Treatment Improvement Protocol (TIP) Series

Transcription

1 Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Integrating Substance Abuse Treatment and Vocational Services Treatment Improvement Protocol (TIP) Series 38

2 Integrating Substance Abuse Treatment and Vocational Services Treatment Improvement Protocol (TIP) Series 38 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857

3 Acknowledgments This publication was prepared under contract number for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Sandra Clunies, M.S., ICADC, served as the Contracting Officer s Representative. Disclaimer The opinions expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for the instruments or resources described are intended or should be inferred. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Printed Copies This publication may be ordered from or downloaded from SAMHSA s Publications Ordering Web page at Or, please call SAMHSA at SAMHSA 7 ( ) (English and Español). Recommended Citation Center for Substance Abuse Treatment. Integrating Substance Abuse Treatment and Vocational Services. Treatment Improvement Protocol (TIP) Series, No. 38. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD HHS Publication No. (SMA) First Printed 2000 Revised 2002, 2003, 2006, 2010, 2012, and 2014 ii

4 Contents What Is a TIP?...vii Editorial Advisory Board... ix Consensus Panel... xi Foreword... xiii Executive Summary and Recommendations... xv Recommendations... xvii Chapter 1 The Need for Vocational Services...1 Employment as a Goal...2 Challenges to Employing Clients in Treatment...3 Vocational Issues...6 Treatment and Employment...9 National Trends Affecting Employment...11 Chapter 2 Vocational Programming and Resources...17 Vocational Rehabilitation Counseling...17 Screening and Assessment...19 Vocational Counseling...27 Prevocational and Ongoing Services...29 Training and Education...30 Employment Services...33 Overview of Vocational Resources...36 Chapter 3 Clinical Issues Related to Integrating Vocational Services...47 Incorporating Vocational Services...47 Competency Areas for Employment...52 Developing the Treatment Plan...62 Case Studies...69 Chapter 4 Integrating Onsite Vocational Services...75 Planning an Integrated Program...76 iii

5 Contents Implementing and Operating the Integrated Program...80 Outcomes...87 Uniform Data Collection...88 Chapter 5 Effective Referrals and Collaborations...91 Collaboration as the Cornerstone of Effective Referral...91 Authentically Connected Referral Networks...96 Building an Authentically Connected Referral Network...99 Chapter 6 Funding and Policy Issues Managed Care Contracts as a Funding Source Impact of Policy and Funding Shifts Future Considerations Federal and State Funding Sources Endnotes Chapter 7 Legal Issues Part I: Discrimination in Employment and Employment-Related Services Part II: The Revolution in Rules Governing Public Assistance Part III: Confidentiality of Information About Clients A Final Note Endnotes Chapter 8 Working With the Ex-Offender Barriers to Employment: What the Offender Brings to the Process Barriers to Employment: What Society Brings to the Process Program Examples Endnotes Appendix A Bibliography Appendix B Resources: Tools and Instruments Appendix C Published Resource Materials Internet Sites Software Appendix D Addiction Severity Index Appendix E State Employment Agencies Appendix F Federal Funding Sources Appendix G Sample Individualized Written Rehabilitation Program Appendix H Resource Panel iv

6 Contents Appendix I Field Reviewers Figures 1-1 Challenges to Employment Strategies for Promoting Employment Vocational Services Provided to a Residential Treatment Facility Vocational Information From Initial Screen Assessment Tools Prevocational Counseling Activities Job Search Resources: America s Job Bank on the Internet Vocational Opportunities of Cherokee, Inc.: Rehabilitation Facility Providing Primarily Onsite Services The Michigan Drug Addiction and Alcoholism Referral and Monitoring Agency: A Case Management Model Combating Alcohol and Drugs Through Rehabilitation and Education (CADRE) The Texas Workforce Commission: Project RIO (Re-Integration of Offenders) Basic Materials for a Vocational Reference Library Early-Stage Vocational Issues and Approaches Answering Questions Related to Substance Use History A Sample Scenario Steps for Planning an Integrated Program Job Clubs Focus on Client Outcomes: The Future for Substance Abuse Treatment Providers Data-Matching Software Steps for Establishing an Authentically Connected Network Characteristics of Authentically Connected Referral Networks Agency Self-Assessment Categories Americans With Disabilities Act and Rehabilitation Act Protections Services Provided Under the Workforce Investment Act of Sample Consent Form Making a Referral to a Vocational or Training Program A Program That Addresses Women s Issues Summary of Program Examples F-1 Federal Funding Sources F-2 Federal Sources of Discretionary, Time-Limited Project Grants v

