Experiences of VA vocational and education training and assistance services: facilitators and barriers reported by Veterans with disabilities

Abstract

Objective:

To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment.

Methods:

We conducted 26 joint semi-structured interviews with Post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program.

Results:

VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of non-traditional veteran learners.

Conclusions and Implications for Practice:

There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran’s health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran’s goals and abilities could also be beneficial across vocational and educational services.

Introduction

Many Post-9/11 veterans return to civilian life with military-related disabilities that contribute to significant functional impairment (Waszak & Holmes, 2017). Two of the most recognized conditions affecting these veterans are traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Since 2000, there have been more than 380,000 diagnosed TBIs in U.S. service members (Defense and Veterans Brain Injury Center, 2019), and the prevalence of PTSD among Post-9/11 Veterans is estimated to be 11–20% (Fulton et al., 2015; Tanielian & Jaycox, 2008). Mild TBI (mTBI), which comprises approximately 80% of military-related TBI diagnoses (Defense and Veterans Brain Injury Center, 2019), often co-occurs with other conditions, such as PTSD and chronic pain (Carlson et al., 2011; Cifu et al., 2013). This constellation of conditions can lead to behavioral, emotional, and physical limitations that impact activities of daily living and the ability to function independently (Meterko et al., 2012; Pogoda et al., 2016; Waszak & Holmes, 2017).

Work reintegration is a specific challenge that Veterans with disabilities encounter (Kukla, McGuire, & Salyers, 2016; Wyse, Pogoda, Mastarone, Gilbert, & Carlson, 2020). Veterans with co-occurring mTBI and mental health conditions are particularly vulnerable to decreased role functioning at school and work (Erbes, Kaler, Schult, Polusny, & Arbisi, 2011; Kukla et al., 2016), which can lead to economic insecurity and poor health (Dillahunt-Aspillaga & Powell-Cope, 2018; Hamilton, Williams, & Washington, 2015). Conversely, employment can serve as a protective factor for serious mental health challenges, such as suicidal ideation (Elbogen et al., 2020).

To facilitate the transition to a meaningful and productive civilian life, the Department of Veterans Affairs (VA) offers vocational rehabilitation, training, and educational assistance programs—hereafter referred to as vocational and educational services—through its Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA). VBA offers qualified veterans the Post-9/11 GI Bill to help cover tuition, supplies, and housing costs for traditional higher learning institutions, vocational/technical training, on-the-job training, and apprenticeship programs (U.S. Department of Veterans Affairs, 2019a). VBA also offers Vocational Rehabilitation & Education (VR&E), for which eligibility includes a 10% or greater service-connected disability rating and a documented employment handicap (U.S. Department of Veterans Affairs, 2019d). VR&E services include education and career counseling, support in returning to civilian jobs held prior to deployment, job placement services, assistance with self-employment, and longer-term services to help veterans find a new career. VR&E education benefits include coverage for tuition, fees, books and supplies, and a monthly stipend. Veteran students who receive tuition support through VR&E services adhere to an employment-related rehabilitation plan while students who receive benefits from the Post-9/11 GI Bill do not.

VHA offers different vocational rehabilitation options based on level of veteran need (Pogoda, Levy, Helmick, & Pugh, 2017). Notably, Supported Employment (SE) (Davis et al., 2018; Davis et al., 2012; Resnick & Rosenheck, 2007) is an evidence-based program that supports individuals with occupational limitations to obtain competitive employment that is centered on the individual’s strengths and interests (Drake, Bond, & Becker, 2012). Core principles of SE include not requiring any pre-vocational training, and providing rapid job searches, job coaching, and time-unlimited, individualized, follow-along support (Drake et al., 2012). Vocational Rehabilitations Specialists (VRS) also join the veteran’s treatment team so that clinicians and VRS can collaborate to anticipate and address any challenges in the workplace. In one study, 51% of veterans who received SE obtained competitive work (Twamley et al., 2013), which is associated with long-term gains in quality of life (Cotner et al., 2018). SE is offered throughout VHA, but because of the resource-intensive nature of the program, its use is limited (Sripada et al., 2018; Twamley et al., 2013). Target populations include veterans who experience significant employment barriers as a result of mental health conditions, such as psychosis or other severe mental illness (Resnick & Rosenheck, 2007). Recently, SE has been expanded to Veterans with other health conditions that limit occupational functioning, including PTSD and TBI (U.S. Department of Veterans Affairs, 2019b).

