Cognitive Behavioral Therapy to Enhance Competitive Work Outcomes
Phase: NA
Conditions: Mental Disorders, Mental Health Services
Sponsor: VA Office of Research and Development

 
 
 
 
 
 
 
 
“Cognitive behavior therapy for work success in veterans with mental 
illness: A pre-post efficacy study”  
 
Study Protocol and Statistical Analysis Plan 
 
ClinicalTrials.gov Identifier: NCT01918774 
 
 
Principal Investigator: Marina Kukla, Ph.D., HSPP 
 
Version date: 2/26/2016 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Overview of the Problem  
In 2010, 11.5% of all Gulf War-II veterans were unemployed; that figure rose to 
15.2% in January 2011 and continues to grow as the number of veterans from recent 
wars increases (United States Department of Labor, 2011; Seal et al., 2009). The 
prevalence of mental illness among veterans is also notable; estimates range from 31% 
(Seal et al., 2007) to nearly 37% (Seal et al., 2009) for any psychiatric disorder, and over 
half of these veterans are diagnosed with more than one psychiatric condition (Seal et 
al., 2007).  In addition, empirical evidence suggests that some mental disorders are 
more prevalent in veterans than in the general population (Kessler et al., 2005). Linking 
unemployment and mental illness, a recent study found that 65% of veterans using VA 
healthcare were unemployed, and compared to employed veterans, the unemployed 
were more likely to have depression, bipolar disorder, post-traumatic stress disorder 
(PTSD), schizophrenia, or substance use disorders. Vocational dysfunction was reported 
most often in disabled veterans with schizophrenia, PTSD, and substance use disorders 
(Zivin et al., 2011). Not surprisingly, this study also found that unemployed veterans had 
significantly lower income than employed persons. Similarly, a large study focusing 
specifically on veterans with PTSD concluded that vocational dysfunction is a notable 
problem among this group, as they were significantly less likely to be employed after 
participating in VA work programs compared with participants without the disorder 
(Resnick & Rosenheck, 2008). Because most individuals with mental illness desire to 
work in regular competitive employment (McQuilken et al., 2003), the nationwide 
problem of unemployment among veterans with mental illness is particularly troubling.  
The VA is addressing this need by implementing supported employment (SE), a 
psychiatric rehabilitation approach that provides individual vocational assistance to 
veterans with mental illness. While the SE model is empirically validated and SE 
programs have been shown to achieve partial success in improving employment 
outcomes, a sizable proportion of individuals, 40% or more, remain unemployed (Bond 
et al., 2008).  A further challenge is job retention; veterans with mental illness who obtain 
jobs frequently struggle to maintain them long-term. Even in the context of high quality, 
evidence-based vocational services, most studies show only modest job retention of a 
few months (Bond et al., 2008), and consequently, frequent job losses and inconsistent 
vocational functioning remain a substantial and unsolved problem. 
 
Background  
Cognitive behavior therapy (CBT) is an empirically validated, recovery based 
intervention that has been recommended as a best practice in the treatment of mental 
illness (Michon, van Weeghel, Kroon, & Schene, 2005). CBT is a standard component of 
veteran healthcare in the VA—as an integral part of routine outpatient multidisciplinary 
mental health care effectively treating conditions such as anxiety, depression, and 
PTSD. CBT is also a central part of Psychosocial Rehabilitation and Recovery Center 
(PRRC) programming and a core therapeutic technique used in Illness Management and 
Recovery (Gingerich & Mueser, 2005), an effective and widely implemented severe 
mental illness self-management program. Furthermore, research indicates that CBT is 
well accepted by people with mental illness (e.g., Kingdon & Turkington, 1991) and is 
well suited to meet the treatment needs of diverse patients, including various ethnic 
groups (Horell & Voss, 2008), a range of diagnostic groups (Butler et al., 2006), 
inpatients and outpatients (e.g., Drury et al., 1996), and varying illness phases (e.g., 
acute versus stable; Tarrier et al., 2004).  
The majority of psychiatric treatments available to veterans—both 