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8 What Is a TIP? Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic specific best practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at Although each consensus based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey ʺfront lineʺ information quickly but responsibly. If research supports a particular approach, citations are provided. vii

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10 Editorial Advisory Board Note: The information given indicates each participantʹs affiliation during the time the board was convened and may no longer reflect the individualʹs current affiliation. Karen Allen, Ph.D., R.N., C.A.R.N. Professor and Chair Department of Nursing Andrews University Berrien Springs, Michigan Richard L. Brown, M.D., M.P.H. Associate Professor Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D. Associate Director Medical/Professional Affairs Treatment Research Branch Division of Clinical and Services Research National Institute on Drug Abuse Rockville, Maryland Linda S. Foley, M.A. Former Director Project for Addiction Counselor Training National Association of State Alcohol and Drug Abuse Directors Director Treatment Improvement Exchange Project Washington, D.C. Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants and Trainers Richmond, Virginia Pedro J. Greer, M.D. Assistant Dean for Homeless Education University of Miami School of Medicine Miami, Florida Thomas W. Hester, M.D. Former State Director Substance Abuse Services Division of Mental Health, Mental Retardation and Substance Abuse Georgia Department of Human Resources Atlanta, Georgia James G. (Gil) Hill, Ph.D. Director Office of Substance Abuse American Psychological Association Washington, D.C. Douglas B. Kamerow, M.D., M.P.H. Director Center for Practice and Technology Assessment Agency for Health Care Policy and Research Rockville, Maryland Stephen W. Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Rockville, Maryland ix

11 Editorial Advisory Board Richard A. Rawson, Ph.D. Executive Director Matrix Center and Matrix Institute on Addiction Deputy Director, UCLA Addiction Medicine Services Los Angeles, California Ellen A. Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D. Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington Sidney H. Schnoll, M.D., Ph.D. Chairman Division of Substance Abuse Medicine Medical College of Virginia Richmond, Virginia x

12 Consensus Panel Note: The information given indicates each participantʹs affiliation during the time the panel was convened and may no longer reflect the individualʹs current affiliation. Chair Nancy K. Young, M.S.W., Ph.D. Director Children and Family Futures Irvine, California Workgroup Leaders Leslie Chernen, Ph.D. Project Director Brown University Rhode Island Public Health Foundation Providence, Rhode Island Sidney Gardner, M.P.A. Director California State University Fullerton Center for Collaboration for Children Irvine, California Margaret K. Glenn, Ed.D., C.R.C. Assistant Professor School of Allied Health Professions Counseling Virginia Commonwealth University Richmond, Virginia Gale Saler, M.Ed., C.R.C. M.A.C., C.P.C. Deputy Executive Director Second Genesis Bethesda, Maryland Terry Soo Hoo, Ph.D. Clinic Director Assistant Professor Counseling Psychology Department University of San Francisco San Francisco, California Diana D. Woolis, Ed.D. Senior Research Associate Program Demonstration National Center on Addiction and Substance Abuse at Columbia University New York, New York Panelists Diana D. Woolis, Ed.D. Judith Arroyo, Ph.D. Project Director COMBINE University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions Albuquerque, New Mexico Yvonne F. Bushyhead, J.D. Executive Director Vocational Opportunities of Cherokee Cherokee, North Carolina xi