While VA offers a wide range of vocational rehabilitation programs, these services operate under two distinct systems—VBA and VHA. VA does not have a single data system that connects VBA and VHA; as a result, coordination between two these systems is minimal. The lack of coordination between these systems prevents the VA as a whole from delivering a package of services that meet veterans’ comprehensive needs.

The main objective of this study is to describe facilitators and barriers to use of VBA and VHA vocational and educational services among Post-9/11 veterans whose functional disabilities are significant enough to require a caregiver. Post-9/11 veterans are eligible for caregiver support if they sustained or aggravated a military-related serious injury, such as TBI or PTSD, and need a caregiver to perform or supervise activities of daily living (U.S. Department of Veterans Affairs, 2019c). Our study is the first to examine experiences with using VBA and VHA services in tandem among Post-9/11 veterans with caregiving needs. Veterans with significant disabilities are the least likely to be employed (U.S. Department of Labor, 2019) and to suffer consequent economic insecurity. As Post-9/11 veterans are in their prime working years, it is critical to understand their experiences so that VA can provide vocational and educational services to most effectively meet their needs.

Methods

Recruitment.

These data were collected as part of a larger study with a sample of veterans and their family members. Participants were identified from an administrative list of caregivers enrolled in the VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) for at least 90 days between May 1, 2010 and September 30, 2014 (Van Houtven et al., 2019). PCAFC provides education, training, and financial support for eligible caregivers of veterans who were injured on or after September 11, 2001. Study inclusion criteria were veterans having at least one interaction with VR&E, the Post-9/11 GI Bill, or SE documented in VA administrative records. Veterans who used SE were identified if a clinical stop code of 222, 568, or 569 appeared in VA administrative records (Corporate Data Warehouse). Veterans who used VBA services were identified through an Excel file of VBA service use data from the variables called “GI_Bill_Used” and “VR_Applied.” Eligible veterans and caregivers were mailed a recruitment letter and received a follow-up call from study staff to assess eligibility; staff also explained the purpose of the research, duration of their participation, and potential benefits and risks. Interviews were conducted during 2018. Participants provided verbal consent and received $25. An Institutional Review Board approved the study.

Data Collection.

We conducted 26 one-hour semi-structured telephone interviews with the veteran and their caregiver. The results presented here are one component of a larger qualitative study. Interview questions analyzed for this paper solicited information about veterans’ experiences, barriers, and facilitators with using the three vocational and educational services of interest. Additionally, we report on other responses related to questions about how helpful the service had been, whether it aligned with veteran/caregiver expectations, reasons for discontinuing the use of a service (if applicable), and how the service supported the life goals of the veteran. The interview script was developed and piloted with a veteran and caregiver community stakeholder group. Two team members conducted the interviews (MSB, AS) and then recorded impressions from the interviews; interviews were digitally recorded and transcribed.

Data Analysis.

Applied thematic analysis (Guest, MacQueen, & Namey, 2012) was used to analyze participant responses. First, we developed structural codes based on domains in the interview guide (e.g., experience with the services, facilitators and barriers to service use). Then, two analysts (MSB, AS) iteratively reviewed content within these structural codes and came to consensus on a set of content codes. These codes included experience with social service (general), role of service in meeting the veteran’s life goals, personal gain from the service, facilitators and challenges of social service use, and levels at which facilitators and challenges occurred: veteran, family, VA, and academic institution levels. The team assessed intercoder agreement by checking consistency of codes on the initial five interviews and then periodically thereafter; coding discrepancies were resolved by team discussion. Once coding was complete, the analysts organized the data and summarized the themes; coders verified all summaries. ATLAS.ti 8.1 analytical software (Atlas.ti Scientific Software Development, Berlin, 2017) was used to apply codes to the transcript and organize the data.

Results

Demographics and health characteristics.

