein & McAllister, 2009).

The symptoms and comorbidities associated with polytrauma/TBI may increase the difficulty of securing and maintaining employment for former military service members. A national survey of Iraq and Afghanistan war veterans with a VA clinician-confirmed TBI diagnosis (primarily mTBI), the majority of whom had co-occurring PTSD, depression and/or pain, found that 45% were unemployed (Carlson et al., 2017). Another study examining veterans with a positive TBI screen, most of whom clinicians identified as having comorbid psychiatric conditions, found an unemployment rate of 33% (Pogoda et al., 2016). A third study examining veterans diagnosed with mTBI found that, while mTBI alone was not associated with increased unemployment, 19% of veterans diagnosed with mTBI, PTSD, and depression were unemployed (Amick et al., 2017). Mechanisms that may explain the linkage between polytrauma/TBI and reduced workforce participation include lower capacity to perform the same work as prior to injury, changes to memory and executive function, sleep deprivation, headaches, difficulties managing workplace relationships, and frequent medical appointments (Mortera, Kinirons, Simantov, & Klingbeil, 2017).

Recognizing the importance of gainful employment to successful community reintegration following separation from the military, the Department of Veterans Affairs (VA) has offered vocational rehabilitation services since the World War I era (Department of Veterans Affairs, 2017). Table 1 provides a description of the vocational rehabilitation programs available within the Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) at the time the research was conducted.

Table 1.

Department of Veterans Affairs Vocational Rehabilitation Programs

Department of Veterans Affairs Vocational Rehabilitation Programs* *Programs & requirements at time study was conducted
Program	Description	Scope/eligibility
Veterans Benefits Administration (VBA)
Vocational Rehabilitation and Employment	Vocational rehabilitation program offered to Veterans with 10% military Service Connected Disability ratings or higher. The program includes vocational counseling, referral to appropriate employment opportunities and services. Eligible Veterans may also develop a personalized rehabilitation plan with a counselor on one of five tracks: Reemployment with Previous Employer; Rapid Access to Employment; Self-Employment; Employment through Long Term Services; and Independent Living.	Mandated.
Veterans Health Administration (VHA): Therapeutic and Supported Employment Services
Compensated Work Therapy (CWT) Programs:	CWT is a recovery-oriented, vocational model in the continuum of the Veterans Health Administrations’ work restoration services.	Each VA Medical Center must offer CWT with both Transitional Work Experience and Supported Employment for Veterans with occupational dysfunctions resulting from their physical or mental health conditions, or who are unsuccessful at obtaining and maintaining stable employment due to mental or physical impairment.
Supported Employment	An evidence-based clinical model that helps individuals with severe mental illness or physical impairments co- occurring with mental illness engage in competitive employment in the community.
Transitional Work	Transitional work in VA Medical Center or community placements that allow participants to gain work experience and “hardening” while engaged in CWT therapeutic rehabilitation treatment designed to prepare participants for community employment. Placements are time limited.
Sheltered Workshops	Subcontracted piece work from the business community conducted in workshops on the grounds of VA Medical Center under clinical or CWT staff supervision.	Not mandated.
Incentive Therapy	A pre-vocational program for severely disabled Veterans to perform work at VA Medical Centers.	Not mandated. Length of participation not to exceed one year, with possible extension.
Vocational Assistance	A set of assessment, guidance, counseling or related services offered to groups or individuals designed to enable Veterans to realize skills, resources, attitudes and expectations to search for and succeed in locating and securing employment.	Not mandated. Availability based on demand and staffing resources. Time-limited for Veterans who require limited assistance.

Information obtained from VHA Handbook 1163.02 “Therapeutic and Supported Employment Services.” (2011).

The VBA Vocational Rehabilitation and Employment (VR&E) program provides services to veterans with a military service-connected disability. Eligible Veterans work with an assigned Vocational Rehabilitation Counselor to develop an individualized rehabilitation plan (Gade & Wilkins, 2012). Employment supports offered through VBA may include counseling, training, employment accommodations, resume development, job skills coaching, job placement services, and new business development. VR&E also offers “Education and Career Counseling,” which may include career counseling, academic or adjustment counseling, and support and benefits coaching (Department of Veterans Affairs, 2017).

Programs offered by the VHA are diverse, but can be grouped into categories of sheltered workshops, transitional work experiences (TWE), and the Individual Placement and Support model of Supported Employment (IPS-SE). In workshops, veterans work only with other veterans who are also receiving rehabilitation services, and are overseen by VA vocational rehabilitation staff. In TWE, the VA Compensated Work Therapy (CWT) program contracts with employers, who supervise the veterans, while CWT pays the veterans’ wages. TWE positions can be in the community, but are often in the VA Medical Center so that veterans can continue to receive healthcare. Finally, IPS-SE is an evidence-based, resource-intensive program that follows a “place then train” model, in which Veterans are rapidly assisted in finding a competitive, community-based job that matches their interests and experiences. They are provided with on-the-job coaching and supports by an employment specialist as long as is clinically needed (Resnick et al., 2006). IPS-SE has been successful in helping individuals with disabilities, including polytrauma/TBI, find and maintain competitive employment (Bond, Drake, & Becker, 2008; Wehman et al., 2003).