13 Consensus Panel Alfanzo K. Dorsey, M.S.W. State Treatment Director Social Rehabilitation Services Kansas State Alcohol and Drug Abuse Services Topeka, Kansas Eduardo Duran, Ph.D. Clinical Supervisor Behavioral Health Rehobeth Hospital Gallup, New Mexico Paul Ingram, M.S.W. President/CEO Administrative Branch PBA, Inc. The Second Step Pittsburgh, Pennsylvania Gloster Mahon, M.S. Project Manager Illinois Jobs Advantage Project Chicago, Illinois Angela G. Rojas-Dedenbach, M.A. Director Michigan Jobs Commission Rehabilitation Services Lansing, Michigan Alex Trujillo, M.S. Clinical Counselor Counseling and Therapy Services University of New Mexico Student Health Center Albuquerque, New Mexico Tim Janikowski, Ph.D., C.R.C. Associate Professor Rehabilitation Counselor Training Program Rehabilitation Institute Southern Illinois University Carbondale, Illinois xii

14 Foreword The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA s mission is to reduce the impact of substance abuse and mental illness on America s communities. The Treatment Improvement Protocol (TIP) series fulfills SAMHSA s mission to reduce the impact of substance abuse and mental illness on Americaʹs communities by providing evidencebased and best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel s work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field. Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration Daryl W. Kade Acting Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration xiii

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16 Executive Summary and Recommendations 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 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 xv

17 Executive Summary and Recommendations 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 xvi

18 Executive Summary and Recommendations 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. Recommendations The Need for Vocational Services 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 xvii

19 Executive Summary and Recommendations 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) Vocational Programming And Resources Initial vocational screening can be done by an alcohol and drug counselor, and more indepth 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 employmentrelated 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 xviii

20 Executive Summary and Recommendations develop a relationship with the assigned VR office. (2) Clinical Issues Related to Integrating Vocational Services To help clients attain work-related goals that will also support their recovery, the alcohol and 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) Integrating Onsite Vocational Services 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) xix

21 Executive Summary and Recommendations 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) Effective Referrals and Collaborations 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 recognize 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) Funding and Policy Issues 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) Legal Issues 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) xx

22 Executive Summary and Recommendations 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) Working With the Ex-Offender 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 exoffenders 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 gendersensitive program that offers a continuum of care, including aftercare. (2) Counselors should help clients who are exoffenders 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 xxi

23 Executive Summary and Recommendations 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) xxii

24 1 The Need for Vocational Services Work as a productive activity seems to meet a basic human need to be a contributing part of a group. It is critical that the meaning of work be understood in the context of each individual s personal values, beliefs, and abilities; cultural identity; psychological characteristics; and other sociopolitical realities and challenges. But what is work exactly? This appears to be an obvious question, but the nature of work is a multifaceted concept. The most basic definition of work is that it is a purposeful activity that produces something of economic or social value such as goods, services, or some other product. The nature of work is varied and may include physical activities (e.g., laying bricks), mental activities (e.g., designing a house), or a combination of physical and mental activities (e.g., building a house). High- or low-paid, hard or easy, work is effort toward a specific end or finished product. Many individuals in this country, however, are not in the workforce and do not hold regular jobs, including a large percentage of persons who have substance abuse disorders. Employment traditionally has not been a focus or a stated goal of treatment for substance abuse. The standard approach has been to take care of clients addiction problems, and in doing so issues such as employment would take care of themselves because of clients increased selfesteem and desire to succeed. Even in instances where employment has been a stated goal of substance abuse treatment, the vocational services to support such a goal have not been readily available for all clients. Recent reforms in the public welfare system and other benefit programs stress even more the importance of work and self-sufficiency. Because substance abuse disorders can be a barrier to employment, it is imperative that vocational services be incorporated into substance abuse treatment. This is particularly important because these treatment programs must be ready to serve the many welfare recipients with serious alcohol- and substancerelated problems who must find and maintain employment within a very short timeframe. This TIP was developed to assist alcohol and drug counselors with the daunting task of addressing the vocational and employment needs of their clients, especially in light of legislative and policy changes. While the alcohol and drug counselor may not be able to achieve complete mastery of multiple disciplines, she must acquire at least rudimentary skills in the area of vocational services provision, as well as be prepared to function as a case manager who advocates for the needs of the client and calls on other expert professionals as needed to provide the services that support the treatment process. This chapter discusses the rationale for integrating vocational services with substance 1