psychotherapeutic (including CBT) and pharmacologic— target symptom reduction. 
Interventions to improve everyday functioning are lacking, and important veteran 
outcomes such as subjective quality of life are more strongly related to functional deficits 
than symptom severity in itself (e.g., Norman et al., 1999). While some psychiatric 
symptoms in severe mental illness are related to functioning, symptom improvements 
often do not directly translate to substantial functional improvement; these outcomes are 
only modestly correlated (e.g., Wykes et al., 2008). In veterans with PTSD, research has 
demonstrated a stronger relationship between symptom improvement and functional 
benefits, although functional outcomes in these published studies have most often 
measured in terms of physical health and social functioning (e.g., Shea et al., 2010), 
largely ignoring the important area of vocational functioning. Overall, the propensity of 
research suggests that the utility of therapeutic approaches that solely target symptoms 
is limited. Furthermore, utilizing a combined approach that focuses on functional 
improvements (including vocational functioning) in addition to symptomatic relief is 
consistent with the recovery movement, centered on the notion that people with mental 
illness can lead meaningful and productive lives despite the challenges imposed by 
illness (Anthony, 1993). Lastly, as discussed in a later section, the development of 
interventions to aid functioning in mental illness is critical, given the substantial personal 
and societal consequences of such deficits.  
Previous interventions that have combined CBT with rehabilitation practices 
targeting instrumental role functioning have had positive results. One that has been 
studied—CBT combined with social skills training, has shown incremental benefit above 
and beyond the effects of CBT or social skills training alone. In response to this program, 
veterans with severe mental illness have shown improvements in long-term social 
functioning, greater skills mastery, and improved cognitive insight (e.g., Granholm et al., 
2005).  
Competitive work functioning is a promising next application of CBT intervention. 
Empirical findings suggest that dysfunctional beliefs about one’s ability to excel 
vocationally seriously damage work outcomes (Gallo, 1994).  Specifically, people with 
severe mental illness endorse the belief of low likelihood of success at work, even with 
assistance (e.g., Roe, 2001). Influencing these beliefs are other beliefs related to low 
self worth, low levels of perceived competence, and poor general self-efficacy (e.g., 
Davis et al., 2004). Studies have also linked negative self beliefs that may impact work 
ability with illness-related factors such as poor participation in treatment (e.g., Brekke & 
Long, 2000), ineffective coping styles (e.g., Kleim et al., 2008), poor social functioning 
(e.g., Lysaker et al., 2007; Roe, 2003), and barren personal narratives characterized by 
beliefs that one is not an active agent in his or her own life (Lysaker, Buck, Taylor & Roe, 
2008). In addition, prior research has demonstrated that such negative expectations are 
associated with higher levels of alienation, a greater tendency to ignore stressors, and 
more severe symptoms of emotional discomfort (Lysaker et al., 2008).  
Prospective quantitative studies have shown a moderately strong relationship 
between maladaptive vocational beliefs and employment outcomes. For instance, 
Regenold and colleagues (1999) found that work-related self-efficacy significantly 
predicted success in obtaining a job over a 13 month follow-up period in a sample of 
people with mental illness (i.e., mood disorders, anxiety disorder, schizophrenia, and 
personality disorders) receiving supported employment services. Similarly, an earlier 
study (Arns & Linney, 1993) found a moderate association between negative beliefs 
about work ability and employment outcomes (change from unemployed to employed) 
over six months in a community mental health sample.  Moreover, prior theory-based 

