Abstract
Introduction
Within the United States there are approximately 5.5 million Veterans who served during the Gulf War era (from August 1990 until present) [1]. These Veterans are younger, more likely to be of working age (18–55), and looking to secure civilian employment. Ensuring that Veteran employment needs are met is a top priority for the Department of Veteran Affairs (VA) and the United States government. Several policies and programs have been developed at Federal, state, and local levels to help Veterans obtain employment including the American Jobs Act, the Veterans Opportunity to Work to Hire Heroes Act, and the Veterans Job Corps, among others [2–4].
These programs offer a wide range of services from providing web portals that connect Veterans with employment opportunities in their community to providing more personalized services such as matching military skills with civilian occupations, career counseling, resume writing, job retraining and education [2]. However, despite robust programming, several studies have identified difficulties Veterans may encounter when employed especially those Veterans with mental health disorders. For example, Sayer et al. [5] surveyed Iraq-Afghanistan combat Veterans and found that nearly 35% had difficulty completing tasks, potentially affecting their work productivity, and nearly 25% experienced job loss. Additionally, Veterans with post-traumatic stress disorder (PTSD) tended to miss more work days, were unhappy with their employment, and had difficulty getting along with their co-workers when compared to non-Veterans [6, 7].
While many employment related programs for Veterans (with and without mental health disorders) offer numerous services aimed at helping them gain employment, it remains unclear how many offer services related to maintaining employment. In fact, a study by Burnett-Zeigler et al. [8] found that Veterans with mental health disorders may have more difficulty maintaining their employment rather than obtaining employment. Studies have also noted the need for research and information on reintegration experiences and on-going needs, including those related to employment of Veterans [4, 9].
Considering that studies [4, 10–13] have found that unemployment can impede successful reintegration, it is crucial to not only offer employment support to Veterans, but to identify gaps in services to maintain employment. Therefore, the aim of this study was to understand factors that may affect the ability of Veterans with mental health disorders to maintain long-term employment.
Methods
Study design, sampling and recruitment
We conducted an exploratory qualitative study to better understand the general employment experiences of Veterans with mental health disorders, and their ability to maintain long-term employment specifically. We chose a purposive sampling approach which enables a “detailed exploration and understanding of the central themes” (p. 78) of interest [14]. Thus, Veterans from one VA primary care clinic were mailed a survey exploring employment related issues and mental health status [15]. Inclusion criteria for the survey consisted of patients who had a recent primary care visit with planned follow-up and were between the ages of 18 and 55 (ages most associated with employment). Based on 287 survey responses, 32 respondents who screened positive for depression and/or anxiety and indicated that they were experiencing unemployment, under-employment (workers who are overqualified for the job they perform or workers who are working part-time but prefer to work full-time), or considered themselves to be insecurely employed were eligible for the interview portion of the study. All 32 survey respondents were contacted by phone by the study’s project manager, explained the purpose of the study, and offered a phone or in-person interview. If they agreed to participate, they were mailed a letter describing the study and the informed consent form. Informed consent was obtained prior to the interview. Of the 32 eligible, 10 survey respondents agreed to participate in semi-structured interviews (October 2014-February 2015). Each participant received a $25 gift card as a token of appreciation. The local VA medical center Institutional Review Board approved all aspects of this study.
Data collection and analysis
Semi-structured interviews focused on employment, mental health, and reintegration (Appendix A). The questions were developed to be open-ended and explore if and how Veterans were able to maintain employment. Each interview lasted, on average, 48 minutes (30–89 minutes), was audio-recorded and transcribed. Transcripts were analyzed using an iterative [16], inductive thematic analysis approach [17]. Prior to coding, all transcripts were read by the first author (MH) and principal investigator (KZ) to better understand the data set as a whole. Then, each transcript was re-read resulting in codes being created, defined, and applied. As coding progressed and additional codes emerged, previously coded transcripts were revisited to ensure new codes were applied to all transcripts. All codes, definitions, and criteria were documented in a codebook. Once initial coding was complete, pattern coding, in which codes are reanalyzed and grouped into categories based on similarities and relationships, was performed to develop themes [18]. NVivo 10® software was used to manage the data and check for consistent application of codes. This process led to the development of themes discussed below.