Respondent demographics are reported in Table 1. On average, the veterans were in their early 40s and their caregivers were in their late 30s, with the majority reporting a spousal relationship. While we did not ask about specific health conditions, most dyads spontaneously disclosed or alluded to conditions that contributed to substantial functional limitations. The most common conditions were musculoskeletal problems (i.e. loss of limb, surgery, joint pain or damage), PTSD, other mental health conditions, and TBI (severity not disclosed or probed). Most veterans in the sample (n=21) reported more than one health problem and many reported both physical and mental/cognitive limitations. Nine veterans volunteered that they received a service-connected disability rating ranging from 60% to 100%. Several veterans reported that they had a VA designation of “total disability based on individual unemployability” (TDIU; n=4), defined as being unable to obtain substantially gainful employment because of one or more service-connected disabilities.

Table 1:

Veteran Descriptive Characteristics and Use of Educational/Vocational Services

Baseline Characteristics (n = 26)	%	n
Mean Veteran Age (Mean ± SD)	42.2	-
Mean Caregiver Age (Mean ± SD)	38.3	-
Veteran Sex %
Male	100	26
Race %
White/Caucasian	63.5	17
Black/African American	9.6	2
Other/Prefer not to answer	26.9	7
Hispanic, Latino(a)	11.5	3
Veteran/Caregiver Relationship, %
Spouse	84.6	22
Parent/Child	7.7	2
Significant Other	7.7	2

Demographic information was collected from participants during the study eligibility screening and informed consent telephone call.

Vocational and educational services use.

Self-reported service use is shown in Table 2. Nearly 50% of veterans used at least two of the vocational and educational services; of these, most combined the Post-9/11 GI Bill and VR&E benefits to pursue professional degrees. Four veterans reported transferring their Post-9/11 GI Bill benefits to family members.

Table 2:

VBA and VHA Vocational and education assistance and training service use and outcomes

Service use (per respondent self-report) a	%	n
Used VBA Post-9/11 GI Bill benefits	65.4	17
Spouse/children used Post-9/11 GI Bill	15.4	4
Used VBA VR&E more than once	57.7	15
Used VHA SE at least once	15.4	4
Used at least 2 of the services	42.3	11
Outcome of service use by each service (per respondent self-report)	%	n
VBA Post-9/11 GI Bill
Completed degree	47.1	8
Degree in process	35.3	6
Unable to complete degree	35.3	6
VBA Vocational Rehabilitation and Education
Completed degree	33.3	5
In process/on-going participation	26.7	4
Unable to complete degree	53.3	8
VHA SE
Participating as of date of interview	00	0
Not participating as of date of interview	100.0	4

^aTable 2 demonstrates self-reported service use which differed in some cases from administrative records.

^*Note that percentages under Outcomes of Service Use do not add up to 100 because veteran may have used the VBA Post-9/11 GI Bill and VR&E to pursue multiple degrees, therefore the dominator in this table is the number of attempted degrees that veterans pursued. In other words, veterans may have completed an initial degree, but did not complete a secondary degree.

^**Information about veteran service use was assessed through VA administrative records and verified with participants during the interviews. The statistics presented reflect yarticiyant- reported information. Information about the outcomes of service use was collected from participants during the interviews.

Sixteen veterans used the Post-9/11 GI Bill, and 14 veterans used VR&E, to pursue traditional degree programs. Fourteen reported they had not completed either degree program. A smaller number of veterans used these programs for correspondence courses or skills workshops. Veterans who completed their programs received associate and bachelor’s degrees in business and finance, applied science, automotive science, and multi-media. Of the four respondents who reported using SE, none were currently engaged in or working for pay in a job obtained through that program.

Respondents perceived that VA vocational and educational services improved the potential for veterans to successfully integrate into the civilian workforce.

Respondents reported that military-related injuries altered veterans’ job skills and capabilities, but that VA vocational and educational services provided financial support and guidance to help them develop new skills, qualifications, and connections for identifying work opportunities that accommodated their new limitations.

“The goals have been to help [Veteran] reinvent himself again. Before he was in the military, he was a metal fabricator. And then when he was in the military, he was a military police officer, and [then] he didn’t qualify for his jobs anymore because of his back injury…the GI Bill helped him figure out another path and reinvent himself.” [Caregiver, Post-9/11 GI Bill]

Veterans and caregivers identified other advantages conferred by these services, including strengthening professional credentials, improving self-confidence to engage in the workplace, and refining how the veteran interfaced during job searches.

