Employment has been positively correlated with retention in treatment. By holding a job, a client establishes a legal source of income, structured use of time, and improved self-esteem, which in turn may reduce substance use and criminal activity. Years of research show that the best predictors of successful substance abuse treatment are
Gainful employment
Adequate family support
Lack of coexisting mental illness
Unemployment and substance abuse may be intertwined long before an individual seeks treatment. Although the average educational level of individuals with substance abuse disorders is comparable to that of the general U.S. population, people who use substances are far more likely to be unemployed or underemployed than people who do not use substances. According to the U.S. Census Bureau, employment rates for the non-substance-using population ranged from 72.3 percent in 1980 to 76.8 percent in 1991. However, employment rates of the population with substance abuse problems before admission or at admission to treatment have remained at relatively stable, low levels since 1970, ranging from 15 to 30 percent. Most of the research on the employment rates of persons with substance abuse disorders has focused on opiate-dependent persons (usually heroin), and employment rates for other substance users may vary. The data clearly indicate the need for interventions to improve employment rates among this population in treatment and recovery.
Two major reform efforts have affected the substance abuse treatment field: health care reform and welfare reform. Both of these reforms highlight the role of vocational training and employment services in substance abuse treatment. Under the cost-saving initiatives of health care reform (i.e., managed care), treatment providers face demands to reduce length of care and still produce cost-effective, positive outcomes. Treatment providers must also attempt to match a client's individual needs to an appropriate level of care. Recent welfare reform efforts, which limit benefits and impose strict work requirements, stress vocational rehabilitation for people with substance abuse disorders in an effort to move clients off welfare and into work.
Treatment providers will need to learn how to operate under the imperatives of these two major reform efforts. Because of their increasing emphasis on efficacy and outcomes, welfare and health care reforms promise to enhance the availability and provision of not only substance abuse treatment services but also necessary supporting services, including vocational rehabilitation. Substance abuse treatment that is cost-effective and shows verifiable positive outcomes is the ultimate goal. However, this goal cannot be achieved unless all the client's service needs are met, and this will occur only through the integration of treatment and wraparound services, including vocational counseling and employment services. Vocational counseling is an effective way to refocus substance users toward the world of work. Employment subsequently serves as a means of (re)socialization and integration into the non-substance-using world.
This Treatment Improvement Protocol is intended for providers of substance abuse treatment services. However, it can also be of use to vocational rehabilitation (VR) staff, social service workers, and all who are involved in arranging for and providing vocational and substance abuse treatment services. The TIP introduces vocational issues and concepts and describes how these can be incorporated into substance abuse treatment. While the alcohol and drug counselor is not expected to achieve complete mastery of vocational counseling, she should acquire at least rudimentary skills in providing vocational services and be able to recognize when her client should be referred to a VR counselor.
The Consensus Panel for this TIP drew on its considerable experience in both the vocational rehabilitation and substance abuse treatment fields. Panel members included representatives from all aspects of vocational rehabilitation and substance abuse treatment: VR specialists, alcohol and drug counselors, academicians, State government representatives, and legal counsel.
The TIP is organized into eight chapters. Chapter 1 provides an overview of the need for vocational services and discusses how employment and substance abuse treatment are interconnected. Challenges to employing clients in substance abuse treatment and strategies for promoting employment are discussed. The chapter also contains an overview of Federal and State legislative reforms and trends that have a deep impact on substance abuse treatment and the need for integrating employment services into substance abuse treatment.
Chapter 2 introduces the elements of vocational programming, such as screening and assessment tools, vocational counseling, prevocational services, training and education, and employment services. The roles of the VR counselor and vocational evaluator are discussed. A section on resources provides an overview of the vocational resources that are available for substance abuse treatment clients.
Chapter 3 focuses on the clinical issues related to integrating vocational services into substance abuse treatment. This chapter helps the alcohol and drug counselor incorporate vocational components into a treatment plan for the client and actively involve the client in his rehabilitation by assessing strengths and interests, setting goals, and finding and maintaining employment. The chapter also discusses legal and social challenges to securing employment. Three case studies are presented to illustrate the concepts discussed in the chapter.