research has attempted to explain these findings, highlighting the importance of self-
efficacy and perceptions of employment barriers in determining motivation, decisions to 
seek out work in the community, and purposive action towards career goals (Albert & 
Luzzo, 1999). 
Stigma is another key factor linking negative self beliefs with poor work 
outcomes. Society often views people with mental illness as being unable to work; 
accordingly, persons with mental illness are frequently advised to lower their career 
expectations much below that of their educational background, expertise, and previous 
work experience (Link et al., 1999).  Self stigma, or internalization of this belief, often 
leads to poor self esteem and expectations of work failure that may take the form of a 
self-fulfilling prophecy, such as: “I’ll never be able to do this job.” Consequently, persons 
with mental illness are often less likely to seek out employment opportunities, tend not to 
persevere when faced with complex challenges on the job, and engage in less active 
problem solving (Lysaker et al., 2009). Consistent with these notions, extant studies 
have found a relationship between endorsement of self stigma, poor self esteem, and 
lower participation in community activities, including work. In general, stigma is accepted 
as a barrier to mental health care and personal recovery across psychiatric conditions, 
including mood disorders, schizophrenia and PTSD (e.g., Corrigan, 2004). 
In addition to maladaptive thoughts about work ability, the challenges and deficits 
imposed by mental illness often substantially decrease the likelihood of gainful 
employment. In the past 10 years, studies have linked neurocognitive deficits (Green, 
Kern, & Heaton, 2004), poor intrapsychic functioning (e.g., Rosenheck et al., 2006), 
deficits in social functioning (Banks et al., 2001), and severe psychiatric symptoms (e.g., 
Milev et al., 2005) with lower vocational attainment. Recently, studies have also begun to 
examine the role of metacognition, defined as the ability to think about one’s own mental 
activity and that of others, thinking about oneself and others in a larger social context, 
and integrating that knowledge to face life’s problems and challenges (Semerari et al., 
2003). Metacognition has been found to be independently related to work performance 
(Lysaker et al., 2010) and has been identified as a mediating variable involved in the 
complex relationship between neurocognition, social discomfort, and vocational 
functioning (Bell et al., 2009). Metacognition is also inextricably linked with the tenets of 
CBT, and similarly, several of the other aforementioned challenges and deficits are 
effectively treated with CBT based approaches. 
Despite this solid evidence base and the serious problem of vocational 
dysfunction among veterans with mental illness, no CBT interventions have been 
developed specifically to improve competitive employment outcomes.  The sole existing 
CBT program addressing work-related themes is the Indianapolis Vocational Intervention 
Program (IVIP). The IVIP was designed and tested at the Roudebush VAMC in 
protected work programs that placed veterans with schizophrenia into temporary 
sheltered (noncompetitive) work positions within the VA and in businesses contracted by 
the VA (Davis et al., 2005). However, competitive employment differs in several notable 
ways from noncompetitive employment: 1) noncompetitive work settings are not 
integrated (i.e., they are reserved only for those with mental illness); these “protected” 
work environments are not consistent with the goals of community inclusion and 
independence (Wehman, Revell, & Brooke, 2003); 2) noncompetitive jobs are most often 
“low level” jobs and feature less rigorous and complex job demands and responsibilities 
than competitive jobs; 3) competitive jobs often offer unique and interpersonally complex 
work environments (Loveland, Driscoll, & Boyle, 2007); 4) noncompetitive jobs typically 
pay less than minimum wage; 5) noncompetitive jobs are time limited, i.e., temporary; 6) 

noncompetitive positions offer little opportunity for career advancement; 7) Lastly and 
perhaps most importantly, veterans with mental illness overwhelmingly desire 
competitive jobs in the community in which they can reach their vocational and career 
aspirations (e.g., Wehman et al., 2003).  As a result, an intervention specifically tailored 
to achieve this goal is essential.  
This project is critical for veterans with mental illness and is consistent with 
national priorities. Recently, federal lawmakers have heavily emphasized the vital need 
to help veterans succeed vocationally. Accordingly, in November 2011, President 
Obama signed into law the “VOW to Hire Heroes Act”(P.L. 112-56), which includes 
measures to target the growing problem of unemployment among veterans with service-
connected disabilities. The goals of my proposal are also consistent with the “Americans 
with Disabilities Act,” which spearheaded the movement to equalize vocational 
opportunities for all, despite physical or mental challenges (Americans with Disabilities 
Act, 1990).  
This CBT intervention has the potential to complement existing supported 
employment services within the VA. CBT addresses psychosocial barriers to vocational 
functioning, whereas supported employment addresses the long-term logistical aspects 
of finding and keeping a job.  Together, these empirically validated approaches will fulfill 
the mission of improving veteran outcomes by addressing the whole person; this notion 
is also consistent with the VA goal of providing patient-centered care (Seal et al., 2007). 
Both CBT and SE further promote patient centered care by focusing on individual 
preferences, goals, and adopt an educational and collaborative style that is well-
accepted by consumers (e.g., Beck et al., 2009; Drake & Bond, 2011; Kingdon & 
Turkington, 1991). 
Significance to Veterans’ Health 
Employment is not only a means of economic independence, but it is crucial to 
maintaining psychological health (see Blustein, 2008). The link between work and 
mental health benefits has been repeatedly demonstrated in general population studies 
(e.g., Murphy & Athanasou, 1999). In line with these findings, in psychiatric populations, 
work is related to better overall functioning (Mueser et al., 1997; Burns et al., 2009) and 
a host of clinical, social, and quality of life benefits (Bond et al., 2001; Burns et al., 2009; 
Twamley et al., 2008). Studies of veterans actively employed in VA work programs are 
consistent with these findings, demonstrating clear benefits of work activity on overall 
veteran well-being (e.g., Bryson et al., 2002). In contrast, mere participation in supported 
employment has largely not been shown to improve nonvocational outcomes, including 
clinical outcomes, quality of life, socialization, and beliefs about the self (Burns et al., 
2009; Gold et al., 2006; Mueser et al., 2004; Twamley et al., 2008). For instance, 
Mueser and colleagues (2004) found that participation in supported employment did not 
impact self-esteem in persons with mental illness over two years. Work itself, rather than 
supported employment services, seems to be the critical ingredient positively impacting 
nonvocational outcomes. That is, persons with mental illness who participate in 
supported employment services and successfully find and keep work in the community 
for long stretches have the most favorable outcomes. Conversely, persons with mental 
illness who engage in SE services, but still cannot find and keep jobs (i.e., the 
“nonresponders”), have poorer personal outcomes. 
In contrast to employment, unemployment in people with mental illness is 
associated with a higher risk of poverty and a greater reliance on government 
entitlements and the service system. Psychiatric disabilities represent the largest and 