“I’m going crazy sitting in the house while not having anything to do and I don’t think that I will progress forward without having some sort of a challenge…We need money, and I need to be mentally stimulated, so I’ll work…I was getting a lot of confidence with just interacting with people in the public. When I was doing my resume, and trying to figure out what things that I can do, it’s helped guide me and focus my expectations. I haven’t started working yet, but now it doesn’t seem impossible…starting school has helped with that too. It gave me confidence building and familiarity with being in those types of positions again.” [Veteran, SE]

Participants acknowledged that the structure of the programs helped veterans readjust by providing exposure to tasks needed to function successfully in civilian life. One caregiver described how SE helped her husband cope with his anxiety by identifying small steps he could take to enter the workforce: “[SE] helps a lot with anxiety …especially for those with PTSD who have severe anxiety about everyday life. This program helps ease that…it helps him starting with the baby steps and I can do that baby step.” (Caregiver, SE)

Veterans also reported that job skills they gained, or expected to gain, from these services would reduce economic insecurity: “I don’t have a choice. It’s either do [VR&E] or find a nice cardboard box for me and my family to live in on the streets. Because if I can’t pay my bills then I have to find some way for me to get some income to support my family and this is helping.” [Veteran, VR&E]

While some veterans did not pursue jobs after receiving vocational and educational services, the skills they learned improved their quality of life in other ways: “I pursued a correspondence course that the GI Bill covered in dog training. I had hired a local dog trainer to help me train my dog as a PTSD service dog. And found that I loved working with dogs, so I pursued it. But it was a personal enrichment thing.” [Veteran, Post-9/11 GI Bill]

Veteran motivation, caregiver support, and engaged VA and academic counselors were key factors reported to promote use of VA vocational and educational services

Veterans’ indicated that their initiative and tenacity to seek VA services, academic programs, and to engage counselors were key facilitators of service use. Family members also helped veterans to identify academic programs, complete school-related assignments, and advocate for the veterans’ needs (Shepherd-Banigan, Sperber, McKenna, Pogoda, & Van Houtven, 2019).

“…a lot of it was legwork on my part and [family member’s] part as well. Not a whole lot of the information was available from the VA…and so it was a lot of searching on the internet and then calling different people and finding out is this covered, how do we pursue this.” [Veteran, Post-9/11 GI Bill]

Efficient VA program application processes and staff were also facilitators of vocational and educational services use. Participants described the Post-9/11 GI Bill application process as “easy” and “streamlined.” The VR&E counselors helped veterans to navigate the process from applying to VR&E to attending classes. VRSs were described as “hands-on.” For example, one VRS met with the veteran’s health team to help set expectations about the veteran’s capacity to work; in addition, with the veteran’s permission, the VRS contacted job sites to inform them about the veteran’s health conditions. Other VRSs thoughtfully matched the veteran with jobs that would fit his skills and capabilities: “She went above and beyond to really try to accommodate him, I remember sitting on our floor with the computer and she was looking over the resume and said, ‘I can take that and I can add different things to it’. And the job [she found] was [from] a contact that she had; she said, ‘hey, there’s a gal I know that has a heart for veterans’. That [job] helped for a time. It wasn’t a lot of money but it helped to fill a blank space for a season.” [Caregiver, SE]

Veterans who used the Post-9/11 GI Bill and VR&E services provided many examples of how broad academic institutional support for veterans and an understanding of the needs of non-traditional learners (i.e. learners with disabilities, older students with substantial life experience) was important for their success.

“The school has been very accommodating, aware, and responsive. The school has a veteran service office that also has its own disability coordinator within the office, they have the whole staff, so they’ve been really proactive with me. And then it didn’t take very much to start when I started to realize I was having some issues. And they just said, ‘here are the things we could roll out to you.’ So they’ve just been more responsive and oriented toward my issues and probably [towards] similar veterans.” [Veteran, VR&E]

One of the most widely cited components of this support was the university-employed veteran liaison¹; these representatives support veterans by managing course enrollment, payments from VA, and other VA-related paperwork. One veteran said that the veteran liaison did an “exceptional job” of providing information about degree programs and courses and “presenting multiple scenarios for him to make the best decisions for his life” [Post-9/11 GI Bill].

Veterans also discussed the importance of academic instructors offering disability accommodations to facilitate class completion.

“I’ve learned that it’s more difficult for me to consume information and remember it, so they’ve given me more time because everything is online and timed, so that was a big one.” [Veteran, VR&E].

