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Center for Substance Abuse Treatment. Integrating Substance Abuse Treatment and Vocational Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2000. (Treatment Improvement Protocol (TIP) Series, No. 38.)

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Integrating Substance Abuse Treatment and Vocational Services.

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Chapter 4—Integrating Onsite Vocational Services

A key purpose of this TIP is to help treatment programs rethink their philosophies and restructure their services around the belief that productive activity (work) is crucial to the health and long-term recovery of clients. One way to ensure that clients receive the necessary vocational services is to provide them in-house as an integral part of the substance abuse treatment program, rather than by referral to outside agencies. Each program must decide to what extent it wants to and can provide onsite vocational services. This chapter is designed to guide programs in this important decisionmaking process. Even those programs that cannot offer a full range of vocational training and employment services within their program setting can benefit from the information in this chapter. The chapter also describes how programs in various treatment modalities, from therapeutic communities to low-intensity outpatient treatment, can begin to address the vocational needs of their clients.

Employment and vocational services need to be a priority in every treatment program and 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 vocational rehabilitation (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. No matter the treatment modality or level of service, inclusion of a vocational specialist who is cross-trained in or at least sensitized to substance abuse disorder issues will create a new dynamic in the program. Through both formal and informal interactions, this staff member will begin to raise the awareness level of other treatment staff members about vocational issues. The vocational specialist can identify ways in which the staff members are already addressing vocational issues but simply not thinking of their efforts in vocational terms. For example, when one therapeutic community hired a VR specialist to help its treatment counselors provide vocational services to residents, she pointed out that many aspects of the program already addressed clients' vocational needs. She demonstrated how the job assignments given to residents emphasized the development of prevocational skills and explained that they were really operating a work adjustment training program. However, a VR counselor can provide more intensive and specific counseling, assessment, resource development, and treatment planning.

Unfortunately, some programs do not have the resources for such a staff specialist. However, a consortium or network of programs may sometimes be able to share a specialist as a consultant who provides training and other staff development activities on an occasional basis and guides work with particular clients. At the same time, it must be acknowledged that even the most comprehensive program cannot meet the treatment and vocational needs of all clients. Welfare reform, health care reform, and other funding pressures can overwhelm treatment programs because they must meet the vocational needs of all clients with less support and in shorter periods of time. Referrals to outside vocational service agencies are necessary for many clients.

Every treatment program should consider itself part of a collaborative interagency effort to help clients achieve productive work. For the purposes of this TIP, the onsite integrated services model is discussed separately from the integrated services through referral model (discussed in Chapter 5). In reality, most programs exist on a continuum with onsite programs making fewer referrals, but where referrals continue to be a key part of providing services to all clients.

Planning an Integrated Program

Any decision to integrate vocational services into a substance abuse treatment program must be supported by the board of directors, the administrative staff, and the alcohol and drug counselors. This level of support is necessary to effectively change the existing "culture" of the treatment program and ensure that vocational services are a core part of treatment and not just a supplementary service.

To effect this change, the mission statement should be modified to encompass vocational goals and to ensure that all staff members embrace these goals (see Figure 4-1). An important philosophy to articulate in the mission statement is the belief that work is crucial to the health and long-term recovery of clients and that implementing vocational services is in itself therapeutic. As discussed later in this chapter, outcome studies must consider employment as one of the key variables in measuring program success. It is important to be aware that work in the competitive market may not be possible for all clients. Moreover, people often seek to contribute to their community, either by volunteer work or by some other type of educational or similarly productive involvement with the larger world that enriches their interactions with others and their sense of self-worth. Thus, the concept of employment "success" may need to be broadened when the outcomes of substance abuse treatment programs are evaluated.

Choosing a Program Model

The treatment program must decide the parameters of what it can offer clients in terms of vocational services. Many factors will enter into this decision. To begin the decisionmaking process, the program must addressseveral questions:

  • What type of substance abuse treatment does the program provide?
  • Who are the program's clients and what are their vocational needs?
  • What are the staff members' skills, experiences, and backgrounds that can influence how they learn and incorporate new ideas and approaches?
  • What vocational training and employment programs are available in the local community, as well as funding sources for vocational services?
  • What are the program's capabilities for providing vocational services?

The most important factors in choosing a program model are (1) the modality of the substance abuse treatment program and the intensity of services provided, and (2) the specific needs of clients. Treatment programs vary from the least intensive level of outpatient treatment to highly structured residential programs, such as therapeutic communities. The degree to which the program can structure the client's daily life and the length of time spent in the program significantly dictate the range of onsite vocational services that can feasibly be offered. A therapeutic community in which clients generally reside for several months can offer a much wider range of vocational services than a short-term (14- to 28-day) residential program whose main objectives are to stabilize clients and initiate the recovery process before discharge.

