Integrating Substance Abuse Treatment and Vocational Services
Treatment Improvement Protocol (TIP) Series 38

Developing and Integrating a Vocational Component Into the Treatment Plan

Regardless of the client's employment situation--employed, looking for better work, or unemployed--it is appropriate for the treatment plan to have a vocational component that specifies objectives developed jointly with the client. Goals should be set that can be achieved through counseling (such as improving relationships with coworkers, handling anger or stress appropriately in the workplace, improving attendance), or the client may require referral to vocational rehabilitation (VR) counselors. The following are situations in which a clinician should refer the client for vocational services:

• The client is asking questions about employment or vocational goals that the clinician has difficulty answering.
• The counselor and client cannot develop a clear and concise set of goals concerning vocational issues because of a lack of information or guidance.
• The client needs special vocational testing or training beyond the expertise of the counselor or has a disability that requires special accommodations to obtain employment.
• The client's vocational history is either nonexistent or has been so seriously affected that another person with expertise in this area should be introduced to assist the client with vocational issues.
• The client clearly wants to accomplish something meaningful through work but needs help, for whatever reason, to make such a major life change.

Counseling Clients To Address Vocational Goals and Employment Needs

Research suggests that counselors can help clients progress by focusing on what clients feel is most important (Jongsma and Peterson, 1995; Linehan, 1993; Meyers and Smith, 1995). For many clients, employment is the primary concern. For women with children, their care is of primary concern, and employment is the means to obtain that goal. For clients coming from incarceration, employment may be a condition of their parole. For others, work may seem unrelated to their current needs and desires as they perceive them. Still, exploring vocational goals can help these clients attain other goals, such as increased financial independence or a more satisfactory living arrangement. By helping the client appreciate the benefits of work, expressing optimism about the client's ability to obtain work, and preparing the client for the work environment, the clinician can foster positive change in the client's sense of worth, increase hope for the future, and positively affect many other areas. Figure 3-1 presents a list of early-stage vocational issues to explore with clients.

Many persons in recovery share common internal and external challenges in regard to employment. These include out-of-control feelings, coexisting disorders or disabilities, low self-esteem and self-efficacy, poor work histories, fear of failure, fears and anxieties severe enough to block needed actions, deficiencies in life skills such as financial planning, and poor problemsolving or coping skills. As these challenges become clinical issues, the clinician should address them in an empathic but motivational style, building rapport and trust and practicing reflective listening skills. A solution-focused approach can be used to help clients recognize that although it feels as if there are no alternatives, they can choose from among a range of options. The timing of the introduction of elements of vocational services depends on a number of factors, which are presented below in the section on developing the treatment plan.

A treatment plan for substance abuse ideally includes professionals from a number of disciplines. This multidisciplinary approach is discussed in greater detail below. The roles assumed by two of the players--the alcohol and drug counselor and the VR counselor--differ from one program to another and sometimes even within programs from one client to another. If the alcohol and drug counselor is the only person addressing employment issues, this clinician's tasks will be different from the case where the client is engaged in a formal vocational program.

The clinician--either the alcohol and drug counselor or VR counselor--has important responsibilities in (1) activating and supporting the client's desire for change, (2) motivating the client to take the risk of seeking new or better employment when appropriate, (3) helping the client learn to anticipate and solve problems, and (4) referring the client to community resources that can provide support at various points on the employment continuum.

Appropriate therapeutic goals in the realm of employment include the following:

• Help the client establish a positive life vision. What were the client's childhood dreams?
• What kind of person does she want to be now?
• Establish life goals with the client that are consistent with this life vision and realistic in terms of the client's knowledge, skills, and abilities
• Identify the objectives, resources, and specific steps needed to enable the client to meet those goals within an appropriate timeframe.

It is also important to have an understanding of the client's cultural and family values and beliefs about work. For example, many Asian Americans are likely to focus heavily on returning to work because of the strong work ethic within their culture and the shame associated with being out of work. Family members are likely to be pressuring the client (possibly not with great sensitivity) to return to work. However, the client may be reluctant to explore the reasons for job loss or to identify the specific steps needed to make a change.

In such cases, the clinician should validate and support the cultural value placed on the importance of work and acknowledge the client's sense of being pressured to return to work. In addition, it is sometimes helpful to frame the treatment as a rebuilding process similar to the body's healing and reconstruction after an injury.

