Vocational identity of veterans with co-occurring mental health and substance use disorders

Abstract

BACKGROUND:

No studies have examined vocational identity among individuals with co-occurring mental health and substance use disorders.

OBJECTIVE:

Influenced by Blustein’s relational theory of working (2011), this study examined the relationships between several social-environmental variables (external/relational conflicts, employment barriers, substance abuse stigma) and vocational identity.

METHODS:

Eighty-four veterans receiving treatment from the Veterans Health Administration (VHA) for co-occurring mental health and substance use disorders participated in this survey study.

RESULTS:

Education, employment, clinical, disability, and substance abuse factors were not associated with vocational identity, but external/relational conflicts, employment barriers, and substance abuse stigma were. Multiple regression analysis found that these variables accounted for 34%of the variance in vocational identity and that external/relational conflicts was the only significant predictor.

CONCLUSIONS:

Findings suggest that more conflictual messages about work from external/relational sources is related to less clarity around one’s vocational interests, goals, and talents.

Keywords

Veterans disability vocational identity mental health substance use

1 Introduction

The presence of a co-occurring mental health and substance use disorder poses significant challenges to an individual’s ability to maintain employment (Strickler et al., 2009). Among veterans, the presence of a co-occurring mental health and substance use disorder puts individuals at risk for unemployment and underemployment (Greenberg & Rosenheck, 2007; O’Connor et al., 2013). Moreover, Veteran Affairs (VA) employment specialists and administrators perceive “substance use” as the number one barrier to veterans’ work success (out of 21 psychosocial barriers), followed by “psychological stress” and “mental health” (Kukla et al., 2016). Indeed, veterans with co-occurring disorders are at high risk of vocational problems, which requires more empirical investigation to understand this population’s unique career development needs.

A growing body of literature demonstrates that employment services improve the vocational outcomes of veterans living with co-occurring mental health and substance use disorders (Bell et al., 2002; Davis et al., 2018; Drebing et al., 2005). However, a sizeable portion of veterans utilizing vocational services remain unemployed (Abraham et al., 2017) and virtually no research exists on career development among this group. Recently, scholars have advocated for the integration of career development theory to models of vocational rehabilitation to enhance employment outcomes among individuals in rehabilitation settings (Millner et al., 2015). However, a notable critique of career development theory is that they have primarily focused on individuals with privilege, resources, and a relative high amount to agency within their work-lives (Blustein, 2006), making the applicability of these theories to clinical populations, such as individuals with co-occurring mental health and substance related disabilities, questionable. In response to this critique of career development theory, Blustein (2011) proposed that a relational theory of working that is applicable to all people, regardless of resources, privilege, and agency.

From a relational theory of working lens, vocational developmental, vocational decision-making, and vocational behaviors are understood as inextricably bound to social-environmental factors. From this perspective, Blustein (2011) highlights areas for more research: (1) enhancing our understanding of the interplay between relationships and other social-environmental factors and vocation, (2) the role of relationships in providing instrumental support, (3) care work (unpaid caretaking of family members) and market work (paid competitive work), (4) family supports for adaptive vocational transitions, (5) enhancing relational support to facilitate adaptive working experiences, and (6) individual differences in relational functioning and vocational behavior.

Guided by the relational framework of working discussed above, this study seeks to explore the interplay between social-environmental factors and vocational identity development in veterans with co-occurring mental health and substance use disorders above and beyond educational and employment background as well as clinical, disability, and substance use factors. In doing so, this study will explore the fit of a relational lens to career development among individuals with significant psychiatric rehabilitation needs.

