Cognitive Behavioral Therapy to Improve Work and Wellness in Veterans With Mental Illness (WORKWELL)

Work as a Determinant of Health: A Pragmatic Trial of Enhanced Cognitive Behavioral Therapy to Bolster Competitive Work and Wellness in Veterans With Serious Mental Illness (WORKWELL)

Vocational instability in Veterans with serious mental illness (SMI) is pervasive, costly, and harmful. Over 75% of Veterans with SMI are unemployed, resulting in economic difficulties and trouble meeting basic needs. Overall, among adults with depression, work dysfunction results in a 36 to 51 billion dollar loss annually. Unemployed Veterans with SMI also suffer major health consequences, including a more severe course of illness and poor recovery over time, leading to increased inpatient and emergency service use. The WORKWELL study will synergistically address these deficits in health, recovery, and work functioning by testing the Cognitive Behavioral Therapy for Work Success (CBTw) intervention. Using a pragmatic design, this project will address work as a major social determinant of health and close the health disparity gap among people with SMI. Further, through promotion of work and healthy thinking, CBTw holds promise to reduce risk of suicide among vulnerable veterans with SMI.

Study Overview

• Status: Completed
• Conditions: Posttraumatic Stress Disorders
• Intervention / Treatment: Behavioral: Cognitive Behavioral Therapy For Work Success (CBTw); Behavioral: Psychoeducation

Detailed Description

Project background: Work is a major social determinant of health. In people with serious mental illness (SMI), work is associated with better wellbeing, physical and mental health, quality of life, and may prevent the onset of disability. Among Veterans with SMI, work is a protective factor against suicide.

Most veterans with SMI are unemployed and suffer substantially worse health and recovery across key domains. Despite quality VHA vocational services, such as supported employment (SE), two-thirds or more of Veterans who receive these services experience work dysfunction. A probable explanation lies in unsolved cognitive and behavioral barriers, such as low work-related self-efficacy, ineffective coping skills, little hope that work is attainable, poor work motivation and sense of self.

The Cognitive Behavioral Therapy for Work Success (CBTw) intervention was designed to target these problems and augment VHA SE services to synergistically improve work, as well as health and recovery, in Veterans with SMI. In an open trial pilot, CBTw was associated with significant increases in hours worked and wages earned and the majority of CBTw participants became steady workers. Veterans also experienced improvements in symptoms, recovery, and quality of life.

Project goals: Using Hybrid 1 RCT design, this project will test the effects of CBTw on competitive work and health and recovery outcomes over a 12-month study period at 3 VA SE programs. Informed by the RE-AIM framework, an implementation evaluation will examine the success of using SE staff to deliver CBTw, barriers and facilitators to implementation, and strategies utilized.

Relevance to priorities: This project has high implementation potential and is responsive to the VHA priority regarding Health Equity, as it will address work functioning, an under studied social determinant of health. WORKWELL also holds promise to improve health and recovery outcomes among Veterans with SMI, another HSR&D area of emphasis. Lastly, this study is consistent with the goal of finding novel strategies toward suicide prevention among vulnerable Veteran groups, including those with SMI.

Objectives: Aim 1: Test the effects of CBTw + SE compared to a control of psychoeducation + SE on work. Hypotheses: Participants in the CBTw+ SE arm will work significantly more total weeks in competitive jobs (primary study outcome) and will be more likely to become steady workers.

Aim 2: Test the effects of CBTw + SE on health and recovery. Hypotheses: Participants in the CBTw + SE arm will have greater improvements on subjective recovery and health-related quality of life, and decreases in symptoms, suicidal ideation, and inpatient service utilization.

Aim 3: Guided by the RE-AIM implementation science framework, conduct an evaluation of the implementation of CBTw, including examination of the feasibility of using SE staff to deliver CBTw, and related barriers and facilitators. The objective is to spur future wide scale CBTw implementation.

Project Methods: WORKWELL is a pragmatic, Hybrid 1 design RCT. CBTw will be tested at 3 SE sites-Roudebush VA Medical Center, the Edward J. Hines VA Medical Center, and the VA St. Louis Health Care System. 276 unemployed Veterans with SMI will be randomly assigned to receive CBTw plus SE or a control of psychoeducation plus SE. Outcomes including total weeks worked in competitive jobs (primary), achievement of steady work, symptoms, recovery, health related quality of life, suicidal ideation, and service utilization will be assessed at posttreatment (12 weeks), 6 months (primary endpoint), and 9 months (to examine sustained effects). Primary work outcomes will be collected monthly over a 12-month period. CBTw implementation planning, training, and consultation will be provided. CBTw implementation (fidelity), barriers and facilitators to implementation, and other RE-AIM elements will be examined using mixed methods.

• Study Type: Interventional
• Enrollment (Actual): 294
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Illinois
    • Hines, Illinois, United States, 60141-5000
      • Edward Hines Jr. VA Hospital, Hines, IL
  • Indiana
    • Indianapolis, Indiana, United States, 46202-2884
      • Richard L. Roudebush VA Medical Center, Indianapolis, IN
  • Missouri
    • St Louis, Missouri, United States, 63106
      • St. Louis VA Medical Center John Cochran Division, St. Louis, MO

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Unemployment, defined as no current participation in a competitive job
• A competitive work goal, which denotes a goal of a regular job in the community that pays at least minimum wage

• Presence of a serious mental illness including one or more of the following conditions:

  • major depression
  • bipolar disorders
  • schizophrenia
  • schizoaffective disorder
  • posttraumatic stress disorder (PTSD)
• Currently enrolled in and receiving VA vocational rehabilitation services

Exclusion Criteria:

• Previous participation in cognitive behavioral therapy intervention geared toward work
• Presence of a severe medical or cognitive impairment that will prevent participation in the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Cognitive Behavioral Therapy For Work Success (CBTw); Veterans will participate in 12 weekly group sessions to discuss thoughts, feelings, and behaviors that promote work success in the community	Behavioral: Cognitive Behavioral Therapy For Work Success (CBTw); Veterans will go to 12 weekly group sessions and will learn healthy thinking about work, positive behavioral coping related to work, and will form a work success plan based on their work goals.
Active Comparator: Psychoeducation; Veterans in the control group will participate in 12 weekly group sessions in which they will learn more about their mental health conditions.	Behavioral: Psychoeducation; Veterans will go to 12 weekly group sessions and will learn more information about their mental health conditions. Psychoeducation modules are from the Illness Management and Recovery program.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total Weeks Worked in Competitive Jobs	Mean number of weeks worked in competitive jobs. Competitive jobs are regular jobs open to all that pay at least minimum wage. More total weeks worked in competitive jobs is indicative of a positive outcome.	Baseline to 3 months
Total Weeks Worked in Competitive Jobs	Mean number of weeks worked in competitive jobs.	3 to 6 Months
Total Weeks Worked in Competitive Jobs	Mean number of weeks worked in competitive jobs.	6 to 9 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Short Employment Hope Scale (EHS-14)	The Short Employment Hope Scale (EHS-14) measures employment hope, defined as the psychological construct characterized by possession of work-related empowerment and motivation for the future, envisionment of meaningful and satisfying employment, job-based goal orientation, and progress toward employment using skills and resources. The EHS-14 is comprised of two subscales-Psychological Empowerment and Goal-oriented pathways (7 items each). The EHS-14 is made up of a total of 14 items scored on a 0 (minimum) to 10 (maximum) scale with total scores comprised of a mean of all 14 items. Higher scores indicate better (increased) employment hope and lower scores indicate worse (decreased) employment hope.	baseline to 9 months
Recovery Assessment Scale (RAS)	The Recovery Assessment Scale (RAS) measures subjective mental health recovery. The RAS consists of 41 items and an overall score is calculated using a mean of all items, with scores ranging from 1 (maximum) to 5 (minimum). Higher RAS scores indicate better (increased) subjective recovery with lower RAS scores indicating worse (decreased) subjective recovery. This outcome was only examined for patient participants and not for provider participants arm.	baseline to 9 months
Scale for Suicidal Ideation Change	Outcome measure is a 21-item interviewer rated measure of a continuum of suicidal ideation, including thoughts, attitudes, plans, and behaviors. Total scores range from 0 to 42 with higher scores indicating more suicidal ideation.	baseline to 9 months
Cognitive Behavioral Therapy for Work Success (CBTw) Fidelity	Fidelity to the Cognitive Behavioral Therapy for Work Success (CBTw) model was measured using the Cognitive Therapy Scale-Revised. The Cognitive Therapy Scale-Revised is comprised of 8 items gauging core components of the CBTw intervention and overall fidelity is measured as a mean of the 8 items. Total fidelity scores range from 0 (minimum) to 6 (maximum) with higher scores indicating greater adherence and proficiency to the CBTw model. Scores of 3 or higher indicate adequate fidelity in which the CBTw intervention is considered delivered as intended. Fidelity was only measured for provider participants and was not measured for participants in the Cognitive Behavioral Therapy for Work Success and Psychoeducation arms.	12 weeks (during the CBTw intervention period)

Collaborators and Investigators

• Sponsor: VA Office of Research and Development
• Investigators: Principal Investigator: Marina Elizabeth Kukla, PhD MS BS, Richard L. Roudebush VA Medical Center, Indianapolis, IN

Publications and helpful links

General Publications

• Kukla M, McGuire AB, Weber KC, Hatfield J, Henry N, Kulesza E, Rollins AL. An Investigation of Employment Hope as a Key Factor Influencing Perceptions of Subjective Recovery among Adults with Serious Mental Illness Seeking Community Work. Behav Sci (Basel). 2024 Mar 19;14(3):246. doi: 10.3390/bs14030246.
• Kukla ME, Rollins AL, Weber K, Hatfield J, Wu W, Faith L. A., Carter J. L., Wiesepape C, Connors MJ, Wahle SS, Pashka NJ, McGuire AB. A Pragmatic Randomized Controlled Trial Investigating Work Enhanced Cognitive Behavioral Therapy for People with Serious Mental Illness (WORKWELL): Background, Design, and Baseline Outcomes. Journal of Vocational Rehabilitation. 2025 Nov 1; 63(3):299-311, DOI: 10.1177/10522263251376530

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2021
• Primary Completion (Actual): September 30, 2024
• Study Completion (Actual): September 30, 2024

Study Registration Dates

• First Submitted: August 4, 2020
• First Submitted That Met QC Criteria: August 6, 2020
• First Posted (Actual): August 7, 2020

Study Record Updates

• Last Update Posted (Actual): April 1, 2026
• Last Update Submitted That Met QC Criteria: March 11, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Rehabilitation, Vocational
• Additional Relevant MeSH Terms: Trauma and Stressor Related Disorders; Mental Disorders; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic; Behavior Therapy; Psychotherapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy
• Other Study ID Numbers: IIR 19-176

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Upon request, the Research Service will consider requests for the final data sets underlying the publications to be provided to the public. The limited dataset will include de-identified data relevant to the specific request. Independent research groups can view relevant data to evaluate the extent that data sources support conclusions made by authors in published studies as well as observe additional emergent themes and view supplemental details that might not be included in publications.
• IPD Sharing Time Frame: The data will become available once the study team completes all analyses.
• IPD Sharing Access Criteria: The Research Service will evaluate individual requests.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; ICF

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No