It is important to recognize that all clients, not simply those who belong to cultural and ethnic minorities, approach work from a particular cultural framework. However, the clinician should beware of making assumptions about how clients' cultural backgrounds affect their perceptions and experience because individuals can differ significantly from the norms of their culture.

In addition, the clinician should maintain an awareness of his own values, attitudes, and biases that affect the view of work-related decisions and challenges and how these can negatively affect the client's ability to progress. The clinician who does not see in work the possibility for growth and a way to enhance recovery will inevitably communicate to the client a poor attitude regarding work.

Clinicians often play a mediating role between clients and employers, helping each understand the other's point of view. The clinician's grasp of the employer's view is essential to ensuring the client's smooth transition to the workplace. Clinicians should also take advantage of opportunities to educate the employer on substance abuse disorder issues and how to address them in appropriate policies. A service partnership or close collaboration with a VR counselor is especially valuable in mediating and facilitating client-employer relations. VR counselors work regularly with employers in their communities and are trained to negotiate win-win situations with clients and employers.

Identifying Vocational and Employment Goals

As clients envision the possibility of a vocation--purposeful work that is meaningful to them--they also have an opportunity to address important therapeutic goals such as increased self-sufficiency, self-trust, and a sense of efficacy in the world. Although employment accepted for the purpose of gaining money also addresses these goals, the sense of choice that is implied by the term "vocation" is especially powerful. Because of this, the clinician will want to help the client distinguish between short-term employment strategies and long-term strategies for developing a vocation. In guiding the client to address this important topic, the clinician should use appropriate pacing and timing and avoid a confrontational approach. A realistic vocational goal should be part of a positive and compelling life vision that truly belongs to the client.

If the client has a negative work history, the clinician can activate a positive self-image by asking the client about areas in her life in which she has been successful (e.g., helping parents or other family members, participating in a religious group or other community organization). The idea that skills acquired in one setting are often transferable to another is sometimes new and reassuring to many clients.

To assist the client with vocational planning, the alcohol and drug counselor or VR counselor will need reliable information about the client's life experiences, especially past work and educational experiences, as well as his knowledge, skills, and abilities. If available, the clinician should review prior employment and vocational skills assessments and the results of prior aptitude testing. (Information relayed by the client about educational or VR agencies that have previously worked with the client should be verified and records obtained to ensure the accuracy of details.) With a work history, the counselor can perform a "transferable work skills analysis." Typically, this process involves the following steps:

1. Use the relevant job history, training, experience, skills learned, and responsibilities handled and identify the client's relevant characteristics (e.g., physical capabilities, working conditions, education).
2. Translate these characteristics into measurable traits and skills and assign a value or level to skill development.
3. Conserve the value of specific residual skills unaffected by disability (i.e., what the client has not lost because of disability).
4. Apply the residual traits and skill levels to the universe of potential jobs.

Salomone states that transferring skills from one job to another requires the assessment of (1) the worker-specific vocational preparation that classifies work as unskilled, semiskilled, or skilled; (2) the physical demands of previously performed jobs; (3) a medical determination of the client's current physical and mental status and ability; and (4) the identification of specific jobs that the client could perform given the three factors noted above (Salomone, 1996). There are computer-based programs such as the EZ-DOT, CAPCO, and RAVE (Brown et al., 1994) that can be used to assist the counselor in this process.

The client's work history will reveal the skills the client already has. However, some clients may have forgotten parts of their employment history, and many will not be able to articulate the knowledge, skills, and abilities they possess. To elicit this information, the clinician can ask about specific activities the client has done, such as using a jackhammer or cooking, as well as about the client's use of spare time. Hobbies and interests sometimes suggest possible career directions, as well as natural talents. To assess clients' vocational interests, the clinician can use the easy-to-administer Self-Directed Search, mentioned in Chapter 2. The results of this scale can then be discussed with the clients to determine realistic vocational choices to explore.