25 Chapter 1 abuse treatment, given that work is necessary for the physical and emotional recovery of clients with substance abuse disorders. Chapter 2 describes vocational programs and resources and the role of the vocational rehabilitation (VR) counselor. Chapter 3 discusses the clinical issues related to integrating vocational services with substance abuse treatment services, and Chapter 4 continues that theme by describing how to incorporate onsite vocational services in substance abuse treatment programs. Chapter 5 discusses strategies for developing referral networks, and Chapter 6 provides information about seeking funding for these services. Legal issues and available resources are discussed in Chapter 7. Chapter 8 describes how to help clients in the criminal justice system address vocational issues. After reading this TIP, alcohol and drug counselors should have a better understanding of the importance that the world of work has for helping clients recover from abusing substances and how to tap into the wealth of resources available to help their clients gain entry into this critical aspect of human society. Employment as a Goal Unemployment and substance abuse disorders may be intertwined long before an individual seeks treatment. The 1997 National Household Survey on Drug Abuse revealed that 13.8 percent of unemployed adults over age 18 were current substance users, compared with only 6.5 percent of full-time employed adults (Substance Abuse and Mental Health Services Administration, 1998). The unemployment rates of people with substance abuse disorders are much greater than those of the general population, even though the mean educational levels of the two groups are comparable (Platt, 1995). A related finding from numerous research studies is that employment before or during substance abuse treatment predicts both longer retention in treatment and the likelihood of a successful outcome (Platt, 1995). A study of employment outcomes for indigent clients in substance abuse treatment programs in the State of Washington concluded that of the factors measured in this research to determine who was likely to be successful following treatment, pretreatment employment accounted for 50 percent of the reasons why they were successful. Client characteristics explained about 33 percent of the reasons, and treatment factors accounted for only 12 to 18 percent of differences in employment outcomes (Wickizer et al., 1997). Although employed clients who have a strong work history usually respond well to substance abuse treatment, other variables that measure functioning and stability can also influence treatment success, such as education and a positive marital relationship. Employment also helps moderate the occurrence and severity of relapse to addiction (Platt, 1995; Wolkstein and Spiller, 1998). In addition, employment can offer the opportunity for clients to develop new social skills and make new, sober friends who can help clients maintain sobriety. Another important impact of employment on clients is the development of positive parental role models for their children. Metzger found a correlation between parental employment during the childhoods of both African American and White methadone clients and these clients subsequent work histories (Metzger, 1987). Work breaks the intergenerational patterns of unemployment and dependency on social services. Clients have often indicated a desire for vocational services, although they seldom have received sufficient assistance to meet their needs or expectations (Center for Substance Abuse Treatment [CSAT], 1997; French et al., 1992; Harwood et al., 1981; Platt, 1995). However, clients who are interested in training and 2