Reflecting recent research identifying more successful outcomes for veterans who receive vocational services in the community rather than institutions or workshops (Abraham, Yosef, Resnick, & Zivin, 2017; Davis et al., 2018), VA CWT has begun to expand competitive and community-based vocational offerings (Resnick et al., 2006). In fiscal year 2005, IPS-SE was implemented in the VA for veterans with severe mental illness (Resnick & Rosenheck, 2007), though a share of the vocational rehabilitation specialist’s caseload could be filled by veterans evidencing other serious employment needs. In 2006, VHA offered IPS-SE to veterans in its Polytrauma/TBI System of Care through a time-limited pilot program (Pogoda et al., 2017a); however, a recent national study of VHA-using veterans diagnosed with TBI found that less than 1% had accessed any VHA IPS-SE program (Carlson et al., 2018).

Some evidence suggests that VA vocational programs are not reaching veterans with polytrauma/TBI history, or not adequately meeting their needs. In a study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans diagnosed with PTSD, depression, substance use disorder, or TBI, only 8.4% had accessed any vocational service through VHA across a two-year study-period. Possibly reflecting greater need, Veterans with TBI and those with multiple mental health conditions were more likely to access vocational services. However, retention in vocational services was low, with most veterans attending only 1–2 appointments; a number below the level thought to be necessary for job placement success (Twamley et al., 2013). Mechanisms explaining the low rates of access and retention were not explored. In a study tracking access to, and progression through, VA vocational services among veterans diagnosed with severe mental illness, O’Connor and colleagues (2011) found that participants who also had moderate to severe cognitive impairment took significantly longer than those with mild or no impairment to recognize that they had a vocational problem, seek help for that problem, and enter into vocational services. Whether OEF/OIF and Operation New Dawn (OND) veterans with polytrauma/TBI history and sequelae face these or other barriers to engaging in vocational services remains unknown.

In sum, the literature suggests that veterans with polytrauma/TBI history may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in VA vocational rehabilitation programs. In this study, we utilize qualitative methods to interview OEF/OIF/OND veterans with documented deployment-related TBI history to achieve the following aims: 1) describe employment challenges and vocational rehabilitation experiences, and 2) evaluate interest in, as well as facilitators and barriers to, the use of the IPS-SE program.

Methods

Veterans with documented, deployment-related TBI history participated in individual interviews or focus groups at two VA Medical Centers located in large, urban areas. The Institutional Review Boards at both medical centers approved all study materials and procedures. Data collection occurred between May 2014 and February 2015.

Participant Recruitment

Since 2007, all OEF/OIF/OND veterans receiving VA health care receive a four-question TBI screen. Those who screen positive are referred for a comprehensive TBI evaluation with a VA specialist to determine whether veterans’ history and symptoms are consistent with TBI (Department of Veterans Affairs, 2010). OEF/OIF/OND veterans with confirmed deployment-related TBI history who either had documented unemployment status in their VHA electronic medical record or endorsed having experienced unemployment or other employment difficulties since separating from the military were eligible to participate in focus groups or individual interviews. Eligibility criteria encompassed different employment statuses to capture a range of experiences, including challenges with securing employment, being under-employed, and experiencing personal or interpersonal struggles in the workplace. We recruited veterans with all levels of TBI severity (i.e., mild, moderate, and severe), as identified in the comprehensive TBI evaluation, to document the employment and vocational rehabilitation experiences of any potential vocational rehabilitation program user; within VA, vocational rehabilitation services are not restricted to veterans with a particular TBI diagnosis or severity (Pogoda, Levy, Helmick & Pugh, 2017). Exclusion criteria included a severe hearing impairment or other communication disorder that would interfere with the ability to participate in research, inability to read or understand English, or inability to give informed consent. In one location, members of the Polytrauma/TBI clinical team provided the research team with a list of eligible participants who were contacted via letter and follow-up phone calls. In the other location, eligible participants received a recruitment letter from their medical provider, which described the study and provided a contact number. Both sites also advertised the study via posted flyers.