As previously noted, vocational issues are ideally introduced when the client is relatively stable, although there are situations where the need for employment is so compelling that it must be addressed immediately. Whenever this issue is raised, the counselor should tailor the strategy to the client's stage of "readiness to change." A well-known model of change, developed by psychologists James Prochaska and Carlo DiClemente, is relevant (Prochaska and DiClemente, 1982). This model envisions the process of change as a wheel in which the individual moves from a stage of not thinking seriously about change (precontemplation) to seriously contemplating the possibility of change, determining to undertake change, acting to make the desired change happen, maintaining the new behavior, dealing with possible relapse, and then around the circle from contemplation once more. Different skills are required on the part of the clinician when the client is at different stages (Miller and Rollnick, 1991; see also TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999c]). As the client progresses through the cycle of change, it becomes possible to address new and more challenging dimensions of long-term planning.

Clients who are at a precontemplation stage in regard to work may need motivation to help them develop a positive attitude toward the prospect of work. Applicable clinical strategies include encouraging positive "self-talk" and exploring both the benefits and the disadvantages associated with work in a motivational style that elicits "self-motivational statements" (Miller and Rollnick, 1991). The clinician can build on the client's desire to stay "clean" and show how work can support that objective by providing a legal means of income as well as the potential for developing relationships that support a substance-free lifestyle.

Some clients who have clear and pressing reasons to find work are nevertheless in denial about the necessity to make a transition. This condition may present itself as avoidance: "I'm doing 12-Step and that's it--I'm in recovery, and I just can't handle anything else." Some clients enjoy the sharing and social contact that a group offers so much that they want to make it fill their lives; finding or staying in jobs may seem a distraction from what feels most important. The challenge for the clinician is to help them appreciate the realities of the situation and envision the consequences of their decisions, while maintaining the primacy of recovery. Clinicians should be careful not to foster a belief in their clients' fragility that could lead to their being denied useful services. If clients are genuinely unsure of where they stand (e.g., in regard to welfare-to-work requirements), then accurate information should be provided to them, or the clinician should make relevant referrals as appropriate.

For many clients, the transition to work seems a daunting leap from their present situation. Some are used to thinking in terms of getting through 24 hours at a time, and the thought of how to plan for a year or more can be overwhelming. Such clients can benefit from encouragement and from a focus on short-term, specific, manageable goals within the context of a longer term strategy. Clinicians can help clients envision each step and prepare them to overcome the obstacles that each step presents. For clients who lack work experience, a positive framework for considering work issues needs to be built. It should be explained to them that work is sometimes difficult and may require sacrifice but that it offers the satisfaction of achievement. For some clients, a period of temporary work in a supervised and controlled setting is necessary to prepare them for more permanent full-time work. Certain residential programs, for example, have clients engage in mechanical work under the auspices of the program in order to ease the transition and build a positive work history (see Chapter 2).

Clients who must for the first time accept menial employment will have understandable difficulty with the transition to work. Reorienting their values and framing the new work world positively is usually a long-term and difficult task. The clinician will need to help clients develop reasonable job expectations given their skills and environment. It will also be important to emphasize the nonmonetary rewards of work such as no more fear of arrest for selling or using illegal drugs and the esteem from family for having "gone straight."

Clients must also learn to envision a ladder to more prestigious employment and accept a reasonable pace of progress. Use of metaphors that are meaningful to the client helps to illustrate stages of growth leading to the goal. For example, sports superstars start out by practicing, learning, developing, and demonstrating their talents before they can build a reputation. Or, the clinician might compare the injury caused by the substance abuse, and the recovery afterwards, to the time and effort needed to rebuild the strength in an arm or leg after a serious wound or fracture. These analogies can be effective with clients who relate more readily to physical symptoms than to psychological concepts.

Even for clients who are currently employed, a reconsideration of vocational goals is often advisable as part of the recovery process. Some employed clients in recovery should consider a transition because their job exposes them to alcohol or drug use on the job. For example, a construction worker whose crew drinks or smokes pot at lunchtime or after work may not be able to maintain a substance-free life.

Assessing the Need for Education or Training

In defining the client's educational needs and exploring available resources to meet them, it is important to recognize that the client's past experience with the educational system may strongly influence work-related decisionmaking. For example, the client may have had an undiagnosed learning disability and may have experienced repeated failure within the educational system, or the client may have had poor experiences with teachers. Some clients are illiterate, although they may have concealed this fact even from some of their closest associates. Clients who are not native English speakers may have experienced difficulties from the language difference that have affected their education. It is important for the clinician to be aware of the client's history in these areas and to help the client recognize and reframe the impact of a negative learning history on the present situation.