Chapter 4 provides information about integrating onsite vocational services into substance abuse treatment programs. The main premise is that the substance abuse treatment program should not operate alone but should be part of a collaboration of agencies that provide various services to clients. Information is provided about models, staff development and training, integrating services, and, depending on the type of program (e.g., high-structure program, low-structure program), outcomes assessment, and uniform data collection.
Chapter 5 discusses setting up a referral system among agencies. Counselors are introduced to the authentically connected referral network, which is an integrated system where agencies function as equal partners to best serve the various needs of their clients. In an authentically connected network, a holistic view of the client is adopted. Barriers to collaboration, finding potential collaborators, the elements of effective referrals, and building an authentically connected network are discussed.
Chapter 6 offers guidance to administrators who are navigating in the new, unfamiliar funding environment created by recent Federal and State reforms. Funding strategies and sources are provided, and the steps for adapting to the new funding and policy climate are reviewed. Future considerations regarding Single State Agencies, flexible funding mechanisms, accountability and resource redirection, and the role of the Federal government are also discussed.
Chapter 7 provides an overview of legal and ethical issues for alcohol and drug counselors who are providing vocational services directly or through referral. Part I discusses discrimination, Part II discusses welfare reform, and Part III covers confidentiality issues.
Chapter 8 presents information on the impact of increased law enforcement activity on clients with substance abuse disorders. The chapter provides some specific strategies to help clients who are making the transition from incarceration to the community find needed employment.
The TIP also contains several appendices, including source information for various screening tools, Web sites, and other useful resources; a version of the Addiction Severity Index; a list of State employment agency addresses and Web sites; Federal and State funding sources; and a sample copy of an Individualized Written Rehabilitation Program.
Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, it will be used to denote both substance dependence and substance abuse. The term does relate to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders as described by the DSM-IV.
The recommendations that follow are grouped by chapter. Recommendations that are supported by research literature or legislation are followed by (1); clinically based recommendations are marked (2). To avoid sexism and awkward sentence construction, the TIP alternates between "he" and "she" in generic examples.
Vocational services should be an integral component of all substance abuse treatment programs. (2)
If work is to be sustained and enduring lifestyle changes made, the vocational services provided to clients must focus on pathways into careers, on job satisfaction, and on overcoming a variety of barriers to employment, as well as on the needed skills for maintaining employment. (2)
A number of changes that are affecting today's workforce must be taken into account when delivering vocational services to substance abuse treatment clients. Because the world of work is dynamic and job obsolescence is a well-documented phenomenon, vocational services must reflect these changes. (1)
There are several laws in the area of welfare reform with which alcohol and drug counselors should be familiar. These laws must be monitored closely because they signal time periods when financial support will be terminated for clients. These laws are as follows: (1)
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996
The Contract With America Advancement Act
The Adoption and Safe Families Act of 1997
The Workforce Investment Act of 1998
The Americans With Disabilities Act
In response to welfare reform efforts, substance abuse treatment programs should address the vocational needs of women and offer them a full range of vocational services. (1)
Initial vocational screening can be done by an alcohol and drug counselor, and more in-depth assessment should be conducted by a VR counselor or vocational evaluator. (1)
The vocational component of the treatment plan is a dynamic process and should be periodically evaluated to determine whether the stated goals are still viable and appropriate, further assessment is needed, or any adjustments in the plan are required. All professionals involved in the client's treatment plan should maintain a close working relationship and a dialog about the client's progress so that appropriate adjustments to the client's treatment plan can be made. (1)
Screening allows the counselor to determine the kinds of vocational services the client may need and to develop an appropriate vocational component to the treatment plan. Screening should enable the alcohol and drug counselor to accomplish the following (although not to the degree of detail that would be provided through a followup assessment or counseling by a vocational specialist): (1)
Identify the client's major employment-related experience, as well as her associated capacities and limitations
Determine what referrals will help the client attain successful employment (if needed)
Identify the necessary resources to make employment feasible for the client (e.g., transportation, day care)
Determine whether further assessment is needed to develop the vocational component of the treatment plan