Results
In order to contextualize participants’ employment experiences, they were asked about their military history including employment experiences while in the military and since discharge (see Table 1). All of the participants were Gulf War era Veterans. Although post-traumatic stress disorder (PTSD) was not a criterion for participation in an interview nor did we ask specifically about this diagnosis, 5 out of the 10 participants stated they had been diagnosed with PTSD in conjunction with depression and/or anxiety either while they were still active duty or post-discharge.
Veteran demographics
Veteran demographics
What follows are three salient themes regarding the difficulties participants faced in maintaining employment. These themes reflect their experiences of how their mental health symptoms, especially those resulting from PTSD, manifested within the work environment, their feelings of demotion from what they did in the military to their civilian employment, and their feelings of being unable relate to civilian co-workers, all of which affected their abilities to maintain employment. We also include strategies that have helped some of the participants make the transition into the civilian workforce (see Table 2).
Themes with definitions
How PTSD affected some of the participants’ ability to maintain employment came up organically in the interviews. They told vivid stories of how their PTSD symptoms, especially flashbacks which are common PTSD symptoms [19], manifested while they were at work. These unexpected events often left participants struggling with how to react in a civilian context when reminded of their wartime experience. For example:
“I took a month off after deployment and then I went back [to substitute teaching] and I was at [named] High School and as it turns out, their bell for passing between hours was a lot like the incoming fire alarm in Iraq and every time I heard that I would freeze up and at one point I had to say, ‘You know I can’t do this, can I go home?’ and they knew that I had just come home and they were like, ‘Yeah, we’re okay with that,’ ... and after that, you know, I just avoided that school for a little while of course as you can imagine.” (Identification (ID) #200189)
Compounding these feelings was the uncertainty of what might trigger a flashback. One participant spoke of not knowing what his triggers were and therefore, had difficulty controlling how he felt in certain situations.
“ ... [the] hardest part is I don’t know my triggers for my PTSD. I do know when it hits, it hits, you know, the anxiety goes up and stuff like that and the anger just comes right to the top.” (ID #200219)
These types of reactions occasionally affected their interactions with co-workers. In an attempt to control a situation, some of the participants stated that they would often fall back on how they communicated and interacted with their fellow soldiers, assuming this was the way to get work done. They described how the approach to work is significantly different in the civilian context and they would often be perceived as being “aggressive” or “harassing” towards co-workers.
“I get mad at people and talk to them with a really authoritative voice that was really powerful and some people didn’t know how to take that. They thought I was being harassing when I was just telling them to clean the spider webs off a display for the third time ... But that’s just the way I’m used to communicating in the military, you know?” (ID #200700)
Whether it was the unexpected events or the inability to control one’s environment, many of the participants either quit their jobs or were fired. Their military experiences, especially for those with PTSD, seemed to affect how they were able, or not, to adjust to their work environments.
Feelings of demotion
While in the military, the participants stated that they had received copious amounts of training and education. Some had top level security clearance in highly classified jobs, and others spoke of being responsible for leading troops in combat missions. However, once they returned to the civilian workforce, participants stated they felt as though they had been demoted. They felt their civilian work was demeaning and they were not able to use the skills they had acquired while in the military.
“I mean it’s just, it wasn’t fun, it’s pretty demeaning and you go from being a platoon sergeant to ... filling a [expletive] vending machine and you’re getting paid, you know, $10 an hour, so yeah, it was pretty demeaning.” (ID #200848)
While many of the programs offered to Veterans focus on translating skills acquired in the military into a civilian context for securing employment we found that, for some of the participants, it was the context in which those skills were to be applied that was the issue. For example, one participant, who had been a military police officer, knew that because of his PTSD, he was no longer capable of performing these functions.
“I don’t have the mentality and I know I don’t. I get easily aggravated and I’m smart enough to know to not put myself into a situation where I have a gun ... ” (ID #200463)
Feeling demoted and/or that their skills were not being utilized led some of the participants to seek out new employment. However, this resulted in many of them cycling through several jobs in an attempt to find a work environment they felt utilized their skills and knowledge. The two participants who returned to school did so in an attempt to obtain not only better employment but positions that were equivalent to their military experiences. However, both wondered if they would be able to adjust to the work environment, especially the social interactions that are often required, in a way that would be successful.
Inability to relate
Many of the participants spoke about the difficulties they had relating to civilian co-workers. Reasons included differing work ethics, feeling a lack of respect for their military service and skills, and a lack of camaraderie/loyalty.