To support the client in obtaining successful employment, the clinician should be able to answer the following questions:

• What are the client's functional limitations that influence the type of work that would be appropriate?
• What strengths and attributes does the client bring to the world of work?
• Is the client literate in any language?
• Does the client use more than one language?
• What is the client's language preference?
• Is improving language skills important to the client?
• What is the client's level of education?
• What level of education does the client want to have?
• What is the client's past experience with schooling or learning?
• What is the client's present attitude toward schooling or learning?
• What level of literacy or educational attainment is necessary to meet the client's current vocational goals?

The clinician can learn the answers to some questions indirectly by noticing cues from the client, assessing writing skills on the basis of the intake forms, and observing the client's patterns of communication. Other questions are best addressed by asking the client directly at an appropriate time in the treatment process. Typically, the clinician makes a preliminary estimate of the client's educational abilities at the outset, then refers the client to other resources as necessary for a more thorough assessment. Counselors working with clients who are ex-offenders also should be familiar with the educational resources available to those clients through the prison system so that appropriate referrals can be made if necessary.

When the clinician has the information about the client's educational history, needs, and interests, the clinician can then assist the client with identifying career goals and determining the education required to meet those goals. The clinician should help the client recognize when his goals may be either too high or too low. However, it is important to be sure the process is client-driven, emphasizing the client's responsibility for decisionmaking.

As the client demonstrates a capacity to engage in education and becomes more employable, the clinician can support the client by raising the bar of expectation and encouraging the client to take on more challenging educational and vocational objectives. It is important, however, that the pace of progress not exceed the client's ability to experience success and handle whatever disappointments occur.

Finding and Maintaining Employment

The process of finding a job provides an opportunity for clients to grow in many areas important to recovery. It provides an opportunity to practice goal-setting and recognize achievement. Through a successful job search, the client can acknowledge the potential for positive change and movement in a direction of her own choosing.

To be successful, clients may need to grow in a number of different ways. Common growth areas include the following:

• Overcoming the fear of change or the unknown. Counseling can be a valuable resource in overcoming this fear, which can lead to relapse in a newly recovering substance user. This fear is also addressed by pointing the client toward a job club formed by others in a similar position or by helping the client find a peer or mentor who has traveled a similar path. Judicious self-disclosure by the clinician may also be appropriate. Moving toward desired goals may still be anxiety producing, and small steps will maximize success.
• Developing job-seeking skills. These skills include allocating an appropriate amount of time to job hunting, finding ways to compensate for the lack of a network of well-placed contacts, using the job search methods most likely to be successful, being available for employer contact, and mastering the "walk, talk, and dress" of an employable person.
• Being patient. Overcoming the desire for immediate gratification, learning to accept incremental progress, handling disappointments appropriately, and keeping things in perspective are all parts of a healthy approach to work.
• Communicating effectively with the employer. Clients must learn how to present facts about the past and any disabilities to employers in a positive framework as well as how to gauge a prospective employer's willingness to work with a person in recovery. Addressing gaps in employment that have resulted from being fired from previous jobs or from being incarcerated is also important. This provides an opportunity to frame the treatment experience as a transition, focusing on the client's views for the future--but without dishonesty or denial. It can be beneficial for clients to talk with their employer about treatment and the choices they are currently making, placing their past choices firmly in the past. For some, being employed will provide incontrovertible evidence of the changes they have made. Counselors should caution clients to be selective in self-disclosure. Some employers can be very judgmental. Figure 3-2 depicts a model for an appropriate dialog that the client could practice through role-playing exercises with the clinician or therapy group members (recognizing that interviews in the real world are not likely to be so straightforward).

Once the client has found employment, the work setting itself will present challenges and provide opportunities for growth. It provides an opportunity to learn appropriate boundaries and appropriate self-protection. The client may need help discerning when self-disclosure is appropriate and when it is not. Recovering clients who are newly employed--particularly those with criminal records--should be careful of being in vulnerable positions in which they could be accused of stealing or other illegal behaviors (e.g., avoid closing up a store alone). Work will also provide an opportunity for some to recognize and accept responsibility.

Workplace conflict is to be expected, and persons in recovery may find such conflicts powerful triggers for relapse.