The functional assessment should be performed by professionals well versed in how an individual's skills and interests lead to successful vocational outcomes. Normally the VR counselor or vocational evaluator fits this description; however, the alcohol and drug counselor often has vital information about a client's level of functioning. In complex cases, functional assessment can be accomplished with input from a multidisciplinary team. (1)
The next step after assessment is to counsel clients about setting vocational goals and creating short- and long-term plans for achieving those goals. To develop a plan with a client, factors to consider include the results of assessments, employment opportunities in the local area, existing training resources in the client's area of interest, the feasibility of alternative goals when full-time employment is not an option, and client empowerment to make the necessary decisions. (2)
For referral purposes, it is important for the clinician to be familiar with the local vocational resources available to clients. (1) Before referring clients to State VR agencies, the alcohol and drug counselor should first develop a relationship with the assigned VR office. (2)
To help clients attain work-related goals that will also support their recovery, the alcohol nd drug counselor should consider the cultural, sociopolitical, physical, economic, psychological, and spiritual circumstances of each client. This is known as the "biopsychosocial-spiritual" model of treatment. (1)
To successfully incorporate vocational services into substance abuse treatment, the alcohol and drug counselor must first acknowledge that vocational training, rehabilitation, and employment are important areas of concern for clients. (2)
Clinicians can best address vocational issues by considering their relevance at every stage in the client's treatment, including their incorporation into individualized treatment plans. Preliminary information on vocational needs should be collected and assessed at intake. (2)
The Consensus Panel believes, based on its collective experience, that three key elements are essential to effectively address the vocational needs of clients in the recovery process. They suggest that clinicians: (2)
Use screening and assessment tools, specifically for vocational needs, when appropriate.
Develop and integrate a vocational component into the treatment plan.
Counsel clients to address their vocational goals and employment needs.
Clinicians often play a mediating role between clients and employers and should take advantage of opportunities to educate the employer on substance abuse issues and how to address them in appropriate policies. (2)
In defining the client's educational needs and exploring resources available to meet them, it is important to recognize that the client's past experience with the educational system may strongly influence work-related decisionmaking. (2)
Clinicians should receive basic information about clients' medical and psychological condition at intake, since certain medical and psychological limitations may affect the type of employment for which they are best suited. (2)
Clinicians should be alert to clinical and legal issues surrounding clients' past histories and recognize their implications for employment. (2)
The counselor should be alert for the presence of relapse triggers that have affected the client in the past and help the client recognize and cope with them. The treatment plan should provide for effective management of all relapse triggers that are relevant to the individual. (2)
To achieve therapeutic goals in the domain of employment, the clinician should develop a treatment plan that addresses the client's vocational training, rehabilitation, and employment needs. (2)
Employment and vocational services should be a priority in substance abuse treatment programs, and employment should be addressed as a goal in treatment plans. The Consensus Panel recommends that if possible, a substance abuse treatment program should add at least one VR counselor to its staff. Should the size of the program or other fiscal shortcomings prevent this, arrangements should be made to have a VR counselor easily accessible to the program. (2)
Every treatment program should consider itself part of a collaborative interagency effort to help clients achieve productive work. (2)
The treatment program must determine the parameters of what it can offer clients in terms of vocational services. (2)
Programs must ensure that staff members have a thorough knowledge of the diverse populations represented in their treatment program and the particular challenges that different groups face in securing and maintaining work. It is also important to understand various cultural attitudes toward work. (2)
Counselors should evaluate their clients' personal plans for change to determine whether the vocational goals they set are realistic (not too high or too low) and whether achieving the goals will allow them to make a sufficient living and support continued recovery. (2)
Each substance abuse treatment program must define successful outcomes appropriate to the population it serves and ensure that funders understand the importance of these outcomes and the services necessary to achieve them. (2)
Collaboration is crucial for preventing clients from "falling through the cracks" among independent and autonomous agencies providing disparate and fragmented services. Effective collaboration is also the key to seeing the client in the broadest possible context, beyond the boundaries of the substance abuse treatment agency and provider. (2)