Another veteran described how the university disability coordinator advocated on his behalf and communicated directly with the VR&E counselor to explain the veteran’s academic challenges in order to acquire VA support to accommodate his disability needs, “My disability coordinator was really on top of a lot of things. And she even talked with my VR&E counselor…to help my VR&E counselor to understand a couple of things” [Veteran, VR&E].

Veteran health problems, fear of benefits loss, and limited perspectives on the potential of individuals with disabilities inhibited use of vocational and educational services

Veteran impediments to school and work included mobility limitations and pain, cognitive processing issues that veterans felt prevented them from keeping up with peers, and stress and anxiety which, for some, led to high levels of reactivity that negatively affected their interactions with others. Numerous medical appointments also took time away from school and work. One veteran described how his health conditions led to difficulty identifying a suitable job through SE:

“When you got a bad back that means you can’t sit and stand for too long, you suffer from PTSD you can’t deal with too many people; [when] your main job skills is security and construction, you’re kind of lost. She [VRS] was looking hard but everything she found would contradict one or more of my disabilities.” [Veteran, SE]

Several respondents reported that they were not capable of working because they had a TDIU designation. These veterans were pursuing educational and vocational services to grow skills in a leisure activity that increased their sense of well-being. Additionally, several respondents from the overall sample expressed concern that employment would lead to reduction in service-connected disability compensation and the caregiver stipend; this fear discouraged them from seeking services, including SE and VR&E, which are expected to lead to employment. One veteran indicated that he would have earned less money in a job acquired through SE than what was provided through VA disability payments. Moreover, several veterans suspected that their disability payments or caregiver stipend decreased because VA staff perceived employment as a sign of increased function, and therefore indicative that the current level of service-connected disability compensation and family caregiver support was unnecessary. One caregiver summarized how the structure of VA disability and other financial payments can deter veterans from pursuing vocational and educational services:

“…the sad thing about the setup of the VA is that disability kind of pulls the rug out from our veterans. It perpetuates this system where, if you want to be able to survive, you have to have a certain level of symptoms, and you have to embrace this identity of being completely incapable. And so the [Post-9/11 GI Bill] was an opportunity for him to feel like ‘I’m not completely feeble and I can at least do this for myself to improve my overall sense of self’.” [Caregiver, Post-9/11 GI Bill]

Some participants perceived that VA program staff had limited understanding of adults with disabilities based on how they applied program assistance. One veteran expressed frustration that VR&E was reluctant to approve an online program that provided the accommodations he needed to complete a degree. A family caregiver described her experience of having to convince a VR&E counselor to approve educational accommodations that were necessary for the veteran’s success. In several instances, veterans had pursued an area of study that was conducive to accommodating their disabilities (e.g., digital photography and computer game design), but these veterans were unable to continue because VA opined that the degree programs would not lead to competitive employment and VA stopped paying for the courses. In both of these instances (Post-9/11 GI Bill and VR&E), the veterans had already invested in a semester worth of courses. When the VA did not repay this money, it led to substantial financial hardship for the veterans.

“I was doing an associates in digital photography…And I got a letter from the VA saying that not enough people who went to school for photography using [the Post-9/11 GI Bill] receive jobs afterward, so [they] stopped funding people who were going to school for that.” [Veteran, Post-9/11 Bill]

Veterans described instances of insufficient support for needs of non-traditional veteran learners across the three services. Specific frustrations voiced by veterans included limited guidance, communication, and follow-through from VA program counselors. Veterans reported high rates of staff turnover and understaffing in the VR&E units. One veteran who used SE stated that he did not receive help with his resume or guidance on how to make himself marketable; he also reported that once he secured a job he did not receive any follow-on support from the VRS. He eventually left that job because of his mental health symptoms.