The workplace may evoke associations with the family of origin, intensifying and potentially distorting the client's sense of what is at stake in conflict situations. The clinician, alone or through a therapeutic group, can help the client get the distance needed to perceive the situation accurately. The therapeutic process will help the client become conscious of associations and better able to separate past and present issues. Impulse control, problemsolving skills, stress management, and conflict resolution skills may all require development. In addition, the client may need help recognizing the legitimate options open to her in the situation--for example, getting help from the human resource department or requesting a transfer.

Many persons in recovery experience problems with authority that can become clinical issues as they enter the work environment. Some mistrust authority and experience a great deal of stress when dealing with their supervisors. They may have an excessive fear of being fired or a too-quick response to perceived mistreatment. Some fail to manage anger and can explode when the boss is critical or inflexible. The clinician can help the client distinguish between appropriate and inappropriate behavior on the part of the supervisor, and, if this is a problem, help the client separate emotional reactions to the supervisor from feelings about a parent or other authority figure. Clients can work on seeing "the boss" as a person. In addition, clients should learn to recognize their personal power in dealing with the supervisor and notice opportunities to negotiate. These issues can be dealt with successfully in individual or group therapy, or the client may be referred to community resources for training in pertinent job and behavioral skills such as anger management.

Coping With Medical and Psychological Challenges

Some clients have medical and psychological needs and limitations that can affect the type of employment for which they are best suited. The clinician can help them consider how to present these needs and limitations to an employer and acquaint clients with their legal rights concerning accommodations.

Clinicians should receive basic information on the client's medical and psychological condition at intake. The Addiction Severity Index (ASI) can provide a brief history and description of the client's medical needs (See Appendix D). If a more in-depth vocational assessment is needed it should be done by a VR counselor or a vocational evaluator (see Chapter 2). Also, a physical examination is usually part of the intake procedure; the clinician should identify acute and chronic medical needs and identify a process to address them. In particular, clients should be screened for substance abuse-related disorders such as sexually transmitted diseases, HIV/AIDS, and hepatitis, at the initiation of the treatment process so that these disorders may be treated and stabilized prior to the client's vocational training or employment endeavor. The screening should include determining what accommodations might be necessary for a client with medical dysfunction in training or employment settings.

Similarly, at intake or as soon as possible thereafter, clinicians should determine whether the client has coexisting psychiatric disorders. ASI has a psychiatric domain that may be helpful. The client may have problems such as depression, anxiety, anger control, memory deficits, concentration deficits, or more severe symptoms such as hallucinations. In that case, the client should be referred to a psychiatrist for further evaluation and to determine whether medication is necessary (or if current medication is effective). Such disorders have implications for vocational planning and for the kinds of support the client needs from the clinician when actively seeking or trying to maintain employment. Keep in mind that diagnosis of a psychological disorder is impossible if the client is still using. The psychoactive effects of drugs or the manifestations of withdrawal may mimic the symptoms of mental conditions. Generally the client must have abstained from drugs for an extended period of time (6 to 12 months) before a differential diagnosis can be made.

Special issues arise for clients who are either reliant on opioid maintenance therapy (i.e., methadone) or dependent on prescribed medications. If a client is taking methadone, then she may fail drug tests mandated in some places of employment unless she has disclosed the fact to the employer's medical review officer. It can be beneficial for a methadone patient to transfer to treatment with LAAM (levo-alpha-acetyl-methadol) as LAAM cannot be detected in urine drug screens except for thin layer gas chromatography and gas chromatography/mass spectrometry. See TIP 22, LAAM in the Treatment of Opiate Addiction (CSAT, 1995d). Similar problems can arise with certain prescription drugs (see Chapter 7 for a discussion of associated legal issues). The clinician or another knowledgeable specialist should help the client manage appropriate self-disclosure in advance of the drug test so that his right to confidentiality is protected.

Medications can generate a variety of other work issues that, whenever possible, should be anticipated before the client seeks or accepts employment. Some psychotropic medications, for example, can cause side effects such as lethargy, dizziness, and nausea. It is essential that these side effects be considered when determining appropriate work situations for clients so that they are not placed in a dangerous situation or one that will ultimately lead to failure. The timing and conditions under which the medication must be consumed should also be taken into account. Some medications leave the body through sweat, reducing their effectiveness; clients in jobs involving physical exertion, such as construction, should make appropriate adjustments for this. In other cases, a job coach or other monitoring may be needed to help the client cope with coordination problems resulting from medication.