1.1 Vocational identity

Vocational identity, defined as having a stable and clear picture of one’s vocational goals, interests, and talents (Holland et al., 1980), is viewed as a critical component of career development and is often thought of as being reflective of one’s level of career decidedness or career indecision (Hirschi & Valero, 2016; Osipow, 1999). Developing a vocational identity has long been thought of as a paramount developmental task, and research demonstrates that people view one’s vocation as a vital aspect of their overall identity (Kroger & Haslett, 1991). Research also finds that vocational identity is positively related to many important variables such as self-esteem (Munson, 1992), self-efficacy (Gushue et al., 2006), work motivation (Hirschi & Valero, 2016), life satisfaction (Hirschi, 2011; Hirschi & Herrmann, 2012), and community integration (Crisp, 1996; Strauser et al., 2012). Thus, vocational identity appears to have an important role in career development and recovery outcomes, yet, individuals with psychiatric disorders may have difficulty in developing a vocational identity, or even perceiving oneself in a worker role (Ochs & Roessler, 2001; Russinova et al., 2018; Strauser et al., 2006; Yanchak et al., 2005). Thus, more research is needed to understand the factors that contribute or detract from vocational identity development for this population.

1.2 External/relational conflicts

Optimally, close relationships serve as a critical source of support for career development (Keller & Whiston, 2008; Schultheiss et al., 2001). Conversely, research finds that relational conflict is related to a variety of negative vocational outcomes (Penick & Jepsen, 1992; Whiston & Keller, 2004) such as job satisfaction (Ford et al., 2007), career search self-efficacy (Ryan et al., 1996), unemployment (Paul & Moser, 2009), and vocational identity (Lindstrom et al., 2007; Penick & Jepsen, 1992). Multiple studies have demonstrated that individuals with psychiatric disabilities experience significantly greater levels of external conflict related to vocation (i.e., opposing perspectives between an individual’s vocational preferences and a significant other) compared to individuals without disabilities (Dipeolu et al., 2013; Lustig & Strauser, 2003). This is in line with previous research that has found veterans with co-occurring mental health and substance use disorders receive lower quality vocational services due to expressed “paternalistic-unhelpful” beliefs about a client’s ability or preferences for employment (Pogoda et al., 2011). More research is needed to understand how relational conflict impacts vocational development in individuals with psychiatric disorders.

1.3 Employment barriers

Veterans with psychiatric disorders report numerous barriers to competitive employment (Kukla et al., 2015, 2016), and there is evidence that both internal and external employment barriers (e.g., health or cognitive problems, transportation, or availability of jobs in one’s community) impact vocational behavior and occupational outcomes among individuals with psychiatric disorders (Johannesen et al., 2009; Sevak & Khan, 2017). Other research conducted among university and high school students has demonstrated that environmental employment barriers negatively impact vocational identity (Constantine et al., 1998; Gushue et al., 2006). Whether or not employment barriers impact vocational identity among veterans with co-occurring mental health and substance use disorders, is unclear and warrants further investigation.

1.4 Substance use stigma

Stigma is a social construct thought to consist of the labeling, stereotyping, separation, status loss, and discrimination others direct toward an individual or group (Link & Phelan, 2001). It is widely known that social stigma has adverse effects on individuals living with mental health problems including vocational functioning (Corrigan et al., 2012; Yanos et al., 2010). We also know that individuals with substance use disorders experience social stigma related to their addiction (Luoma et al., 2013). The consequences of stigma related to substance use are far reaching and include not accessing treatment (McFarling et al., 2011), delayed recovery (Brewer, 2006), and social isolation (Room, 2005). However, no research has investigated the impact of social stigma related to substance use on vocational outcomes.

1.5 Purpose of current study

Guided by a relational lens of working (Blustein, 2011), this study seeks to examine how relevant social-environmental factors (e.g., employment barriers, external/relational conflicts, and social stigma of substance use) relate to vocational identity among veterans with co-occurring mental health and substance use disorders after controlling for relevant mental health and substance use variables. Information gathered from this study could help identify the social-environmental factors most relevant to the development of a vocational identity - thus, supporting vocational outcomes among individuals living with psychiatric disorders. Based on the literature, we hypothesized that 1) employment barriers would negatively relate to vocational identity, 2) external/relational conflicts would negatively relate to vocational identity, and 3) substance abuse stigma would negatively relate to vocational identity. We also explored whether employment barriers, external/relational conflicts, and substance abuse stigma predict vocational identity above and beyond other vocational (education and employment history), clinical, disability, and substance abuse related factors.