Programs must reflect the fact that it is not feasible or effective to provide everything that clients need "under one roof." A more fruitful approach is to collaborate with other agencies on the basis of client needs and overlapping client caseloads. (2)
All collaborators, including those providing treatment for substance abuse, should be aware that their efforts are likely to be ineffective unless all the client's life areas are addressed. To that end, each agency must ecognize the existence, roles, and importance of the other agencies in achieving their goals. (2)
Building an integrated service model based on community partners must begin from the client's base, taking into account his values and building on the strengths of his culture to create referrals that are appropriate and effective for his particular needs. (2)
To maintain financial solvency in this new era of policy and funding shifts, alcohol and drug treatment agencies must forgo their traditional independence and focus on building collaborative partnerships to meet their clients' needs. (2)
A requirement for system competency (specifically, an understanding of funding sources and strategies) should be incorporated into Certified Addiction Counselor training and certification. (2)
Policymakers at the Federal and State levels should work together to create financial incentives for collaboration between substance abuse treatment providers and agencies that provide other services to an overlapping population. (2)
Alcohol and drug counselors providing VR services directly or through referral should be aware of legal and ethical issues in three areas: discrimination against recovering individuals, welfare reform, and confidentiality. (2)
Counselors should be familiar with the Workforce Investment Act of 1998, which Congress passed to improve the workforce, reduce welfare dependency, and increase the employment and earnings of its participants. A major emphasis of this law is its "work first" approach, which strongly encourages the unemployed to find work before requesting training. (2)
Counselors should be familiar with the Drug-Free Workplace Act and how it may affect their clients in recovery from substance abuse disorders. Counselors should help their clients prepare for interviews and help them deal with any employment discrimination issues that may arise. (2)
Counselors should be familiar with confidentiality and disclosure issues and how these issues affect working with other agencies that are providing services to the client. (2)
Substance abuse treatment programs that engage ex-offenders should offer clients respect, hope, positive incentives, clear information, consistency, and compassion. Counselors need to provide these clients with an understanding of a career ladder that they will be able to climb and help them to see how skills and talents that have served them in the past can help them succeed in legitimate occupations as well. (2)
Programs can encourage and assist clients to acquire a General Equivalency Diploma (GED) by locating the GED classes in the treatment site. (2)
VR staff should be invited to spend some time at the substance abuse treatment program site. In this way, clients will regard VR staff as part of the "treatment family." (2)
Treatment programs can incorporate job and skills training by providing clients with opportunities to perform jobs at the treatment site. (2)
Programs should provide clients with guidance on budgeting. Many ex-offenders have not learned how to budget money. (2)
Counselors should assist clients who are ex-offenders in following through on referrals and assembling necessary documents, such as social security cards and school transcripts. (2)
Programs can match clients to mentors/peers who will assist clients with all components of the vocational training or job placement tracks. (2)
For female clients in particular, programs should include education in parenting skills and skills in finding child care. (2)
Once released from incarceration, women with substance abuse disorders should go immediately to substance abuse treatment centers. Ideally, the treatment program would form a linkage to the prison so that counselors have the opportunity to "reach in" to women while they are still incarcerated. (2)
Counselors should assess safety issues before women return to potentially violent environments, and a safety plan should be developed and implemented. (2)
To increase retention of female clients, it is important to find or develop a gender-sensitive program that offers a continuum of care, including aftercare. (2)
Counselors should help clients who are ex-offenders to focus their job search on occupations and employers who do not bar ex-offenders, develop realistic goals, ?clean up official criminal histories ("rap sheets"), know when to disclose information about a criminal record, and learn to see their employment situation from the perspective of potential employers. These clients need to prepare and practice a statement that acknowledges a substance abuse and criminal history and offers evidence of rehabilitation, a statement explaining their interest, a statement about positive aspects of their backgrounds, and a method of responding to illegal questions such as "Have you ever been arrested?" (2)
Treatment programs can assist clients who are ex-offenders by educating employers about the benefits of hiring such clients, educating clients about the work environments they can expect to encounter, and helping clients assess whether a potential job will provide a supportive environment for recovery from a substance abuse disorder. (2)
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