most rapidly growing sub-group of social security beneficiaries (Goodman & Stapleton, 
2005). Lower vocational attainment in psychiatric populations is also linked with a range 
of poor recovery outcomes (e.g., Kukla, Bond, & Xie, 2012). Qualitative research has 
further highlighted the association between the lack of employment and devastating 
personal consequences, such as depression, self pity, self absorption, higher risk of 
substance abuse, and feelings of worthlessness (Marrone & Golowka, 1999).  
The mental health and quality of life benefits of work have been demonstrated 
most strongly for long term employment, as opposed to a working only a short period of 
time.  Steady competitive work (i.e., working 50% or more of the follow-up period) is 
associated with fewer days of psychiatric hospitalization and improving negative 
symptoms over time in persons with severe mental illness (Kukla et al., 2012).  Other 
prospective studies have supported a link between steady periods of competitive work 
and greater rates of symptom improvement, better quality of life, and higher self esteem 
compared to persons who are unemployed or employed only a short period of time (e.g., 
Bond et al., 2001). A recent study by Bush et al. (2009) found that people with mental 
illness who worked in consistent competitive employment over ten years had a 
significantly more rapid decline across time in service utilization and outpatient mental 
health costs compared with persons who had an unstable employment course and 
worked little over time. This is a notable point because veterans with mental illness often 
have problems with job retention—studies have found that the majority of persons with 
mental illness experience a job loss within the first four to eight months, even with the 
assistance of evidence-based supported employment services (Bond et al., 2008; Bond 
& Kukla, 2011). Short periods of job retention are further harmful because they hinder 
career advancement and vocational growth that typically evolve over time (Gioia, 2005).  
Furthermore, difficulties with job retention in mental illness stem from a variety of 
causes, such as interpersonal problems in the workplace (e.g., Becker et al., 1998), 
psychiatric symptom exacerbations (e.g., Biegel et al., 2010), and active substance use. 
Considering this last point, Zivin et al. (2011) found that unemployment in veterans using 
VA healthcare was associated with a greater likelihood of having a substance use 
disorder.  Currently, VA vocational services are not designed to directly address these 
complex causes; cognitive behavioral approaches have been suggested as useful 
interventions to complement supported employment and overcome individual-level and 
disease-related barriers to employment (e.g., Loveland et al., 2007). 
 
Preliminary Studies 
This current project follows four preliminary studies. In the first preliminary study, 
veterans with a range of mental illnesses provided their perspectives on factors 
impacting work success in the community. Findings illustrate a complex set of 
contributors, including personal motivation, self efficacy, sense of self, interpersonal 
issues, and an array of other health related factors (Kukla, Bonfils, & Salyers, 2015). 
This study also demonstrated that veteran-specific facets, such as combat history, 
notably interplay with factors related to work outcomes (Kukla, Rattray, & Salyers, 2015). 
In the second preliminary study, a nationwide sample of 114 VA SE staff, 
supervisors, and managers rated important factors related to veteran work outcomes 
and answered qualitative questions regarding additional important factors; they also 
provided their views on the usefulness of a CBT intervention as an adjunct to existing 
vocational services. Results emphasize the importance of veteran motivation, 
psychological stress, and self confidence in work ability (Kukla, McGuire, & Salyers, 
2015). Further, SE personnel perceived CBT to be a potentially key intervention to 