2 Method

2.1 Participants and procedures

Veterans were recruited from a VA hospital in Northeastern United States. Researchers coordinated with mental health providers to advertise this study to veterans during different clinical and orientation groups at the VA hospital that typically serve individuals with co-occurring mental health and substance use disorders. To be eligible for this study, veterans needed to have had at least one clinical encounter signed by a licensed mental health provider for both a mental health disorder as well as a substance use disorder in their VA medical records within the year proceeding study participation. The researchers had access to the veterans’ medical records to compete this review. Veterans’ abstinence from substances was not a rule out for participation. Veterans electing to participate in this study completed an informed consent process followed by a packet of questionnaires and measures. To control for order effects, a random number generator was used to randomize the order in which measures were presented to participants. All veterans who participated in this study were given a $25 gift card to a convenience store. This project was approved by the VA hospital’s Institutional Review Board. A total of 84 veterans were recruited for this study. Of these veterans, four chose to discontinue participation without having completed a vast majority of measures (due to length of surveys), and another three veterans did not meet the needed clinical encounters in their medical record to participate. These seven veterans were excluded from the sample. Thus, the final sample consisted of 77 veterans.

A majority of the sample identified their gender as male (84.4%) followed by female (15.6%). The average age was 45.3 years (SD = 11.21). A majority of the sample identified as Caucasian/White (75.3%), followed by African American or Black (15.6%), Hispanic/Latino (7.8%), and Native American/Alaskan (1.3%). Most were currently homeless (88.3%) and unemployed (97.4%), and a majority had not held a competitive job within the three years proceeding their study participation (54.5%). A majority of veterans did not have a college degree (76.6%), some had an associate’s degree (20.8%), and few had a bachelor’s or master’s degree (2.6%). The most common primary mental health diagnoses were Post Traumatic Stress Disorder (PTSD; 71.4%), followed by depressive disorders (10.39%), anxiety disorders other than PTSD (6.49%), bipolar disorders (6.49%), and other disorders (5.19%; i.e., schizoaffective disorder, attention deficit disorder, and adjustment disorder). The most common primary substance abuse diagnoses were alcohol use disorders (57.14%), opioid use disorders (32.47%), cocaine use disorders (7.79%), and other disorders (2.6%, i.e., cannabis and polysubstance use disorders). Most of the sample was receiving VA disability compensation (61%) primarily for psychiatric and medical disabling conditions (27.3%), while others received VA disability compensation for medical conditions (18.2%) or psychiatric conditions (16.9%), only. Some were receiving social security disability insurance (SSDI) (15.6%), and even less were receiving supplemental security income (SSI) for unemployment (9.1%).

2.2 Measures

2.2.1 Career thoughts inventory (CTI)

The CTI (Sampson, Peterson, Lenz, Reardon, & Saunders, 1996) is a 48-item measure used to assess dysfunctional career thinking. The CTI asks respondents to evaluate the degree to which they agree with a statement related to different career beliefs. The CTI contains three subscales that clarify the source of an individual’s dysfunctional career thinking: the Decision-Making Confusion (DMC) subscale, the Commitment Anxiety (CA) subscale, and the External Conflict (EC) subscale. The EC subscale consist of five items that reflect the degree to which an individual agrees with statements indicating conflict between their vocational self-perceptions and the perceptions of significant people in their lives. Given the purpose of this study, only the EC subscale was included in analysis. Sample items include: “Whenever I becomes interested in something, important people in my life disapprove,” and “I’m always getting mixed messages about my career choice from important people in my life.” Responses to items range from 0 (“Strongly disagree”) to 3 (“Strongly agree”). The CTI is widely used in vocational psychology and career development literature and the psychometric validity and reliability of this measure and subscales have been extensively reported (Sampson et al., 1996). In this study, Cronbach’s alpha for the EC subscale was 0.82.