“... so many times I shake my head in different places I’ve worked and thought, ‘Man, you can tell these guys weren’t in the military.’ I guess [the military] just raised my expectations of ... work ethics or respect to other people.” (ID #200016)
Some participants disassociated themselves from their work and were more comfortable not developing work relationships. By keeping these two worlds separate, some participants felt that they were better able to control their work environments.
“I try not to let my personal life interfere with my professional life. I’ve learned over time, when I go to work, I leave home at home and when I go home, I leave work at work ... That’s just the way I’ve wired myself to deal with [problems].” (ID #200219)
However, participants recognized that their inability to cultivate work relationships put them at a disadvantage for work-related opportunities and promotions.
“I just sort of stick to myself when it comes to co-workers ... I think if I was a little bit more outspoken, I probably would get a little bit further but it’s really hard to [do that].” (ID #200848)
Inability to relate to co-workers affected participants work relationships, sometimes in significant ways, and many of them felt that it prevented them from advancing in their careers.
Finding their way
One goal of the interviews was to try to discern what types of employment services participants had engaged in both during and after discharge. Half of the participants stated they had attended the Transition Assistance Program/Transition Goals Plans Success (TAPS) program during their discharge process. TAPS is focused on offering services meant to ensure that the separating service member is career ready when they transition out of the military [2]. Although this program became mandatory in 2012, the participants who had gone through the program found it to be only moderately helpful. They stated that it was too much information at once, they were focused on going home rather than what they were going to do for employment, and they did not know how to apply the strategies they were taught once discharged. For example, one focus of the TAPS program is help with resume writing, including translating military skills into a civilian context, but one participant stated:
“... that’s what the class [resume writing] was and then they say, ‘Oh, just go on the computer and put your resume on the computer.’ But if I don’t know how to explain military life to civilian life, they’re not helping me.” (ID #200145)
When asked if they had used any VA employment support programs since discharge, 9 out of the 10 participants said they had not. A few had met with a Veteran representative at the state unemployment office, but did not find this resource helpful. Most had heard of Veteran job fairs, but for the two who had attended these, they found them to be unhelpful in terms of actually securing a job.
“... it was a lot of people just handing out business cards ... There really wasn’t much to it, like a lot of it was just information I could’ve already received online.” (ID #200189)
Although use of employment services was almost non-existent among participants, some of them were able to manage their work environments in a way that supported their transition back into the work force. They spoke of having employers that understood their circumstances and offered support and a willingness to work with them in times of distress. This often required the participant talking with their employer about what they were going through and the difficulties they were having reintegrating back into the work environment.
“I talked to my boss ... I said, ‘I won’t be able to take it, I’ll explode and I’ll get up and walk out’ ... and we kind of [talked our] way through it and he got me to smile ... he’s a good guy like that.” (ID #200016)
Not all participants were comfortable speaking to their employers about their struggles. Instead, they found jobs in areas that allowed them to work on their own. For example, one participant found that working in a job that offered him more independence and less day-to-day direct contact with co-workers provided him the time and space he needed to respond to stress in a more measured and controlled way.
“I think what has helped me is my independence from somebody being constantly on me ... [it’s] given me more reason to stand back and it’s that time and space that allowed me to react within reason and not immediately, you know, force back when something upsets me.” (ID #200848)
Another participant stated that he found a change in career was needed. He found solace in a factory job that provided an environment that was stable and predictable.
“Like people are puzzled like, ‘Why did you leave the professional world for that? You went to school for how many years and now you’re just a factory worker?’ But I’m like you know what? I’ve never been happier with the job. I mean its menial labor, but it pays well, I get along with everybody, there’s no stress so and I’m actually up for promotion, and I’ve only been there a month, so it works.” (ID #200189)
Even though these participants found ways of reintegrating back into the civilian workforce, almost all had done so without help from a Veteran employment program. Although they had been able to obtain employment, they were not able to maintain their employment, changing jobs frequently or leaving the job market altogether. When asked what they thought would be most helpful in terms of employment services, participants stated knowing what was available, what they were eligible for, and where they could find information would be most useful. Some also stated that support for changing careers was needed given that many had changed jobs and others were still trying to figure out where they fit in the employment sector.