The clinician should also ensure that clients (particularly those with comorbid medical or psychiatric disorders) recognize the importance of finding a job with health insurance. A good number of clients will obtain jobs without benefits or with benefits that phase in after a probationary period. Those involved in treatment should coordinate their efforts to ensure the most positive blend of resources and services possible to assist clients. In addition, counselors should educate clients about their right to confidentiality and accommodation for disabilities (see Chapter 7; see also TIP 29, Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities [CSAT, 1998c]).

Coping With Environmental Challenges

Many clients must overcome logistical challenges to securing and maintaining work. The clinician can play an important role in helping clients identify the most effective approaches to addressing these difficulties. The Consensus Panel suggests using solution-focused strategies, building on coping skills the client has already demonstrated, and applying them to new contexts. Clinicians should encourage the client to identify resources used to accomplish other objectives and determine how these strategies might be useful in negotiating work-related issues. The clinician also should know about community resources, particularly in the frequently troublesome areas of housing, transportation, and child care. Progress and difficulties in meeting employment goals should be discussed regularly.

Coping With Legal Challenges

For some clients, eligibility for work can be affected by criminal records or by issues related to their immigrant or residency status. Clients are sometimes barred from specific jobs (such as child care worker) on the basis of prior convictions. In addition, many have records so complicated they are actually unaware of outstanding warrants; it is not unknown for a client to have rebuilt her life and be gainfully employed, only to be arrested for a crime committed some years ago. See Chapter8 for more information about working with ex-offenders.

Recent immigrants often need assistance in collecting the documents needed to work and in accessing reliable information about legal requirements. The clinician should direct such clients to community resources for help in applying for legal residency, getting a work permit, or learning the process for becoming a U.S. citizen. Clients not familiar with the U.S. Immigration and Naturalization Service and State requirements will need help distinguishing between realistic concerns and those that should not be a deterrent in seeking and maintaining work (see Chapter 7).

Developing Social and Life Skills

The first task in helping a client move toward employment is motivating the client to want to join society rather than be on its fringes. Work is an opportunity to advance the client's progress toward this important goal. The newly employed client can practice effective communication skills in a new environment, including learning how to talk to persons in authority, manage anger, and raise issues effectively. Developing confidence in appropriate self-expression, especially when it leads to the desired result, can enhance the client's sense of self-efficacy. Researchers have demonstrated that when people believe that they are capable of performing a new behavior (i.e., have efficacy expectations) and know that the new behavior will get them what they want (i.e., have outcome expectations), they are likely to persist and be successful in their attempts for change (Bandura and Adams, 1977).

Clients returning to work, or those attempting to maintain employment for the first time after a period of withdrawal from society, may be deficient in the basic skills needed to function within an organizational culture, manage resources, and gain social acceptance. Specific skills that may be needed include

• Communication skills, including appropriate and inappropriate responses to supervisors and coworkers
• Cleanliness, personal hygiene, and appropriate dress
• Management of personal finances
• Healthy eating habits
• Management of time, including getting enough sleep and being at work on time, managing competing obligations to family, work, and treatment (especially regular attendance at AA or NA meetings)
• Coping with crises that can trigger relapse
• Responding to invitations to "happy hour" or office parties
• Recognizing and respecting unwritten "rules" of the work culture, such as not bringing friends or children to work

Although some transition skills may be effectively gained through referrals to other community resources, it is the clinician's responsibility to assure the client of the necessity for change and to engage the client in mastering the social skills that will support recovery. The clinician can use the group therapy format to give clients an opportunity to role-play responses in difficult social situations and receive feedback from the group. If the client is employed at a work site that pressures him to drink, the client may need help avoiding or managing ostracism--or finding a healthier work environment.

For clients moving into the work environment for the first time or after an extended period of withdrawal, family members' behaviors toward the client around work issues can either help or hinder the client's progress. It will be useful for the clinician to have some information on how family members are responding to the client's employment situation.