2.2.2 Perceived employment barrier scale (PEBS)

The PEBS (Hong, Polanin, Key, & Choi, 2014) was used to measure the type and degree of barriers a respondent perceives toward finding and securing competitive employment. The PEBS is a 20-item measure that asks respondents to rate the degree to which a possible employment barrier personally impacts his or her ability to secure a job. Responses range from 1 (“Not a barrier”) to 5 (“Strong barrier”). Sample barriers include: “Transportation,” “Lack of stable housing,” “No jobs in the community,” and “Past criminal record.” Higher scores on the PEBS indicate greater perceived barriers to securing competitive employment. Hong, Polanin, Key, and Choi’s (2014) study provides evidence of validity and reliability for the PEBS among individuals receiving welfare. In this study, Cronbach’s alpha for the PEBS was 0.94.

2.2.3 Substance abuse self-stigma scale (SASSS)

The SASSS consists of two standalone measures of stigma: Self-Devaluation (SD) and Fear of Enacted Stigma (FES; Luoma et al., 2013). The SD measures the degree to which a respondent has internalized stereotypes and judgments regarding one’s substance abuse, while the FES measures the degree to which an individual believes others will hold stigmatizing views. Given our focus on social-environmental influences to vocation identity, only the FES scale was utilized in this study. The FES scale consists of nine items asking respondents to “indicate how many people you think would react to you as described.” Sample items include: “A job interviewer wouldn’t hire me if I mentioned my substance history in a job interview” and “People will think I have little talent or skill if they know about my substance history.” Responses range from 1 (“Few people [0–20 percent]”) to 5 (“Almost everyone [80–100 percent]”). In this study, Cronbach’s alpha was 0.94.

2.2.4 Vocational identity scale (VIS)

The VIS is a subscale of the My Vocational Situation Measure (MVS; Holland, Gottfredson, & Power, 1980) and it was used to assess vocational identity. The VIS consists of 18 true or false items that asks respondents to identify whether the statement is mostly “True” or mostly “False.” Sample items include “I am uncertain about the occupations I could perform well” and “I am confused about the whole problem of deciding on a career.” A respondent’s total number of “False” responses makes up their final score (range = 0 to 18), with higher scores indicating more crystallized vocational decidedness and lower scores indicating greater career indecision. The VIS is extensively used in vocational psychology literature and has demonstrated validity and reliability (Osipow, 1999). In this study, Cronbach’s alpha was 0.88.

2.3 Analysis

We first ran Pearson correlational analysis to identify any statistically significant employment, education, clinical, disability, and/or substance abuse factors correlated with our primary outcome variable of interest, vocational identity. We then conducted Pearson correlational analysis among our primary independent variables of interest (external/relational conflicts, perceived employment barriers, and substance abuse stigma) and vocational identity. From this point, all variables found to have a statistically significant correlation to vocational identity were included into a multiple regression analysis to identify variables that were independently associated with vocational identity. Alpha levels were set to 0.05 for all analyses. Data was examined for patterns in missing data, which none were found. Listwise deletion was used to handle missing data in our analyses.

3 Results

None of the education or employment history variables were significantly associated with vocational identity: education level (r = –0.07; p = 0.54), current employment status (r = –0.11; p = 0.34), and competitive employment status within last three years (r = –0.06; p = 0.60). Additionally, none of the disability or substance abuse variables showed significant relationships with vocational identity: receiving VA disability compensation (r = 0.162; p = 0.17); type (psychiatric vs. medical) of VA disability compensation (r = –0.11, p = 0.36); receiving SSI/unemployment income (r = 0.04; p = 0.75); receiving SSDI income (r = –0.09; p = 0.42); age of first using substances (r = 0.02; p = 0.84); time last used substances (r = 0.11; p = 0.34). These findings suggest that typical indicators of clinical severity and vocational functioning are not related to vocational identity. However, our primary independent variables of interest, perceived external/relational conflicts, fear of enacting substance abuse stigma, and perceived employment barriers were all significantly related to vocational identity (see Table 1). These findings suggest that participants with greater perceived external/relational conflicts, greater fear of substance abuse stigma from others, and greater perceived employment barriers are related to lower vocational identity.