Discussion
Although understanding the difficulties Veterans face when trying to obtain employment is important, we found that understanding their struggles with maintaining employment is crucial. Many of the existing programs were developed with the idea that Veterans reenter and remain in the workforce. However, all of our participants were no longer employed in the job they had immediately following discharge. Several of them had cycled through multiple jobs and 3 remained unemployed.
Resnick and Rosenheck [20] note that because symptoms of PTSD are difficult to control, those with PTSD may withdraw to environments that are known and predictable. Participants in our study described how PTSD symptoms or triggers manifested themselves within the workplace and ultimately impacted their ability to perform at their jobs. As a result, some remained unemployed while others chose to return to school or change careers. We also found that some of the participants felt they had been demoted from the jobs they performed in the military to what they were doing in civilian employment. Feelings of demotion came from not applying the skills they had obtained while in the military and how they felt they were treated within the workplace, especially during their interactions with co-workers. Difficulty relating to co-workers was a common theme among the participants. Inability to relate often prevented many of the participants from developing work relationships, sometimes resulting in negative consequences such as placing them at a disadvantage for work-related opportunities and promotions. While a few of the Veterans we spoke with were able to find employment within predictable environments or adapt their work environments to make work more manageable, they had cycled through several jobs before reaching stable employment. They were not aware of any programs that could have helped them through this process.
Implications for practice
Our findings support prior research that concluded that employment services need to address obtaining employment and effective functioning within the work environment, especially when mental health symptoms are present [21]. Programs that currently do not include counseling on how to identify PTSD triggers and coping strategies to mitigate symptoms should consider adding these to their programs. In addition, employer education should include information on Veteran mental health disorders including depression, anxiety, and PTSD and how the work environment could be optimized to lessen the burden of these illnesses.
A great deal of attention has been paid to the need for skill matching between military experience and civilian job requirements. As noted above, one of the main goals of the TAPS program [2] is to translate military skills prior to discharge so that Veterans are prepared to enter the civilian workforce. However, we found that it may also be necessary to consider the contexts in which they are applying those skills. Assessment of Veteran job skills, or the tasks they can perform, may be insufficient to determine their ability to adjust to a different context. Determining the type of environment a Veteran is comfortable in may help identify jobs that are a better match, potentially making long-term employment more feasible.
Similar to other recommendations, employment service programs should include counseling on how to build and maintain relationships within the workplace for both Veterans and their civilian co-workers. In addition, developing a network of Veterans who have been successful in these pursuits could provide support for newly employed Veterans looking for guidance and mentorship [22].
And finally, because most of the Veterans we spoke with were not aware of any employment programs that could help them maintain employment, employment services should be structured as on-going support programs that are designed not only to help Veterans find initial employment, but also to help them adapt to their workplace and, if unsuccessful, provide additional support so that a change in career is possible.
Limitations
A limitation of this study was the low number of Veterans who participated. Therefore, it is difficult to discern how applicable our findings are to the Veteran population as a whole and may, in fact be limited to the Veteran participants in this study. However, we feel that the use of an exploratory design, purposive sampling strategy, and thematic analysis approach mitigates this limitation in that it presents a richer understanding of the difficulties some Veterans face while trying to maintain employment. Another limitation was that very few of the participants had used a Veteran-related employment service program since discharge. Therefore, it is necessary to talk with Veterans who have participated in employment-related programs in order to determine how these programs currently provide resources directed at maintaining employment and understand their experiences. And finally, we did not include interviews with staff who administer employment programs, including career counseling. Understanding their experiences working with Veterans and the resources required to provide on-going support for maintaining employment is critical.
Conclusion
Our study provides insight into how some Veterans have experienced employment however, additional research is needed on those who have been able to maintain their employment and the skills they employ to do so. Although there has been a tendency to focus on Veteran unemployment rates, a better understanding of the difficulties some Veterans face when trying to maintain employment is also needed. Current employment programs tend to prioritize job obtainment. Our findings suggest that increasing the awareness of existing programs and ensuring that these services provide resources and skills that help Veterans maintain long-term employment is critical.
Conflict of interest
The authors report no conflicts of interest.
Footnotes
Appendix A. Veteran Employment Interview Guide
Acknowledgments
The authors wish to extend a heartfelt thanks to the participants in this study for sharing their time, thoughts, and experiences. The authors alone are responsible for the writing, content and views expressed in this paper and do not necessarily represent the views of the Department of Veterans Affairs.