Embedded Cognitive Rehabilitation in Vocational Rehabilitation Improves Employment Outcomes for Veterans with mild Traumatic Brain Injury and Serious Mental Illness


O’Connor, M., K., Meuller, L., Wwon, E., Drebing, C. E., O’Connor, A. A., Semiatin, A., … Daley, R. (2016). Enhanced vocational rehabilitation for veterans with mild traumatic brain injury and mental illness: Pilot study. Journal of Rehabilitation Research and Development, 53, 307-320. doi:10.1682/JRRD.2014.10.0231


Veterans with mild traumatic brain injury (mTBI) often experience initial cognitive challenges which self-resolve within the first three months post-injury.  However, some experience significant, persistent cognitive and functional impediments, similar to individuals with serious mental illness (SMI).  Such cognitive and functional limitations prevent individuals from successfully reintegrating into their pre-injury life roles, such as employment.  Comorbid mTBI and SMI is common among the Veteran population.  Moreover, having co-occurring mTBI and SMI leads to greater issues for the Veterans than having either mTBI or SMI alone.  Specifically, Veterans with cognitive impairment experience worse employment outcomes and vocational rehabilitation (VR) engagement.  Successful employment is associated to numerous positive outcomes including self-esteem, financial independence, social support, mental health, and quality of life.  Previous studies incorporating cognitive rehabilitation in VR programming with civilians TBI as well as those with SMI showed better results than those who received traditional VR services.  The purpose of this (reviewed) study was to: (1) expand on previous studies by including Veterans with mTBI and comorbid SMI, and (2) determine whether embedded cognitive rehabilitation within VA VR programming would improve employment outcomes beyond standard VA VR services.  The study was a randomized control trial study conducted at a VA.  Inclusion criteria consisted of: (1) 18 years or older, (2) history of mTBI, (3) co-occurring SMI, (4) cognitive functioning impairment, (5) un- or under-employment, (6) potential to return to competitive employment within six months, and (7) enrollment and participation in VR.  Veterans in the embedded cognitive rehabilitation intervention participated in a 12-session program in which they met with a cognitive rehabilitation specialist and taught (1) compensatory strategies to mitigate work-related cognitive difficulties, and (2) skills to promote positive work behaviors, and provided laptop computers containing software with modules selected to assist with rehabilitation by providing homework assignments.  Veterans in the control group also participated in a 12-session program in which they received supportive client-centered therapy, and received laptop computers (without software modules).  Qualitative data consisted of

(1) Veterans’ ratings of usefulness and satisfaction with the sessions and specialized software, (2) the specific topics they found most and least useful to their goals, (3) any general positive and negative feedback, and (4) recommendations for future versions of the intervention.  Quantitative data consisted of obtaining an estimate of effect size.  The main outcome variable was employment, and measured by money earned, time in job, total days worked, and number of hours worked.  Data of 18 Veterans with mTBI and comorbid SMI were included in the study. The treatment and control groups did not differ at baseline on age, education, relationship status, unemployment history, or neuropsychological testing results.  Qualitative results revealed that

Veterans reported being very satisfied (80%), felt the program met their expectations (80%), and would recommend it to other Veterans (90%).  Overall, the results were more favorable for the treatment group, specifically, Veterans in the embedded cognitive rehabilitation group: attained competitive employment at twice the percentage rate (50% vs. 25%), worked more than twice as many days (67.90 vs. 28.00), worked almost three times as many hours (481.60 vs. 160.88), and averaged earnings of $5,193.47 more than the control group.  The authors conclude that the embedded cognitive rehabilitation VR program shows promise for Veterans with mTBI and comorbid SMI and should be evaluated on a larger scale.

I SELECTED THIS ARTICLE BECAUSE it is a relatively new modified program which seems to provide evidence to support its effectiveness in successful competitive employment outcomes of Veterans with mTBI and comorbid SMI.  Employment is a major barrier for individuals with disabilities, especially co-occurring conditions such as mTBI and SMI.  Moreover, Veterans are unemployed at unacceptable rates.  Embedded cognitive rehabilitation in VR programming may be the key to bridging the employment gap for Veterans with comorbid mTBI and SMI.

THIS MONTH’S REHABILITATION SCIENCE SPOTLIGHT was chosen by Jennifer Sánchez, Ph.D., CRC, Assistant Professor, Department of Rehabilitation and Counselor Education, The University of Iowa, and a member of Division 22’s Science Committee.