Data Collection

All participants provided informed consent to complete a survey collecting basic demographic and military-related information, and granting access to their VHA electronic medical record, which allowed the research team to describe participants’ health diagnoses. Focus groups and interviews were led by the project investigators, spanned between 1 and 1.5 hours, and were audio recorded. The semi-structured interview protocol used during study sessions explored participants’ job search and employment experiences following their separation from the military, as well as knowledge of and experiences with VBA and VHA vocational services. Sample interview questions included the following: “After your military discharge, how long was it until you started thinking about or looking for civilian employment?” “What are some reasons you were or were not thinking about civilian employment?” and “What types of support could be provided to Veterans like you to help with this transition process?” Interviewers also presented participants with a written description of the IPS-SE program and probed their thoughts and interests in participation in a similar program, were it offered to them. The description detailed the role of the employment specialist (e.g., to assist veterans with career planning, job search, completing job applications, interview scheduling/preparation, and managing on-the-job responsibilities and challenges). Expected program features were also described, (e.g., “Talking with a benefits counselor about how working may affect your benefits.” “Having it be up to you to decide if you want to talk about your health condition or if you want your employment specialist to discuss your health condition with your employer.”). All qualitative data were transcribed verbatim by the project team.

Participants

Five focus groups and 10 individual interviews were conducted with a total of 37 veterans. Participant characteristics are presented in Table 2. Participants were categorized as having mTBI (92%) or moderate/severe deployment-related TBI (8%) history. Most participants had also been diagnosed with at least one of the co-occurring mental health condition examined (86.5%). The most frequently occurring mental health diagnoses were PTSD (78%) and depression (70%). All participants had deployed overseas: 59% in support of OEF, 43% in OIF, and 3% in OND. Four participants served in support of multiple operations, and service mission was missing for 2 participants. Nearly half of participants had deployed once, 22% had deployed twice, and 31% had deployed three or more times. Recent deployments spanned 1.1 years on average, with a range of 0.3 to 5.5 years. Nearly half (47%) of participants had served in the military for 10 years or more, 39% had served between 5 and 10 years, and 14% had served 3–4 years. The majority (86%) classified their military rank as enlisted, while 14% served as officers. At the time of the focus groups/interviews, less than a quarter (22%) of participants were employed full-time, and only three participants had ever accessed VHA vocational rehabilitation services, ranging from one to three times. None of these had accessed IPS-SE.

Table 2.

Sociodemographic and Clinical Characteristics

Variable	Overall Sample (N =37)
Sociodemographic characteristics, % (N)
Age μ (range)	38.6 (24–69)
Male	92% (34)
Race/Ethnicity
White, Non-Hispanic	78% (29)
Black, Non-Hispanic	5% (2)
Hispanic	8% (3)
Asian	3% (1)
Other/Unknown	5% (2)
Parent	62% (23)
Marital Status
Married/cohabitating	46% (17)
Divorced/separated/widowed	27% (10)
Single/never married	27% (10)
Work Status*
Employed full-time	22% (8)
Employed part-time	11% (4)
Student	24% (9)
Unemployed	14% (5)
Unable to work for pay	19% (7)
Retired	19% (7)
Homemaker	3% (1)
Education (highest level completed)
High school/GED	3% (1)
Vocational/technical	3% (1)
Some college/Associate’s degree	62% (23)
4-year college graduate	16% (6)
More than 4 years of college	16% (6)
Income
$25,000 or less	54% (20)
$25,001–50,000	24% (9)
$50,001–$75,000	8% (3)
Over $75,000	14% (5)
Deployment-related TBI severity history
Mild	92% (34)
Moderate/Severe	8% (3)
Mental Health Diagnosis (of those listed below)	86.5% (32)
Depression	70% (26)
Anxiety	43% (16)
PTSD	78% (29)
Substance use disorder	43% (16)
VHA Vocational Rehabilitation Services
Any service use	8% (3)
Number of visits M (range)	0 (0–3)

^*Totals add up to more than 100%, as some participants listed multiple categories.

Data Analysis

Qualitative content analysis was used to analyze the data (Braun & Clarke, 2006). Each transcript was carefully read by two members of the research team. Next, two members of the research team trained in qualitative methodologies independently coded one transcript, met to discuss any areas of divergent coding, came to agreement on the coding procedure, and updated the codebook accordingly. The developed codebook was brought to the full team, which generated additional areas to consider in code development. The remaining transcripts were divided among two members of the research team and coded independently. AtlasTI version 7, a qualitative data management program, was used to organize and code the data.

Through the iterative coding process, themes regarding barriers to employment, challenges utilizing VA vocational programs, and potential facilitators to program access were identified. Codes identifying quotes pertaining to these themes were retrieved, and text compared both across and within interviews. Themes were developed and refined through this analytic process. Quotes that exemplified key themes were selected for inclusion.