Table 1
Descriptive and correlations of primary study variables

Variable 1 2 3 4

1. CTI-EC –

2. PEBS 0.29^ –

3. SASSS-FES 0.56^* 0.16 –

4. VIS –0.56^*** –0.25^* –0.44^** –

M 5.60 73.43 26.87 8.01

SD 3.28 24.78 9.62 4.98

Range 0–14 27–131 9–45 0–18

Variable	1	2	3	4
1. CTI-EC	–
2. PEBS	0.29^**	–
3. SASSS-FES	0.56^***	0.16	–
4. VIS	–0.56^***	–0.25^*	–0.44^**	–
M	5.60	73.43	26.87	8.01
SD	3.28	24.78	9.62	4.98
Range	0–14	27–131	9–45	0–18

^***p≤0.001. ^**p≤0.01. ^*p≤0.05.

Prior to running the multiple regression analysis, variables were examined for issues of skewness and kurtosis. All variables were found to meet the assumptions of normality. Additionally, multicollinearity diagnostics were run and were found to be acceptable (largest variance inflation factor [VIF] among the variables was 1.55, and the lowest tolerance level was 0.64). Residual plots were examined and no discernable pattern was observed. Results of the hierarchical regression analysis are presented in Table 2. A post-hoc power analysis of our regression model demonstrated excellent power (0.99) for detecting effects. Overall, the regression model was significant and explained 34%of the variance in vocational identity (R² = 0.37, Adjusted R² = 0.34, F = 14.01, p < 0.001). A large effect size was found for this model (f² = 0.59). Of the three variables included into the regression analysis, only external conflicts remained a significant predictor of vocational identity, which suggests that greater perceived external/relational conflict independently predicts lower vocational identity.

Table 2

Linear regression analysis predicting vocational identity

Predictor	B	SE B	β	t
CTI-EC	–0.638	0.173	–0.431	–3.694^*
PEBS	–0.029	0.020	–0.146	–1.490
SASSS-FES	–0.089	0.057	–0.175	–1.558

^*p < 0.001.

4 Discussion

Drawing upon the relational theory of work (Blustein, 2011), this study sought to explore the relationships between several social-environmental factors and vocational identity among veterans with co-occurring mental health and substance use disorders. As hypothesized, several strong, negative relationships (r > –0.50) were found between vocational identity and perceived external/relational conflicts, substance abuse stigma, and employment barriers. These findings confirm previous studies that have demonstrated similar relationships between vocational identity and employment barriers (Constantine et al., 1998; Gushue et al., 2006), and external/relational conflicts (Dipeolu et al., 2013; Yanchak, Lease, & Strauser, 2005). No other study has examined the relationships between vocational identity and perceived substance abuse stigma. Thus, the significant negative relationships between vocational identity and perceived substance abuse stigma are notable considering that individuals with substance use histories experience labor market discrimination (Baldwin et al., 2011). Additionally, while the primary social-environmental variables accounted for 34%of the variance in vocational identity, none of the employment, education, clinical, disability, and substance use variables were associated with vocational identity. Taken collectively, these findings provide support for a relational lens of career development among individuals with co-occurring mental health and substance use disorders.

This study extends previous research (e.g., Dipeolu et al., 2013; Yanchak et al., 2005), by demonstrating that perceived external/relational conflict may be predictive of lower vocational identity in veterans with co-occurring mental health and substance use disorders, specifically. While the negative relationship between external conflict and vocational identity was expected, there was no previous assumption that this variable would be the only remaining significant predictor of vocational identity. The vocational identity development literature largely focuses on internal processes of exploration and commitment (Porfeli et al., 2011), rather than the relational context of vocational identity. Our findings support the propositions of Blustein’s (2011) relational theory of working by providing evidence that relational conflict plays an important role in developing vocational identity. Indeed, more research on the relational influence of vocational identity appears warranted.