address these barriers in veterans with mental illness.  
Third, a recent study involving a secondary analysis of data examined two 
important research questions pertaining to CBT outcomes in working veterans with 
mental illness: (1) What are the predictors of CBT treatment engagement? (2) What are 
the predictors of CBT treatment success and failure? Findings indicate a nuanced, 
differential profile of key predictors where neurocognitive factors (i.e., poor attention) 
played a key role in treatment engagement while psychological factors, such as self 
esteem played a greater role in successful vocational outcomes (Kukla, Davis, & 
Lysaker, 2014).  
In the fourth preliminary study, the Indianapolis Vocational Intervention program, 
a CBT program for persons with severe mental illness seeking noncompetitive, time-
limited work placements (Davis et al., 2005), was adapted for veterans with a range of 
mental illnesses who are pursuing/engaged in competitive work in the community. Using 
an empirically grounded, iterative approach, the revisions and adaptations were guided 
by existing literature, the findings from the aforementioned preliminary studies, and 
formative data collected from veteran participants during the study. The resultant new 
intervention that is the focus of this current study, termed the CBT for work success 
(CBTw ) program, demonstrated promising preliminary benefits; in a small group of 
veterans with mental illness, CBTw was associated improved employment outcomes and 
was highly acceptable to participants and vocational staff. CBTw was also feasible to 
implement (Kukla, Strasburger, & Lysaker, 2016; Kukla, Strasburger, Salyers, Rattray, & 
Lysaker, 2017).  
 
Rationale  
Rationale: Cognitive behavioral therapy (CBT) effectively reduces symptoms across a 
range of psychiatric conditions (Butler et al., 2006; Wykes et al., 2008); however, its 
benefit to functioning remains less well understood. Some studies have evidenced a 
positive influence of CBT on functional outcomes, whereas others have not. One 
possible explanation for these inconsistencies across studies is that CBT interventions 
are most often focused on symptoms rather than community functioning. The few CBT 
interventions that have been specifically designed to address functioning have shown 
promising results. One functional area of critical importance is work—a central goal of 
most veterans with (and without) mental illness. However, work functioning has received 
little empirical attention in the CBT domain. Despite research evidence suggesting that 
maladaptive thoughts about oneself and expectations about the ability to work interfere 
with work success (e.g., Hoffman et al., 2000; Kukla, Bonfils & Salyers, 2015; Kukla, 
McGuire, & Salyers, 2015), no CBT programs have been developed specifically 
targeting vocational themes with the goal of improving competitive work outcomes. 
Further, a recent paper outlined needed avenues of future study in the SE domain; 
Drake and Bond (2011) state that cognitive strategies may be a fruitful area to develop 
to help “nonresponder” consumers with mental illness who struggle with vocational 
dysfunction despite high quality vocational assistance. The goal of the current project is 
to address this gap and the serious problem of unemployment in veterans with mental 
illness by pilot testing the CBT for work success program (CBTw) and assessing key 
employment outcomes before and after the intervention.  
 
 

Overall Design: 
Adult participants will take part in the 12 week CBTw program. All participants will 
receive standard SE services during the study. The longitudinal design will consist of 
assessments of competitive employment outcomes, important psychosocial outcomes, 
and background and demographic variables at baseline and at two follow-up periods—
immediately following the conclusion of the CBTw  program (12 week follow up point) and 
at a 6 month follow up. The 6 month follow up period is exploratory.  
 
Setting and Participants:  
Inclusion criteria is a diagnosis of any mental disorder as confirmed through 
medical record review; common diagnoses include schizophrenia, bipolar disorder, 
PTSD, personality disorders, anxiety disorders, and depressive disorders. Second, 
participants must be enrolled in VA supported employment services. Third, participants 
must also have an active goal of working in the community; participants can be currently 
working in the community or unemployed and searching for work.  Both veterans 
seeking employment and those currently employed will be eligible for the pilot study in 
order to enhance the external validity of our findings. That is, people with mental illness 
commonly move in and out of job search and job maintenance phases over time and our 
findings will apply to the average veteran receiving SE services.  In addition, including 
veterans in steady employment as well as those who are searching for a job (and may 
be experiencing more vocational instability) will reduce selection bias. In other words, we 
are not limiting our sample to only those veterans who are highest functioning with the 
greatest work ability.  
Exclusion criteria is a major cognitive deficit or severe medical condition that 
would prevent participation in the intervention and/or community work.   
 