The vocational needs of the majority of the program's clients, as well as other client-related factors such as their values and the realities they face in finding employment, are other key factors to consider in deciding the parameters of the onsite services offered. The important issue of cultural competence is discussed more fully in Chapter 5. Suffice it to say here that 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.

In any program, clients' ability to work will vary greatly. Some clients who have never worked or who are chronically unemployed will need habilitative and prevocational training. Others with more regular work histories may need help learning new job skills, finding work, or recognizing work-related relapse triggers. Some programs treat a large number of clients with a high level of coexisting disorders (e.g., serious mental illness). Clients with extensive or special needs outside the program's vocational capacity should be referred to collaborating agencies. Collaboration is discussed in Chapter 5.

One approach to evaluating the vocational needs of the client population is to survey clients who are currently in the program. A series of focus groups is an effective way to understand the particular needs of a program's client population. In these groups clients can discuss their needs and support each other in articulating their problems, gaining confidence about themselves, exploring employment goals, and preparing for finding and maintaining work. Another approach is to follow up with former clients to document their current vocational status and ask them which services they received at the agency were most and least helpful, and what services they would have wanted.

Training and Developing Existing Staff

As noted previously, hiring or contracting with a VR counselor familiar with substance abuse treatment issues is an effective strategy to begin addressing the vocational issues, awareness, and training needs of program staff. Another option is to collaborate with State VR agencies that offer inservice training on vocational issues to alcohol and drug counselors. Joint training of alcohol and drug counselors with VR specialists should be encouraged, when appropriate. Key resources for such training and education are State and Federal VR authorities, which are found in every State, as well as the Rehabilitation Research and Training Center (RRTC) on Drugs and Disabilities. Other resources include university-based rehabilitation continuing education programs located throughout the country. Whether an agency is large and multiprogrammed or smaller, appointing someone as case manager can help ensure efficient collaboration, both intra- and interagency.

Another strategy for bringing VR expertise into the program is to form linkages with undergraduate and graduate programs in VR counseling and to offer the treatment program as a training site for internships in which students in these programs can be cross-trained in substance abuse treatment issues--provided that supervision and support are adequate and appropriate.

Recruiting and Hiring New Staff Members

Integrating vocational services and ensuring that all staff members share the program's values and mission will involve examining and changing job descriptions to recruit staff with vocational experience and training. Advertising and recruiting efforts can be broadened to include journals and programs of interest to VR counselors. Again, linking with a university to provide an internship site is a highly effective strategy for recruiting permanent staff members who possess the necessary skills. As part of their professional service obligations, university faculty should be open to providing inservice training programs on VR topics for the agency's staff. In turn, treatment staff may be able to help university faculty by offering to give guest lectures on substance abuse issues, becoming a resource for the university's employee assistance program, or helping with student intervention services.

Developing Relationships With Employers

A key aspect of incorporating vocational services into a program is to develop relationships with both large and small local employers. Many mutual benefits can result from ongoing relationships with employers because programs develop an understanding of the types of workers these employers are seeking and employers begin to perceive the program as a good source of job applicants. In geographic areas where there are multiple treatment programs, consideration should be given to a collaborative effort to develop relationships with potential employers. A centralized clearinghouse can also lead to better matches between jobs and the applicants for them.

The VR field has developed several approaches to initiating and maintaining such relationships. Becoming familiar with a particular employer, researching its products and human resources, and using a businesslike approach (e.g., professional dress, business cards, promptness) can be effective approaches (Vandergoot, 1984). Another approach offers an employment service or pool of qualified potential workers to employers as an incentive for establishing an ongoing relationship (Shafer et al., 1988). Documents describing these approaches can be obtained from the National Clearinghouse of Rehabilitation Training Materials (see Appendix C, "Published Resource Materials").

In addition, many large employers have on-the-job training programs. For example, a large hotel chain offered on-the-job training for entry-level positions as front desk clerks, housekeepers, and laundry and kitchen personnel that allowed them to advance in their chosen job areas. Large employers also usually provide some level of employee benefits, such as medical leave, insurance, and access to child care. Relationships with small family-owned businesses can also be an important source of ongoing employment for clients. One program placed a client several years ago in a family-owned carpet business as a warehouse worker. That individual is currently the warehouse supervisor and hires many of the program's clients, giving them a chance to return to or enter the workforce in a supportive work environment. Clients who have completed treatment and are successfully working are excellent resources for information about job opportunities and prospective employers.