An understanding and encouraging family can provide much needed emotional support to the client. Unfortunately, however, many families may have covert reasons for not wanting to see the client recover fully in the area of work. For example, clients may fear losing disability benefits if they recover sufficiently to work or a wife may be ambivalent about her husband's return to work because she has grown accustomed to being the sole decisionmaker in family matters while her husband was disabled by his substance abuse. If these issues are not addressed, then family members might not support the client's attempts to return to the job market. In fact, the family members might actually sabotage the client's efforts to return to work, viewing work as competition. For example, a client's child may begin acting out at school to get his attention. Recognizing and dealing with family resistance to work is a complex and continuing task with some clients.

Planning for a Career and Resilience

Preventing Relapse

As discussed previously, job-seeking and employment present an opportunity for growth and stabilization that can support recovery. However, the process can also be stressful and present many potential triggers for relapse. For example, if a client witnesses substance abuse on the job, should he report it or try to be "one of the guys?" General assistance in managing stress effectively should be provided. Even if the client can find employment that provides good support for a substance-free lifestyle, the workplace will almost inevitably present challenges that could trigger renewed use. The clinician should be alert for the presence of triggers that have affected the client in the past and help the client recognize and cope with them. For example,

• Losing a job may trigger relapse.
• Jobs that do not provide sufficient structure can lead to boredom--a common trigger for use. Time away from work, formerly structured by alcohol or drug-related activities, will also need to be structured.
• Some workplaces offer frequent invitations to socialize where alcohol or even, in some environments, drugs are consumed. The client may need help maintaining a substance-free lifestyle without becoming an outcast.
• Job finding will have a systemic impact on the family, especially when the "screw up" suddenly becomes the breadwinner and wants a major or leading role in family decisions. To help other family members cope with such changes, family therapy should be considered at an early stage of vocational counseling (if it is not already a component of substance abuse treatment). Family members are more likely to support the client's vocational goals if they understand the issues and feel included in the process.

Multidisciplinary Participation

To provide adequate support to the client in gaining successful employment, multidisciplinary participation is often needed. The case manager, whether the clinician or another person, should identify people from a range of professional disciplines who are able to supplement the clinician's skills and meet the client's needs. Most should be involved at the time of intake, then consulted afterward as needed. The group will most likely not come together as a team, but members should recognize that they each have significant responsibilities toward the client. Because of their ability to help clients meet therapeutic goals in their domain of employment, the group frequently includes the following members:

• VR counselor
• State or local employment service representative
• Education specialist or special education person for school or transition programming
• Nurse, physician, mental health clinician, or psychiatrist (for coexisting disorders)
• Adult education consultant
• Vocational trainer or work adjustment trainer
• Social worker
• Disability specialist
• Job placement specialist

Some clinicians would include the client's new employer or a representative of the client's school as a member of the treatment recovery team. Advantages to this approach include the potential for educating this person, as a representative of an institution that will play a key role in supporting recovery, to understand potential triggers for relapse in the workplace and increase the likelihood that the client will receive appropriate support. However, even assuming the client's informed consent, issues related to confidentiality, boundaries, and stigma should be carefully considered. Conflicts of interest could arise. The employer or educator may treat the client differently and project a bias, consciously or unconsciously, that affects the individual's employment experience.

Timing of Vocational Training, Rehabilitation, and Employment Services

Unless a client needs time for detoxification or adjustment to sobriety, some aspects of prevocational counseling can begin in the early stages of treatment. If the client has an immediate need for employment and is capable of managing it successfully, the timetable can be accelerated to encourage the client to accept an available entry-level job.

Although treatment initially focuses on use issues, a brief discussion of long-term treatment goals, such as work, will lay groundwork for later therapy. The client should have, in the back of his mind, the notion that work will be an important component of recovery, and although not addressed directly at first, vocational issues will play an important role in his treatment. The time for introducing vocational services must be paced according to the client's specific situations. Among the factors that must be considered are

• The client's stage of recovery
• The client's stability
• Any external legal mandates
• Impending termination of public assistance benefits (for either the client or dependent children)
• Limits on duration of treatment
• The client's goals
• The identification of therapeutic goals that may be addressed through the vocational domain (such as the need to learn to structure time or respond appropriately to authority)
• Client recovery needs that can only be met through gainful employment (such as earning funds necessary to move from a house where people are using substances)

It is important to coordinate treatment services to avoid conflict with the client's current job or educational pursuits because both of these may be helpful in stabilizing the client and supporting a substance-free lifestyle.

Tailoring Treatment Plans