Results

Perceptions of experiences in the civilian workforce

Many participants described a difficult transition moving from the military to the civilian workforce. While some of these factors could characterize the challenges experienced by returning service members in general, participants described many as linked with polytrauma/TBI neurobehavioral symptoms, mental health conditions, or both. Veterans described both individual-level and interpersonal barriers that impeded their ability to succeed in the civilian workforce.

Barriers to finding work

Participants described numerous challenges with finding employment. During job searches, veterans described encountering employers with negative preconceptions and fears about veterans, which participants believed prevented them from being hired. Participants also found that employers, unfamiliar with military work, had difficulty translating military experiences into civilian job skills, which could mean that veterans’ competencies were undervalued.

Veterans also described a reduced capacity to do the work in which they had been trained or employed previously, attributing this change to polytrauma/TBI or to mental health problems:

Before I went into the military, I grew up in construction, building tall buildings. Up off the ground, walking around 2×6s didn’t bother me at all. And [that was] my plan when I got out, but when I got out, I don’t know if it was because of the anxiety, PTSD, traumatic brain injury, or whatever, but once I get up over 10 feet, get up to 20 feet in the air, where I used to just walk along and do my work, I just couldn’t do it.

Although this participant struggled to isolate the reason for the change, he nonetheless knew that the work he had done prior to military service was not currently possible.

Another veteran who had welded professionally before his military service similarly described barriers to working in his prior field, “Since my brain injury my depth perception is off, my hand-eye coordination is off, so I can’t professionally weld anymore.” Notably, despite these physical limitations, he had found that he was still able to weld, albeit at a greatly reduced speed, and absent an externally imposed time pressure. Other participants also struggled to work under time constraints or stressful situations, describing an increase in anxiety that could limit their productivity. Veterans unable to pursue past career options often found it difficult to chart a new path forward upon their return.

Maintaining Work: Individual barriers

Securing a job after military separation was just the first step; with physical and interpersonal challenges, keeping that job was, for many, just as difficult. Veterans described memory and cognitive problems, visual disturbances, debilitating headaches, and chronic sleep problems that kept them from performing at work as they had in the past, and at the level they expected of themselves:

My mood swings would fluctuate quite frequently; I couldn’t concentrate on my work; I wasn’t dependable. And I’ve never not been dependable in my entire life. And I get these real bad headaches sometimes that’s followed with blurred vision and constant ringing in the ears…there’s times it’s so bad that my room is totally dark—it’s like a dungeon. I have to go in there and just meditate… it’s been really difficult because I’ve always been able to do my part, lead by example, and go the extra mile. When I got to the point where I wouldn’t even hire myself, because maybe I’d be there a half a day— in the morning or in the afternoon, who knows?… Just because of the confusion of my head, the memory loss, just not remembering to do stuff…. It’s humiliating for a person like me, and probably for most people that get it…I just—I still don’t feel like myself.

For this veteran, his physical symptoms not only kept him from doing his job efficiently when at work, they also frequently kept him from going to work at all. His inability to work to his previous capacity had emotional consequences that made him question his identity and who he had become.

Others experienced intense emotions while in the workplace that were difficult to control. Emotions could be triggered by noises or stimuli, arise from a disagreement with a coworker, or by frustration with symptom onset and volatility. As described by one participant:

…unpredictable emotions, and that’s something that I’ve had to constantly deal with. Some people call them flashbacks or whatever … when I talk about emotions I’m talking about severe emotions. Sometimes it’s anger; sometimes it’s sorrow; sometimes it’s being manic and not having the people there that can deal with that. And having to explain that to somebody or somebody wanting to know what’s going on with you, and you can’t explain it because you’re unable to open up and people will then make assumptions and then call every problem we have PTSD.

For this veteran, emotional swings were problematic because they required constant energy to manage on a personal level, and sparked confusion and misunderstanding with coworkers. For others, these emotions could lead to workplace problems when they arose in interactions with managers or coworkers. Although some used strategies to manage these encounters, such as defusing the situation with humor, many worried that these incidents could endanger their employment over time.

Finally, frequent medical appointments were necessary to address physical, emotional, and cognitive problems, which some veterans described as resulting in substantial time away from work.

Maintaining Work: Interactional barriers

Veterans perceived their polytrauma/TBI-related symptoms and comorbidities as the cause of difficult interactions with coworkers. Issues with memory could lead to frustration or conflict with coworkers, strong emotions could lead to arguments and misunderstandings, and cognitive challenges could cause frustration:

I had a blowup at work. I made a scene and stormed out, feeling very vindicated. In the current position that I am in I am at odds with the folks that I work with. Some of that has to do with my issues with short-term memory. “I told you to do this,” “I don’t remember you saying that.” I have done my best to adapt with notes and Outlook [email] reminders, things like that. I’m able to operate where I haven’t had things officially hurt me. There are things in my file that are concerning to me, that could cause a problem…The memory issues and agitation—sometimes I get frustrated where I just shut down.