Some cities have business advisory groups that assist with return-to-work programs. Another good resource may be the Welfare to Work Partnership, a nonpartisan, nationwide effort designed to encourage and assist private sector businesses with hiring people on public assistance. This network of both large and small employers is committed to hiring individuals with multiple barriers and little work history. The partners are committed to working with many social service agencies to find solutions and promote a healthy workforce. See their Web site,, for more information.

Finding Employers for Ex-Offenders

Ex-offenders are one group for which it is often particularly difficult to find job placements; therefore, treatment programs that involve job placement activities will need to make a special effort to locate employers for this population. Providers should be proactive when possible, in order to convince potential employers of the reliability of their clients. It will take time to develop strong and lasting relationships with employers willing to hire ex-felons, and providers working with this population should not expect immediate success. Once relationships with employers are formed, providers should exert effort to maintain these relationships and ensure that employers are satisfied with clients they hire.

Programs should inform potential employers about any financial benefits for which they may be eligible if they hire an ex-felon. For example, under the Tax and Trade Relief Extension Act of 1998 (P.L. 105-277) employers who hire ex-felons from low-income families are eligible for a tax credit of up to $2,400. Funds are also available for States from the Federal government under the Job Training Partnership Act (29 U.S.C. §§201-206) as amended by the Workforce Investment Partnership Act of 1998 (P.L. 105-220), which States can use for a variety of services including on-the-job-training. Ex-offenders are one of the groups specifically covered in this legislation. These latter funds are distributed through the States, and individual State departments of labor should be contacted for more information on the funds available. There are also Federal funds, distributed through State employment services (also known as One-Stop Career Centers), to pay for bonding for ex-felons and people in recovery from substance abuse disorders. This bonding service is provided free-of-charge to employers who are willing to hire ex-felons.

Implementing and Operating the Integrated Program

The specific procedures that a program develops will depend on the scope of vocational services it decides to incorporate into its treatment protocol. However, in an integrated program, vocational services are regarded as therapeutic, and a client's attitudes toward work, work skills, work history, and work goals are clinical issues that have an impact on recovery. Even if clients pass through the program very quickly, vocational concerns can be introduced and addressed in individual or group counseling, through brief screening in the form of work-related questions as part of an intake interview, or as part of relapse prevention in discussing work-related triggers.

Once the treatment program has decided to integrate vocational services, the degree to which the program can structure the client's daily activities while in treatment and the length of time the client spends in the program dictate the range of onsite vocational services that can feasibly be offered. The following section describes three levels of treatment programs and the types of vocational services that can be incorporated into each setting. The three levels of programs include high-structure programs (therapeutic communities and day treatment programs), which can offer the broadest range of services; medium- and low-structure programs (intensive outpatient treatment, standard outpatient treatment); and short-term residential programs (programs shorter than 30 days). Strategies for other kinds of programs, such as detoxification programs, opioid management programs, and halfway houses, are also discussed.

High-Structure Treatment Programs

Clients in therapeutic communities both live and work in these facilities, and their daily lives are highly structured by the ground rules and operations of the program. The length of stay in these programs varies widely, ranging from 10 days to 1 year or more. Clients in day treatment programs may spend about 6 hours a day at the program facility. Compared with a therapeutic community, the length of stay in day treatment programs is generally shorter, ranging from 4 to 6 weeks to several months. Interactions among staff members and clients and their peers are potent aspects of these high-structure programs, in which clients tend to seek the approval and respect of other members of the circumscribed and structured community.

Many clients in high-structure programs have little or no work history. Many lack education, are not competitive for training or career-track positions, and lack the financial skills to handle a paycheck or control impulse spending. Few have experience in setting and achieving personal goals or successfully completing treatment for their substance abuse. Many have a personal or family welfare history, and many have a criminal record. Clients' low self-esteem and lack of appropriate role models, combined with distorted expectations and ideas of "success" and the lack of a positive vision for their lives, all strongly contribute to their difficulty in obtaining and maintaining stable employment.

Therapeutic communities and day treatment programs are ideal sites in which to establish vocational services based on a classic rehabilitation model (Rubin and Roessler, 1995; Wright, 1995). Such a model includes the following components:

  • Prevocational stage testing and work skills evaluation
  • Work adjustment training, including education about work
  • Attention to activities of daily living
  • Formal vocational training and services (both classroom and on the job)
  • Goal setting and developing a personal plan
  • Postplacement job retention strategies

Some of these vocational components and ways they can be integrated into high-structure programs are discussed in more detail below.

