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The impact of enhanced incentives on vocational rehabilitation outcomes for dually diagnosed veterans (Drebing et al. 2005)

Absence of conflict of interest.

Citation

Drebing, C. E., Van Ormer, E. A., Krebs, C., Rosenheck, R., & Rounsaville, B. (2005). The impact of enhanced incentives on vocational rehabilitation outcomes for dually diagnosed veterans. Journal of Applied Behavioral Analysis, 38(3), 359-372.

Highlights

  • The study examined the impact of enhanced incentives within an existing Veteran’s Administration (VA) Compensated Work Therapy (CWT) program on sustained abstinence from substances, transitioning to competitive employment, retention in competitive employment, and wages.
  • The study was a randomized controlled trial that compared outcomes for the intervention and control groups over 16 weeks. The CWT program’s clinical and financial records were used to assess employment and wage outcomes. Urine screens and participant reports were used to measure substance use outcomes.
  • The study found that total wages for the enhanced incentives group were significantly higher than for the control group. The study also found that the intervention group abstained from substance use for a significantly longer time than the control group.
  • The quality of causal evidence presented in this report is low for the employment and earnings outcomes because the authors did not establish that the intervention and control groups were equivalent one year before the intervention in terms of earnings or employment. This means we are not confident the estimated effects on these outcomes are attributable to the enhanced incentives in the CWT program; other factors are likely to have contributed.

Intervention Examined

Veterans’ Administration’s Compensated Work Therapy Program with Enhanced Incentives

Features of the Study

The study was a randomized controlled trial that examined the effects of an enhanced incentives program incorporated into an existing VA CWT program at the Bedford VA Medical Center. Dually diagnosed veterans younger than age 55 who had had competitive employment in the past 3 years and more than 10 years of education were eligible for the study. A dual diagnosis was defined as those with current drug or alcohol dependence and either a diagnosis of schizophrenia; major depression; or posttraumatic stress, bipolar, or other anxiety disorder. Veterans with a history of significant head trauma were excluded from the study.

The intervention group received financial incentives for completing job search activities and for abstaining from drugs and alcohol. Job search incentives were awarded for creating a resume and attending a job interview. Participants received additional incentives for consecutive weeks of competitive employment, with increasing payments for each additional consecutive week of competitive work. Participants also received monetary incentives for passing drug and alcohol screens throughout the study period. Incentives increased for each consecutive week the screen showed no drug or alcohol use. To be eligible to earn any of these incentives, individuals in the intervention group were required to maintain enrollment in CWT. This means individuals were indirectly incentivized to participate in CWT activities and meetings. In total, participants could earn up to $1,006 for completing all of the activities during the 16-week period. The control group participated in the CWT program without enhanced incentives.

The study included 19 eligible participants. The OnTrak TestCup 5 and the OnSite Alcohol Assay (Roche Diagnostics Inc.) urine screens as well as participant reports were used for the drug and alcohol screen. The CWT program’s clinical and financial records were used to assess employment and wages. Pay stubs, or other similar work documentation, were used to determine competitive work and related durations and hours. The authors used a statistical model to compare the outcomes of intervention and control group members.

The study also examined job search intensity, measured by the Job Search Behaviors Scale. This outcome is not a focus of the review.

Findings

Employment

  • The study found no statistically significant relationship between the intervention and weeks or hours of competitive employment.

Earnings

  • Receiving enhanced incentives during the course of the CWT program was associated with significantly higher wages over the course of the 16-week period ($4,701 for the intervention group versus $2,796 for the control group).

Health

  • The study found that the intervention group abstained from substance use for a significantly longer time than the control group.

Considerations for Interpreting the Findings

As noted by the authors, the sample size of the study was very small.

The employment and wage outcomes received a low rating because the randomized controlled trial had high attrition and the authors did not show that the intervention and control groups were equivalent one year before the intervention for these two measures. If individuals typically enter training programs after a period of especially poor employment outcomes, even in the absence of a training program, outcomes would probably improve over time. Without knowing study participants’ employment status or wages one year or more before the intervention, we cannot rule this out.

Causal Evidence Rating

The quality of causal evidence presented in this report is low for the employment and earnings outcomes because the authors did not establish that the intervention and control groups were equivalent one year before the intervention in of terms of earnings or employment. This means we are not confident the estimated effects on these outcomes are attributable to the enhanced incentives in the CWT program; other factors are likely to have contributed.

Reviewed by CLEAR

January 2019

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