Intervention:  
The CBTw program includes 12 sessions that are delivered in a weekly one-hour 
group format. Sessions focused on identifying and modifying maladaptive thoughts 
related to work, enhancing self efficacy and beliefs in one’s ability to succeed at work, 
identifying and addressing personal barriers to work, and increasing beneficial coping 
strategies that can be applied across employment settings, including during the job 
search phase and working on the job. The intervention is tailored toward both employed 
and unemployed persons seeking community work. Session content includes the 
following modules: Introduction—Work goals and work story; CBT model and work; 
Thinking about work; Barriers to work; Coping with stress and anxiety; Coping with anger 
and difficult emotions; Communication at work; Dealing effectively with people at work; 
Managing work success; Personal work success plan.   
 
Procedures: 
Participants will be recruited from the SE program at the Roudebush VA Medical 
Center. Eligible participants will be approached by their SE vocational specialist who will 
inform them of the study; if veterans express interest in participating, they will be 
provided with a study information sheet further explaining details of the study and a 
member of the study team will call them to schedule a time for the baseline assessment; 
during this time, written informed consent will be obtained.  
Baseline and follow-up assessments (post-intervention and 6 month follow-up) 
will be conducted by trained study personnel. Currently, several research assistants in 
our VAMC research service have been trained in interviewing veterans with mental 

illness including completing standardized symptom and psychosocial rating scales.  The 
assessments will take approximately 60-90 minutes and participants will be paid $30 for 
each of the three assessments. Next, participants will be assigned to an CBTw group. 
Once a cohort of eight veterans has been enrolled, we will begin a new CBTw group.  
CBTw groups will occur weekly for 12 weeks and last for a duration of 60 minutes 
per session, taking place in one of two RVAMC locations. Participants will be provided 
with the CBTw participant manual containing materials pertaining to each of the 12 
modules. Each CBTw group session will be conducted by two facilitators, Dr. Kukla (PI), 
a licensed clinical psychologist with extensive clinical and research expertise in CBT or 
the project manager, who has years of experience facilitating CBT interventions for 
veterans with mental illness (including the preliminary study of the adaptation of the 
CBTw program) along with a pre-doctoral clinical psychology practicum students. Student 
facilitators will first be trained in the CBTw program by Dr. Kukla. Lastly, periodic fidelity 
assessments will be conducted by a senior investigator and trained research staff to 
assess adherence to the general CBT model.   
 
Study Measures: 
 
Unless otherwise specified, study measures will be collected baseline and the 
12-week follow up point (post intervention). Some measures will be assessed at the 6 
month follow up; these are exploratory.  
 
Background Characteristics. Collected at baseline only, participant background 
characteristics will include sex, age, ethnicity, mental health diagnosis, educational 
attainment, marital status, residential status, current work status 
(employed/unemployed), work history (i.e., weeks worked during the six months 
preceding the study), residential status, and legal history (i.e., number of felony 
convictions). We will collect this data through a combination of SE records, patient 
medical records (i.e., CPRS), and participant self-report.  
 
Competitive Employment Outcomes. Competitive employment outcomes will be 
assessed at baseline and the follow up periods through participant self-report and 
supported employment records when available. These outcomes are standard in studies 
of employment in persons with mental illness and will include change in competitive 
employment defined as change in number of weeks worked in competitive jobs, 
comparing the baseline period (i.e. 6 months preceding baseline) and the 6 month follow 
up point. In addition, achievement of steady competitive employment will be assessed at 
the 6 month follow up point, defined as working at least 50% of the follow up period in a 
competitive job. 
 
Work-related self-efficacy.  Work related self-efficacy is defined as one’s 
perceived ability and confidence to perform work activities.  Given that the adapted CBT 
program will seek to improve these perceptions, we will measure this construct using the 
Work-Related Self-efficacy Scale (Waghorn et al., 2005). The 37-item self-report scale 
yields a total score on a 100-point scale, in which higher scores indicate stronger work 
related self-efficacy. Studies suggest that the scale has adequate to good reliability and 
validity in adults with mental illness living in the community (Harris et al., 2010).  
 