“It was very frustrating because we were gung-ho and excited about it and he [the veteran] was like, “yes! I can pursue this other career…this is what I want to do.” He was more than willing to do whatever he needed to do, get whatever paperwork he needed to get, and he was there on time when he was supposed to be, but the VA just dropped the ball getting [SE-related] appointments. I believe he had an appointment in one location with an individual at a specific time, showed up, come to find out she was two hours away, so. It was very frustrating, and when he gets that over and over and over again, you lose…. interest in doing that. You lose faith in the system that’s supposed to be helping you to overcome your obstacles.” [Caregiver, SE]

Conclusions and Implications for Practice

Our results demonstrate that, from veteran and caregiver perspectives, VA vocational and educational services have helped veterans readjust to civilian life by providing skills and opportunities for engaging in everyday tasks. In general, veterans expressed appreciation for VA vocational and educational services and described both benefits and limitations of each. Moreover, veterans expressed a strong desire to use these services to identify meaningful ways to engage in post-military life, whether it be for job development or education that leads to future employment or general self-improvement. Several respondents had completed degree programs as a result of participating in these VA services. Veteran motivation, caregiver support, and engaged staff at the VA and academic institutions were perceived to be important drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, VA bureaucratic processes, and VA and academic programs that did not accommodate the needs of veteran students with disabilities.

Veterans are interested in services to help readjust to civilian life (Carlson et al., 2018; Sayer et al., 2010; Sripada et al., 2018); respondents in our study generally spoke highly of VA vocational and educational services. Financial support for education was cited as especially critical to alleviate financial burden on the household and allowed the veteran to focus on academic pursuits (Browning, 2015; Steele, Salcedo, & Coley, 2011). Veteran motivation and the perceived engagement of VA and academic program counselor support were important facilitators for success in work (Kukla et al., 2016) and school. Similar to other findings (Kukla, McGuire, Strasburger, Belanger, & Bakken, 2018), veterans in our study who worked with VA or academic staff who understood and advocated for the veteran’s needs reported favorable impressions of the VA educational assistance programs and of their own ability to succeed. Supportive family members were also an important facilitator. Given the lack of coordination between VHA and VBA, caregivers could play an especially important role in helping veterans to develop a comprehensive program to support their health and reintegration needs. Moreover, family members can help veterans to overcome some of the barriers that they experience using vocational rehabilitation services by providing emotional, logistic and advocacy support (Shepherd-Banigan, Sperber, McKenna, Pogoda, & Van Houtven, 2020).

Veteran students tend to have different attributes than traditional college students; they are usually older, have more life experience, and may struggle with health conditions that impede their ability to complete academic assignments in a timely way (Bell, 2015; Cate, 2011; Gregg, Howell, & Shordike, 2016). In one study, staff on college campuses reported that they are not well-equipped to manage the mental health needs of student veterans (Niv & Bennett, 2017). Mental health conditions and cognitive limitations can challenge veterans to fulfill work tasks (Kukla et al., 2016; Reddy & Kern, 2014; Wyse et al., 2020), and as a result, veterans may feel socially and functionally out of place in work and academic environments (Elliott & Gonzalez, 2011). Other studies also found that limited program resources, low capacity of frontline staff to connect veterans with appropriate work, and stigma negatively impacted veteran success (Kukla et al., 2016). In a few cases, similar to other findings, participants reported that counselors and medical providers expressed low confidence in the veterans’ ability to return to work or school (Shepherd-Banigan et al., 2019; Wyse et al., 2020); for veterans this was frustrating and demoralizing (Wyse et al., 2020).

One path towards reintegration into civilian life for veterans with disabilities is vocational and educational services. However, skills development efforts for workforce participation can be at odds with concerns about potential VA disability payment loss if they obtain employment (Meshberg-Cohen, Reid-Quinones, Black, & Rosen, 2014; Wyse et al., 2020). When there is ambiguity about outcomes (e.g., symptom relapse, job loss), and the potential for loss (e.g., reduction in disability compensation), combat veterans with PTSD are risk averse (Ruderman et al., 2016), and veterans have indicated that they would rather reject a job offer than lose benefits (Meshberg-Cohen et al., 2014). Disability compensation that disincentivizes employment-related income has been associated with lower rates of vocational rehabilitation participation (Drew et al., 2001). Participants in our study gave examples of reductions in VA caregiver and disability payments once veterans became employed. It is critical that veterans receive benefits counseling prior to pursuing education and employment so they can be informed of how return to work may impact disability compensation. Such counseling is a key component of SE (Drake et al., 2012). However, the potential disincentive of reduction in disability compensation must be carefully considered against the financial, mental health, and social advantages of employment (van der Noordt, H, Droomers, & Proper, 2014; Waddell & Burton, 2006). Indeed, in our study, several veterans referred to themselves as “unable to work.” Through probes we traced this back to a VA TDIU designation or feedback they received from their health care team. Some veterans identified closely with their VA disability label and described feeling that it meant they were incapable of working, which is perhaps an unintended consequence of the VA disability payment structure. Not only can this limit perceptions of the role of veterans with disabilities in society, it can narrow the potential of what these veterans aim to accomplish and what assistance is offered to them.