Clinically, findings from this study seem to underscore the importance of addressing any relational conflict, pressure, or mixed-messages an individual experiences in relation to his or her vocational preferences as this may be related to less vocational clarity. Two studies have found that some vocational counselors hold unhelpful and conflicting beliefs about the employment goals of their clients living with mental health and/or substance use disorders, resulting in lower quality vocational services (Brucker & Duty, 2019; Pogoda et al., 2011). This study highlights how external conflict (such as clinicians questioning client’s employment goals) may contribute to an individual’s unclear view of his or her vocational talents, preferences, and strengths. Whether or not a career counselor should challenge a client’s employment goals that are deemed to be unrealistic or problematic in some way has been identified as the most pervasive ethical dilemma within vocational counseling (Cardoso et al., 2012). While there may be instances when confronting a client’s employment goals is clinically appropriate, this study highlights the possible consequences of such an intervention. Thus, reinforcing the importance of vocational rehabilitation counselors maintaining a supportive stance toward their clients’ employment goals and remaining cautious and intentional when offering any conflictual information or perspectives.

4.1 Limitations

The cross-sectional nature of this study needs to be considered when interpreting the results of this study. Mainly, it is important to note that findings should not be interpreted as causal. Although it makes theoretical sense that employment barriers, external/relational conflicts, and substance use stigma negatively impact vocational identity, it is plausible that these relationships occur in the opposite direction. Future research is needed to confirm directionality and causation of these relationships. Moreover, although many relevant demographic, clinical, disability, and substance use factors were accounted for in this study, it is possible that some underlying variable not included is accounting for the findings. Given the dearth of research explicitly examining the influence of social-environmental factors on vocational outcomes of individuals with psychiatric disabilities (Bond & Drake, 2008), this study offers only an introduction. More research is needed to continue investigating the social-environmental factors influencing vocational outcomes among individuals with co-occurring mental health and substance use disorders.

5 Conclusion

Overall, findings from this study support a relational view for understanding vocational identity development among veterans living with co-occurring mental health and substance use disorders. This study highlights several social-environmental variables related to more crystallized vocational identity, in particular external/relational conflict. It is likely that addressing conflictual messages one receives about their employment preferences and promoting access to positive and supportive relationships will lead to enhanced clarity around one’s vocational goals, interests, and talents.

Conflict of interest

None to report.

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Vocational identity of veterans with co-occurring mental health and substance use disorders

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

1.1 Vocational identity

1.2 External/relational conflicts

1.3 Employment barriers

1.4 Substance use stigma

1.5 Purpose of current study

2 Method

2.1 Participants and procedures

2.2 Measures

2.2.1 Career thoughts inventory (CTI)

2.2.2 Perceived employment barrier scale (PEBS)

2.2.3 Substance abuse self-stigma scale (SASSS)

2.2.4 Vocational identity scale (VIS)

2.3 Analysis

3 Results

Table 1 Descriptive and correlations of primary study variables Variable 1 2 3 4 1. CTI-EC – 2. PEBS 0.29** – 3. SASSS-FES 0.56*** 0.16 – 4. VIS –0.56*** –0.25* –0.44** – M 5.60 73.43 26.87 8.01 SD 3.28 24.78 9.62 4.98 Range 0–14 27–131 9–45 0–18

4.1 Limitations

5 Conclusion

Conflict of interest

References

Table 1
Descriptive and correlations of primary study variables

Variable 1 2 3 4

1. CTI-EC –

2. PEBS 0.29^ –

3. SASSS-FES 0.56^* 0.16 –

4. VIS –0.56^*** –0.25^* –0.44^** –

M 5.60 73.43 26.87 8.01

SD 3.28 24.78 9.62 4.98

Range 0–14 27–131 9–45 0–18