Motivation to work: Motivation to work will be measured by the 18-item Work 
Extrinsic and Intrinsic Motivation Scale (WEIMS) based on self determination theory. 
The WEIMS is scored on a 1 to 7 Likert scale (‘Does not correspond at all’ to 
‘Corresponds exactly’) with higher scores indicating higher levels of each domain of 

motivation.  The WEIMS has been shown to have strong predictive validity, correlating 
highly with work behaviors (e.g., Tremblay et al., 2009). 
 
Work effectiveness & Work Productivity.  The Work and Health Interview 
(Stewart et al., 2003) will assess work effectiveness and work productivity for 
participants who are currently working (unemployed participants will not complete these 
measures). Work effectiveness will be measured by one self-report item—“ On days that 
you worked during the past 4 weeks, how effective were you in your job on 
average?  Please tell me, on a scale of 0 to 100, where 0% means that you were not at 
all effective, and 100% means that you were completely effective, how effective would 
you say you have been on your job during the past 4 weeks?” Work productivity will be 
measured by 7 self-report items scored on a Likert scale ranging from 0, “none of the 
time” to 4, “all the time” (item example: “Work more slowly than usual?”). Participants will 
report on work productivity over the last two weeks. The Work and Health Interview has 
been used widely in patients with chronic conditions, demonstrating good psychometric 
properties.  
 
Self-esteem: The Rosenberg self esteem scale, a 10-item Likert scale (1-strongly 
agree; 2-agree; 3-disagree; 4-strongly disagree) will examine self esteem (Rosenberg, 
1965); higher scores on the RSES indicate higher levels of a unidimensional self-esteem 
construct. The RSES has been used extensively in samples of persons with and without 
mental illness and across various ethnic and cultural groups, demonstrating good 
reliability and validity (e.g. Link et al., 2014). 
 
Quality of Life. Prior studies in the mental health domain have demonstrated that 
quality of life improves in response to CBT treatment, therefore, as discussed above with 
regard to symptoms, quality of life may be enhanced in response to CBT treatment, 
regardless of the impact on work outcomes. The Quality of Life Interview (QOLI; 
Lehman, 1988), developed specifically for a psychiatric population, will measure veteran 
quality of life. We will focus on the health domain of the QOLI.  The QOLI has been 
shown to have very good reliability and validity in adult outpatients (Lehman, 1988; 
Lehman et al., 1993).  
 
Subjective Recovery: Global perceived recovery will be assessed by the 
Recovery Assessment Scale (Corrigan et al., 1999), a 41 item scale designed to assess 
perceptions of recovery held by persons with mental illness. Because perceptions of 
recovery may be amenable to CBT and have been associated with key functional 
outcomes, including employment, it is appropriate to examine in this study. The self-
report RAS is scored on a 1 to 5 Likert scale from ‘strongly disagree’ to ‘strongly agree’ 
(e.g., “I have a desire to succeed.”). Higher scores indicate stronger held perceptions of 
personal recovery. The RAS has shown good test retest reliability, internal consistency, 
and criterion-related validity (Corrigan et al., 1999). 
 
Psychiatric Symptoms. Symptoms are essential to assess in this study, as they 
are often the primary beneficiary of CBT intervention, demonstrating moderate to large 
effect sizes in randomized trials across numerous psychiatric conditions. Thus, it is 
possible that symptoms may improve in response to CBT treatment, regardless of 
change in employment status.  
Psychiatric symptoms often present in schizophrenia-spectrum disorders will be 
assessed by the Positive and Negative Syndrome Scale (PANSS), which has been used 
extensively in studies of psychiatric rehabilitation and CBT. The PANSS (Kay et al., 
1987) is comprised of 30 items scored on a 1 to 7 Likert scale, in which the total score is 