For this veteran, although conflicts with coworkers had not affected his employment, he worried that such incidents might cause problems in the future.

Participants also described struggles with communication. These included problems with focus and comprehension, needing to search for or explain words or concepts they could not remember, and miscommunication and conflict resulting from the cognitive and emotional symptoms described previously. One veteran described struggling to follow conversations with coworkers following a “flare up” in the dyslexia and ADHD he had struggled with as a child:

…when someone goes on with the conversation too long and they’re trying to get a point through I have to stop them. Then they get mad because I can’t get through the whole thing or because I’ve lost the beginning by the end. They don’t understand it and they just get pissed. I’ve also lost my filter. It’s almost like I’ve got Tourette’s [syndrome] but I don’t. And my dyslexia has come back pretty hard. So I’ll say sentences, words, meanings completely backwards and people who don’t understand what is going on will go off on one weird direction, I won’t understand why they are doing it and I’ll be pissed. So it goes both ways.

For this participant, not only does his struggle to comprehend anger coworkers, their inability to understand his language angers him. Others’ challenges with communication were not cognitively-based but physical in nature:

I pick up things quick verbally, but when having to pay attention and read something I feel nervous. I’m sharing an office with somebody right now which, they are behind me and it’s real hard and I have people talking and my hearing is a little bit off now so that makes things even more difficult because I mishear and misspeak.

Participants described multiple health domains that they perceived to be affected by polytrauma/TBI that impacted their ability to communicate and comprehend effectively in the workplace.

Barriers to Engagement in VA Vocational Rehabilitation Programs

Given the challenges participants described with successfully securing and maintaining employment, there would seem to be an important role for vocational rehabilitation programs to facilitate job search and employment success. Such VA programs are diverse and range from less intensive services (vocational counseling) to quite intensive programs focused on a rapid search for competitive employment within 30 days (IPS-SE). Participants described low involvement with, or even knowledge of, VHA and VBA vocational rehabilitation programs. They also detailed substantial barriers to accessing and participating in these services, as well as personal circumstances and beliefs that discouraged help-seeking.

Program Access Barriers

The majority of participants’ experiences with VA vocational rehabilitation programs were with the VBA. In contrast, interaction with, and knowledge of, VHA vocational rehabilitation programs was rare. When queried regarding who would be the most effective person to communicate with veterans regarding vocational rehabilitation programs, several responded that simply having the information communicated was more important than the source. One veteran, unemployed since his separation from the military, succinctly stated, “To be honest I’ll tell you that I have been out for 3 years now, and I didn’t know about this vocational rehabilitation program [VHA Compensated Work Therapy] until now.”

Veterans who did have experience with VA vocational rehabilitation programs described logistical barriers to accessing them, such as the testing and paperwork required to enter some of the programs. Members from one focus group spoke with exasperation about, “a bloody four-hour poly psych test!” the VBA required for participation in the career and academic counseling and benefit program known as “Vet Success.” For veterans who struggled with concentration and anxiety in pressured environments, as many described, such an entry requirement could feel insurmountable.

The point being is that we wonder why so many Vets live on the streets; so many Vets are just going, “[What] the hell am I supposed to do? Well, how are we supposed to fit into society that we once understood?” … I have a hard time concentrating for 15 minutes… I don’t understand the tests; I don’t get it… And so it’s difficult. And that’s why I’m still in that transition stage. I’m still trying to get through Vocational Rehabilitation.

Veterans described testing and paperwork requirements as impediments to initiating or becoming fully engaged in VBA vocational rehabilitation programs. One veteran described receiving helpful advice from an OEF/OIF counselor, only to be assigned a thick stack of paperwork to complete at home and on his own. While he did not articulate reasons for not completing the VBA paperwork, he suggested counselor follow-up may have helped. Another veteran, who successfully connected with numerous VA assistance programs, nonetheless described feeling lost amidst the steps required to actually participate in those programs:

It’s frustrating because we are trying to get the help from the VA, we’ve been through Polytrauma and Voc Rehab and Independent Living and all this stuff and for people like us who are having problems focusing on stuff that is simple for everyone else—get your paperwork turn[ed in], go see the doctor, go to this. For us it’s like twenty thousand things coming at us and we can’t figure out which straw to grab and we get lost in the system. It gets discouraging. Why would you fight when you always feel like you are getting swept under the rug?

What might appear to be straightforward steps to engage and participate in a program felt too overwhelming for this veteran.