We note several limitations. Our study included only veterans who had a caregiver, and the functional impairment that veterans with caregivers experience is likely more substantial, and therefore may have different experiences than veterans with disabilities who typically use Post-9/11 GI Bill, VR&E, and SE services. Also, it was a challenge to recruit veterans who used, and remembered using, SE. Many veterans whose administrative data indicated they received SE at least once did not recall using it, and among the four Veterans who did, none were still engaged in work obtained through SE at the time of interview. During this time, use (Twamley et al., 2013) and knowledge of (Carlson et al., 2018; Wyse et al., 2020) SE in VA among veterans with PTSD and TBI was generally low, likely because veterans with PTSD and TBI were not target populations until more recently (Pogoda et al., 2017).

Implications

Our findings suggest the need to bolster VA vocational and educational services for veterans with disabilities; this can be accomplished by modifying the roles of frontline staff and increasing integration between vocational counselors and health care teams to better accommodate the veteran’s health-related limitations. The roles of VR&E and Post-9/11 GI Bill counselors are different, but few veterans reported experiences with VBA counselors who extended support beyond their specific service. For example, VR&E counselors provide more support in helping veterans to identify and create a plan to achieve their career goals. Post-9/11 GI Bill counselors appear to primarily manage paperwork and payment transfers related to these benefits. However, at times veterans need more support from VBA counselors to help them navigate the complex menu of VA programs, serve as a liaison with academic disability counselors and veteran liaisons, and help veterans to manage the transition into academics. In our study, many veterans were able to do these tasks, but they required a high level of organizational skills and motivation. For veterans with disabilities that affect executive function, these tasks can be very difficult. Therefore, veterans with significant disabilities would benefit from a VBA counselor who could help veterans navigate the vocational rehabilitation and education resources necessary to meet their needs within VA and academic settings (Wyse et al., 2020).

One gap is that vocational and educational services, particularly those provided in VBA, are not always designed to accommodate limited function (Bell, 2015). VHA provides high quality psychological and physical health care to increase functioning for individuals with mental health, cognitive, and physical disabilities; yet, communication between VHA health care providers and VBA social service counselors was rarely described. Lack of engagement between the VHA health care team and VBA (VR&E, Post-9/11 GI Bill) counselors is a missed opportunity to address this gap (Shepherd-Banigan et al., 2019; Wehman et al., 2019). Improved communication between the VHA health care team and VBA counselors could target health interventions and identify vocational and educational accommodations to facilitate veteran success in these settings.

SE and Supported Education approaches offer an example for how to bolster VBA services. SE proposes an excellent model of supporting psychosocial recovery of individuals with disabilities. A fundamental principle of SE is integration with the veteran’s clinical team (Drake et al., 2012); integration is facilitated by a trained VRS. Similarly, VHA Supported Education, another recent addition to the VHA Vocational Rehabilitation Service, which is not yet widely offered throughout VHA, could assist veterans to transition into educational settings. Supported Education is an individualized program that helps veterans identify career development needs through assessment, referrals to training, and as-needed supports for training completion. For those who qualify for VBA vocational and educational services, Supported Education can include vocational and educational assistance, cognitive rehabilitation, and organizational and other skills development. It can also facilitate connections with college disability services and obtaining academic accommodations, and offer assistance with using VA educational benefits and state vocational programs (U.S. Department of Veterans Affairs, 2019b).

VA provides an array of health and vocational supportive services; these programs offer substantial positive impacts for veterans with disabilities. VA could enhance these positive impacts by applying small modifications to vocational programs using effective approaches that VA is already implementing. Our findings provide support for the importance of scaling up these approaches, including SE.

Impact and Implications.

VA vocational and education services help veterans with disabilities transition from the military to civilian society. Veterans identified numerous facilitators that can be used to enhance these programs. However, veterans also cited important barriers at the VA and academic institution levels that could be addressed by bolstering frontline staff to coordinate between vocational rehabilitation, health teams, and academic counselors/employers to ensure veteran success.