obtained by adding up scores on all 30 items (total scores range from 30 to 240). The 
PANSS has five subscales identified via factor analytic studies including the Positive 
syndrome (6 items), Negative syndrome (8 items), Emotional discomfort (4 items), 
Hostility (4 items), and Cognitive (7 items). The PANSS has adequate reliability and 
validity (Kay et al., 1987).  
In addition, we will assess depression and anxiety, two commonly occurring 
psychiatric conditions in veterans (Seal et al., 2007); depression and anxiety are linked 
with vocational dysfunction and have been demonstrated to respond well to CBT (e.g., 
Butler et al., 2006). Current levels of depression will be assessed using the Beck 
Depression Inventory, Second Edition (Beck, Steer, & Brown, 1996). The BDI-II contains 
21 items that assess the various mood and bodily symptoms of depression; participants 
are asked to respond based on symptoms during the past two weeks. There are four 
response options for each item reflecting increasing severity of depression; the total 
score is obtained by summing up the scores on each item (0-3). The BDI-II is the gold 
standard tool to assess depression in both non-clinical and psychiatric populations and 
has been shown to have excellent reliability and validity across several prior studies 
(e.g., Yin & Fan, 2000).  
Thirdly, symptoms of anxiety will be assessed using the Beck Anxiety Inventory 
(Beck & Steer, 1993). The BAI has 21 items, each describing a psychological or 
physiological symptom of anxiety (e.g., “Nervous”) that respondents rate on a 0 to 3 
Likert Scale (“not at all” to “severely”) based on how much they have been bothered by 
the symptom within the past week. The BAI has been widely used to assess anxiety in 
adults with mental illness and has been demonstrated to have strong psychometric 
properties (e.g., Fydrich, Dowdall, & Chambless, 1992).   
 
Privacy/Confidentiality Issues: 
The possible risks to participants associated with participation of this study are a 
remote risk of loss of confidentiality and psychological risks. We will keep all research 
records private to the extent of the law. Original copies of assessment materials and 
digitally recorded CBTw sessions will be kept in a locked file cabinet and on a secure 
server. The data will be maintained in a secured computer database in a password-
protected computer, located in a limited access, locked room. Access to all data will be 
restricted to members of the evaluation team.  Data will be kept for seven years 
according to state and federal regulations and destroyed at the end of that period. The 
other possible risk may be psychological risks associated with participation in the CBTw 
group. We will try to minimize this potential psychological risk by informing subjects the 
CBT program and assessments are strictly voluntary and that they may drop out or quit 
at any time without any consequences. Participants may also skip or refuse to answer 
any questions that they would like. 
    Given the low anticipated risk of adverse events, special safety-monitoring 
procedures above and beyond those of the VA will be minimal. Participants will have 
access to the principal investigator’s e-mail address and phone number and will be 
invited to inform the principal investigator of any concerns. All adverse events will be 
reported to the principal investigator who will be responsible for reporting them to 
IUPUI’s IRB. Given that the pilot study proposed does not involve the use of 
experimental drugs or devices, reporting will be limited to the IRB and will not include the 
NIH OBA or the FDA. All procedures for safety monitoring required by the IRB will be 
observed. 
 
 
 
 

Statistical Analysis Plan 
 
Data will be analyzed using the Statistical Package for the Social Sciences 
(SPSS), version 24. First, frequency distributions and histograms will be generated to 
determine the normality of the sampling distribution and inspect for outliers. If the 
distribution is skewed, data transformations and the use of nonparametric tests in 
primary analyses will be considered. Secondly, descriptive statistics will be generated to 
characterize the demographic and background composition of the sample and levels of 
outcome variables at baseline and post-treatment (12 week follow up). This mean and 
standard deviation information obtained will be used for sample size calculation for a 
future expanded randomized trial.  
Next, the primary study outcome of weeks worked during the baseline period (6 
months preceding baseline) and the 6 months study period will be compared using 
dependent groups (paired samples) t-tests. Significance values for t-tests will be set at 
p<.05. The secondary work outcome, attainment of steady competitive work will be 
characterized using percentage of total participants achieving this benchmark. Because 
secondary outcomes are exploratory, these will be characterized using descriptive 
statistics, such as means and standard deviations. 
 
Missing Data: 
To address the issue of missing follow-up data, participants’ baseline 
characteristics will be compared between those with and without missing data. We will 
also fit a logistic regression model to compare intervention and control participants with 
missing outcome data to determine whether missing data is completely at random. If not 
random, we will perform the analysis with complete cases, using LOCF imputation 
method. Multiple imputation techniques will be used to evaluate the robustness of our 
analysis for the main outcome. 
 
 
 
 
 

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