For some, difficulty arose in trying to understand the nature of VA vocational rehabilitation programs. Specifically, veterans mentioned that there could be greater clarity of written program descriptions, eligibility requirements, and how participation might affect veterans’ benefits. One veteran who read about VHA’s “Sheltered Workshop” vocational rehabilitation program described his frustration trying to make sense of the information:

Explaining it to me, is totally different than me… I know what sheltered means, I know what a workshop is; it means nothing to me together…I can imagine other…frustrated, impatient, pissed off veterans are probably looking at it the same way: “I don’t know what that frickin’ means…” why no one’s ever told me what that program means; I don’t have time for this. And that just seems to be the general feeling between me and at least a lot of other people that I associate with. We want to know [what] these things are; we want to understand it. It’s not that we’re so oh so lazy we can’t look it up because a lot of times we do, but sometimes we don’t understand the verbiage, or we do understand the verbiage and are okay with what it is, but do I qualify for this? Okay, I do qualify, if I apply, is it going to take me forever, or if I do apply and am accepted, am I going to get whatever portion or monthly whatever, and then is it [VA financial benefits] going to cut out?

A short program description was not enough for this veteran; he needed someone to walk him through his options, and help him decide whether a program might be worth the time and energy he knew it would take to apply.

Barriers posed by program characteristics

Despite the barriers to program access described above, many participants were ultimately able to engage in VBA’s Vocational Rehabilitation Program, what participants referred to as “Voc Rehab.” Nonetheless, few had secured employment through the program. Rather, several participants described being told that they were not qualified to work, and thus the program would not support them, or that the program would not support the job plans that the veteran proposed. One veteran found himself unable to complete paperwork and managerial tasks as he had in the past. After his separation from the military, he struggled to find a new career:

I was trying to get into a different aspect of my career in the union where I’d be doing the same thing but through my hands and my brain on the computers, but it just didn’t work out. So they tried a couple of things with me. I went to [VBA] Voc Rehab and they tested me all out, and I’m a two-time college 4.0 [grade point average; GPA] student, and I was 6^th grade, 9^th grade level. All of a sudden my GPA dropped that low. Voc Rehab said ‘we will not support you to work’.

Other veterans described applying for VBA Vocational Rehabilitation at multiple sites, only to be told repeatedly that the program would be unable to help them. Such a pronouncement from a vocational rehabilitation specialist was deeply troubling to veterans, as one veteran put it, “I’m still a viable person you know.”

While not rejected outright, others who discussed specific career goals with VBA vocational rehabilitation specialists were told that the program would not support those goals:

At school I tried going to the V[B]A Vocational Rehab for the dive program out of Seattle, because that’s numerous job opportunities…I was told at Voc Rehab that they wouldn’t do that for me because of my conditions. That was V[B]A Voc Rehab. I was told that “For someone with your health concerns that’s not a career field to look into.” I was like, well that’s heartbreaking. (Laughs) Like I’m showing you the ability, I have dive certifications for it already and they were just like “nope.” So I just left the office kind of mad.

Later in the interview he continued, “Voc Rehab was like ‘No dive shop is going to hire you.’ And I was like ‘It’s not a dive shop… it’s an office building.’ And it still wasn’t an option. If they are just going to give up on you through hardships then what’s the point?” For this veteran, he interpreted the vocational rehabilitation staff’s response as the program “giving up” on him. Veterans did not perceive program staff as willing to engage with them in finding a career in which they were interested. Further, the perceived lack of support for proposed plans was demoralizing for veterans, who were already struggling to envision their future role in the workforce.

Financial fears as a barrier to program participation

Veterans who depended on government benefits (e.g., VA disability, unemployment) for financial support worried that employment in a low-wage job was their only realistic option, yet feared that such work would ultimately result in a net financial loss. While nearly all veterans wanted to work, the financial risks of participation in the low-wage labor market were a barrier:

Well it just seems that—this has been my issue is that yes, I can get a minimum wage paying job working at Happyville or McDonalds, whatever. But it’s not going to cover what my family is currently accustomed in living. And so I’m basically stuck, “Why would I do that if it’s not going to cover my family?” And so I get that run around feeling-stuck feeling. Because I don’t want to be stuck and not work; I’d like to work, but it doesn’t make sense for me to endanger my family’s welfare over me working…So, that’s my problem.

While the monetary benefits veterans received were not large, as one Veteran described, “I’ll be poor my whole life,” they feared that returning to the labor market would mean a lower income, and erosion of their financial stability.

Help-seeking beliefs as a barrier

Finally, several veterans described a military culture that discouraged help-seeking. Self-sufficiency was drilled into service members from their first day of military training. As one participant explained, “A lot of times in training they tell the soldier, ‘You’re weak if you seek help… Stay on your own two feet.’ That’s our psyche.” Thus, veterans may not follow-up with VA in response to outreach efforts to provide information about available resources. As the veteran continued, “There’s only so [much] the VA can do; if they’ve got the services for you and you don’t take it, then it’s not really their fault. And you can’t, and you can’t force a Vet…”

Perceptions of program elements that could facilitate employment

In response to the previously mentioned challenges, veterans articulated ways in which vocational rehabilitation programs might better meet their needs, and endorsed key components of the IPS-SE model. Many of the suggestions centered around facilitating communication with the employer, and the need for hands-on assistance in navigating vocational rehabilitation programs and the job market.