26 The Need for Vocational Services employment services may have unrealistic goals and expectations about the kind of work they are qualified to do. Therefore, clients should be referred to educational programs where they can acquire the education or training they need to meet their employment goals. In an ongoing effort to develop model training and employment programs (TEPs) for treatment facilities in Connecticut, a 4 site survey of 337 clients found that 88 percent were actively interested in vocational services leading to fulltime jobs paying $8 to $10 per hour. When asked what they hoped to do, however, 34 percent of these clients said they wanted a technical or professional occupation, and another 21 percent wanted a craft or skilled labor position. However, these were not realistic expectations for the skill levels possessed by these individuals (French et al., 1992). Challenges to Employing Clients in Treatment Unemployed clients in substance abuse treatment programs face many challenges and obstacles in obtaining and keeping jobs. Employed clients may need help finding more satisfying work or identifying and resolving stresses in the work environment that may exacerbate ongoing substance abuse or precipitate a relapse. The barriers clients face may exist within themselves, in interpersonal relations with others, or in coexisting medical and psychological conditions. Barriers also stem from society, scarcity of lower level jobs, and prejudice against employing people with substance abuse disorders. Comprehensive and individualized substance abuse treatment can help overcome existing barriers to employment but is often not sufficient by itself. Vocational services can help clients obtain marketable skills, find jobs, develop interviewing skills, and acquire attitudes and behaviors necessary for work, such as punctuality, regular attendance, appropriate dress, and responsiveness to supervision (Wolkstein and Spiller, 1998). Alcohol and drug counselors can help clients address work-related issues, even when VR counselors are not available. For example, a methadone or outpatient program where clients are required to report several times during the week presents a setting to help clients develop punctuality, regular attendance, and appropriate dress and behavior skills that could later be transferred to the work place. Figure 1-1 presents common challenges faced by substance abuse treatment clients who are seeking work. These have been cited by Consensus Panel members and a many investigators and specialists in the area of vocational services. Employability appears to be inversely proportional to the number of coexisting disabilities and social disadvantages faced by each client (Platt, 1995; Wolkstein and Spiller, 1998). Different investigators identified various hierarchies and combinations of obstacles that seem critical in predicting employability. The priority of barrier will vary by individual and the specific situation. In a review of the research, Platt notes that special disadvantages such as culturally distinct population status, physical disability, criminal record, mental instability, and a lack of a high school education or equivalency all decrease the likelihood of employment (Platt, 1995). The Urban Institute found a similar set of barriers to employment for welfare recipients, including substance abuse, physical disabilities, mental health problems, children s health or behavioral problems, housing instability, learning disabilities, and, most important, low basic skills (e.g., literacy, job skills, life skills) (Olson and Pavetti, 1996). A risk index for welfare recipients reaching Statedefined and Federal time limits (60 months) without employment cites some female-specific, but similar, disadvantages. 3

27 Chapter 1 Figure 1-1 Challenges to Employment Client Obstacles Personal Substance use (substances used, history and pattern of use, relapse, associated problems) Mental or physical disabilities (psychiatric comorbidity, physical or medical condition, neuropsychiatric disability, cognitive disabilities, HIV/AIDS) Deficits in education and skills (education level, learning disability, literacy, language, computer knowledge, obsolete or low-level job skills, little or no work experience) At-risk history (developmental, familial employment, employment, criminal, loss of parental rights) Unrealistic expectations and attitudes (toward job demands, work habits, authority, capability for self-sufficiency, personal competencies, change, failure, impulse control, delayed gratification) Inadequate income (for clothing, food, transportation, housing, child care, job-related equipment) Work disincentives (from welfare-based income, illicit activities, relatives) Discontinuation of health benefits Crisis lifestyle (illnesses, children s illnesses, violent community, numerous family tragedies and deaths, children s school problems) Learned helplessness or dependence taught to clients over the years First things first approach where the client is conflicted about seeking employment and instead encouraged to focus exclusively on sobriety (often this approach is used by 12-Step programs) Attitudes Negative attitudes toward vocational rehabilitation Negative attitudes toward disability Interpersonal History of violence or abuse (e.g., domestic, physical, sexual, and psychological abuse; criminal activity) Competing family responsibilities (e.g., child or elder care, disabled family members or relatives) Inadequate social supports (e.g., spousal, familial, peer group, community, institutional) Lack of positive modeling (e.g., peer group, familial/parental, societal) Substance Abuse Treatment Program-Level Obstacles Staffing No onsite VR counselor No staff knowledge about or use of available employment and vocational services No staff training in delivery of vocational services Lack of understanding about vocational issues Client Counselor Interactions Poor therapeutic relationship Discrepant expectations with respect to vocational goals and needed services Agency and counselor attitude about addressing substance abuse disorder before any other issues (e.g., vocational services) 4