Translator and Advocate

Veterans described an important role for third-party “translators” to clearly explain VA programs to veterans with polytrauma/TBI history, describe military experiences in civilian terms, and communicate with employers about veterans’ symptoms. Veterans believed that a VA staff person serving in this role would help address the significant communication challenges that impeded both their use of vocational rehabilitation programs and their job search process. One veteran described:

I wouldn’t mind if the employment specialist disclosed that [polytrauma/TBI symptoms and comorbidities] on my behalf. I wouldn’t have a problem with that because it would break the ice. It’s not… easy to say oh, by the way, I have PTSD and anxiety and traumatic brain injury and all this stuff– this guy doesn’t know me. It’s not an easy thing to tell a prospective employer. I like having somebody to bridge the gap.

Veterans explained that having an advocate experienced in helping with disclosure would alleviate their anxiety about how to discuss diagnoses and symptoms with employers. The staff person could serve as an emotional buffer, removing veterans from sensitive or difficult conversations. As described by one participant, “The third-party is a blanket that covers it so nobody feels uncomfortable.”

One veteran described the advocate as playing an important educational role, “That advocate has to change thinking on the employer’s part on, “Do you know what TBI is?” [And employer would say,] “Oh yeah, that’s when the brain’s all screwed up.” [The advocate would say,] “Wrong. Let’s start again. Your brain’s screwed up, and we’re going to educate you, Mr. Employer. Okay?” From this perspective, VA staff would educate employers about polytrauma/TBI symptoms that veterans felt uncomfortable with or unprepared to discuss.

Navigator

Finally, veterans voiced the need for a vocational rehabilitation specialist who would provide hands-on help with navigating the complex menu of VA vocational rehabilitation programs, describing these programs in understandable terms, guiding veterans through the program application process, and ultimately steering them to likely employment prospects in the community. Reflecting on the IPS-SE program description presented by the interviewer, one veteran contrasted this hands-on process with the “boot-straps” approach he had experienced accessing other vocational rehabilitation programs:

You’re on your own. You want to find a job? You’ve got to do the research; you got to do all the work by yourself… All the ground work. That’s a very positive piece. That an employment specialist would go out there and try to find something that’s suitable for you, that’s a very good tool. It’s kind of like they are setting it up to be tailored to your needs. To your needs and to what the employer wants. I like that.

Veterans believed that vocational rehabilitation programs would be strengthened by the addition of a specialist who would sift through the myriad of possible opportunities to identify a job that was not just available, but also well-suited to the veteran. This was emphasized in light of the significant challenges that they had described with comprehension, organization, and communication.

Discussion

Veterans in this study identified individual and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and comorbidities. While the workplace challenges described are likely to reflect a complex array of physical, mental health, and cultural/reintegration dynamics that shift over time, and are not attributable to polytrauma/TBI history alone, participants were consistent in describing physical and cognitive impediments to finding civilian employment, and emotional and interactional challenges to maintaining and flourishing in that work.

Participants described features of the VHA and VBA vocational rehabilitation programs that made engagement in these programs difficult. Communication and logistical issues acted as primary barriers to program access (e.g., not knowing about programs, and difficulties with paperwork completion and testing requirements), while barriers to program utilization included eligibility criteria (e.g., veterans being rated as ineligible to participate or having specific career plans rejected based on assessments and perceived limitations), fear of losing financial benefits, and an ingrained military cultural belief of self-sufficiency that made help-seeking difficult.

Yet barriers described by veterans are modifiable. For instance, the VA could facilitate program access for veterans with polytrauma/TBI history by providing an alternative to the lengthy testing requirements, providing more hands-on help with paperwork, and making information about vocational rehabilitation programs more readily available. Veterans’ beliefs and concerns (e.g., help-seeking stigma, “bootstraps” mentality, fear of losing benefits) are also addressable through therapeutic intervention and targeted educational outreach from benefits counselors regarding how VA or other government benefits may be impacted by program participation and/or competitive employment.

An aim of this study was to assess interest in the IPS-SE program among veterans with polytrauma/TBI history. Study participants expressed strong interest in the program, a finding consistent with a subsequent national survey of veterans with TBI of all severity levels that was independent of the current study’s sample (Carlson et al., 2017). Veterans in the current study endorsed key aspects of the IPS-SE model, such as vocational rehabilitation staff serving as translators, advocates, and navigators of the job search and maintenance process. Participants felt that an employment specialist working with them in these ways could help them to overcome challenges they had struggled with on their own in the past. Although not discussed with participants, another program feature that could prove similarly supportive is the integration of clinical and vocational rehabilitation teams, a structure that allows the teams to work together to develop interventions and strategies addressing health and functional limitations in the workplace. At some VA sites, VHA IPS-SE staff are co-located with the Polytrauma/TBI clinical teams (Pogoda et al., 2017a), thereby increasing the potential to address neurobehavioral symptoms and co-occurring mental health conditions interfering with workplace success.

At the time the study was conducted, IPS-SE was primarily targeted to veterans with severe mental illness. Since that time, VHA has expanded its IPS-SE program eligibility criteria to include other patient groups with intense employment support needs. It also offers a related, evidence-informed program, Community Based Employment Services, which is targeted to veterans interested in competitive employment but who require vocational interventions less intensive than those offered by IPS-SE (Pogoda et al., 2017a). Such changes are encouraging and, based on the findings reported here, likely to be embraced by veterans with polytrauma/TBI history, regardless of TBI severity level, who are struggling to find and maintain employment. Future research should examine whether these programs are reaching and engaging this veteran population.

This research also has implications for clinical practice. The barriers described by the study’s participants suggest that a vocational rehabilitation specialist integrated within the VA Polytrauma/TBI team could play an important facilitating role: making referrals to appropriate vocational rehabilitation services, providing education on how vocational rehabilitation participation may impact benefits, working closely with clinicians to develop and implement assistive strategies in the workplace, and generally serving to minimize system navigation barriers. Clinicians, too, may also consider checking-in with veterans during regular medical appointments to inquire about their job search or experiences in the workplace, help troubleshoot common problems that may arise on-the-job, and provide encouragement and education on the types of vocational rehabilitation programs available and the importance of vocational rehabilitation. For VA facilities that do not have a dedicated Polytrauma/TBI team, there is potential for vocational rehabilitation staff, in partnership with a local VA primary care or mental health provider, to liaison with a regional VA Polytrauma/TBI team virtually, as communication and integration between VA providers is facilitated through secure email, an electronic medical record system, and video-teleconference capabilities (Pogoda et al., 2017b). The integration of clinical and vocational rehabilitation teams, whether through IPS-SE or other approaches, allows for veteran health and vocational needs to be addressed concurrently, and ultimately increases the likelihood that veterans with polytrauma/TBI history will regain productive, meaningful work.

While this research has provided insight into the employment challenges and vocational service experiences of veterans with deployment-related polytrauma/TBI history, there are limitations posed by this qualitative investigation. The sample was comprised of a relatively small number of veterans residing in proximity to two urban VA Medical Centers, which may not represent other OEF/OIF/OND Veterans who have experienced unemployment following their separation from the military. As such, data presented may not characterize the experiences of all OEF/OIF/OND veterans with a history of polytrauma/TBI. Further, participants generally spent their early working years in the military, which may have negatively impacted their ability to translate or demonstrate their skills in a civilian setting. Thus, lack of civilian work experience may have also contributed to difficulty with finding and maintaining work after separating from the military. In addition, the majority of our sample had been diagnosed with mTBI thus, while reflective of the VA’s polytrauma/TBI patient population, which includes veterans with TBI of all severity, our findings may not fully capture the range of experiences of those diagnosed with moderate or severe TBI. We note, however, that the majority of TBIs sustained by U.S. service members are diagnosed as mild, and a substantial proportion of these service members and veterans experience mTBI-related sequelae (Defense and Veterans Brain Injury Center, 2018). Another limitation is that we were unable to link important participant information, such as TBI diagnosis, severity, or comorbidities, with quotes in the text, as our data collection procedures did not allow for this. Finally, the data describe perceptions of workplace and VA vocational rehabilitation program experiences among veterans who use VA services; the extent to which these descriptions are similar to the experiences of non-VA using veterans, or represent barriers to non-VA vocational rehabilitation programs (i.e., those offered by other government or non-government organizations), requires future examination.

Conclusion

Interviews and focus groups with OEF/OIF/OND veterans with deployment-related polytrauma/TBI history identified perceived individual and system challenges to seeking and maintaining civilian employment, and accessing and benefiting from VA vocational rehabilitation programs. Additionally, program features that could facilitate vocational rehabilitation participation and employment were described. As of 2018, more than 94,000 OEF/OIF/OND Veterans seeking care through the VHA have been diagnosed with all-severity TBI (Department of Veterans Affairs Comprehensive TBI Evaluations, 2018). Thus, tailoring VA’s vocational rehabilitation programs to best meet the needs of this population is imperative.