Work adjustment training

Work adjustment training, as described in Chapter 2, uses work in a structured environment to teach accepted employment practices (i.e., education about work--the workplace, employer expectations, etc.). Therapeutic communities provide a wide range of internal work adjustment opportunities in the form of chores or job functions that support the day-to-day operations of the program and facility. Day treatment programs also can create such opportunities by establishing client-operated departments or services that are important to the operation of the program.

In a work adjustment environment, clients are assigned various jobs after they enter the program. Early work assignments are designed to enhance clients' strengths and build self-esteem by helping clients "discover" skills they did not realize they had. These work assignments focus clients on the importance of completing a task, working as a team member, and developing a sense of pride and personal satisfaction in a job well done. Early work assignments usually are less complex, guarantee initial success for most clients, and offer an opportunity for advancement to more responsible positions in the structure. Later, as clients demonstrate a commitment to their treatment goals and an ability to handle work positions of increasing responsibility, assignments become more complex and are designed to address behavioral areas clinically identified as essential to progress in recovery.

Other work skills emphasized in work adjustment training are attention to details, successful task completion, frustration, tolerance, and accountability.

In addition to acquiring supervisory skills, clients learn how to handle on-the-job advancement and how to model appropriate work behavior for newer members of the program. For many clients in these programs, a key work-related issue is understanding and dealing with authority in constructive ways that will not jeopardize their job.

When vocational rehabilitation and treatment for substance abuse are integrated in this way, clients not only work at various tasks with peers but also encounter these same peers in substance abuse disorder group counseling. Thus, work-related issues are addressed by clients in clinical groups, and clinical themes arise in vocational activities. Substance abuse disorder recovery and "vocational recovery" are synchronized, and clients are afforded opportunities for insights into problems and the interrelatedness that occurs when services are so thoroughly integrated.

Activities of daily living

High-structure programs can establish groups that focus on job issues addressing positive workplace behavior such as appropriate grooming, dress, and proper socializing on the job, as well as self-defeating and negative behavior in the workplace. Work-related triggers for relapse, such as disappointments and frustrations, can also be addressed in recovery in vocationally oriented group and individual counseling and in work adjustment training. Financial management skills can be provided on both an individual and a group basis. Efforts to improve skills in activities of daily living should also focus on social supports: making friends, having hobbies, networking for job-related information, and structuring leisure time. The importance of a client's hearing the same messages in all aspects of her treatment and from both alcohol and drug and vocational staff members should not be underestimated.

Formal vocational services

Work adjustment training involves bringing all clients to a basic level of work readiness before actual job-seeking activities begin. All programs should establish specific criteria that a client must meet before beginning formal vocational counseling. These criteria will define the point in the treatment process when a client will begin receiving formal vocational services, which is dictated in part by the length of a given treatment program. Formal vocational services provided at this point can include assessment, counseling, planning, résumé and interview preparation, and teaching other job-seeking skills, as well as job placement and monitoring. These services are described in detail in Chapter 2. A comprehensive vocational program would also include a vocational library that both staff and clients could use as resources for vocational planning and job placement. Figure 4-2 provides information about job clubs.

Setting goals and developing a personal plan

Developing and implementing a personal plan for change is another key aspect of vocational rehabilitation. The client develops the plan in consultation with vocational and treatment staff. The plan lays out the direction in which a client wishes to go and demonstrates that the client understands the steps necessary to achieve his goals. The plan can address vocational, educational, social, familial (including children), and housing goals, as well as relapse triggers and ongoing needs for substance abuse treatment. It generally requires the client to anticipate obstacles and develop contingencies or alternative strategies for coping with them.

The idea of the plan may be introduced to clients early in the treatment process so that they can begin to think about it. However, clients in high-structure programs may not be ready to actually develop a plan until they have learned about the effects of substance abuse on all aspects of their lives and have learned about the world of work and their vocational strengths and deficits. The length of the individual's proposed treatment is again a factor, and clients in shorter term treatment programs may be encouraged to develop plans that are more focused on specific, immediate vocational goals. Plans can also be used effectively in counseling groups because "going public" with a plan often enhances the client's commitment to it.

Counselors should evaluate the client's plan to determine whether the vocational goals the client sets are realistic (not too high or too low) and whether achieving the goals will allow the client to make a sufficient living and support continued recovery. In many ways the process of developing the personal plan is more important than the actual content of the plan. Situations and goals change, but once clients have mastered the process, they can create new plans on their own as their future situations require. In any case, it should be emphasized that the plan will be most useful if both the goals and the timeframe for achieving them are as specific as possible.

High-structure programs that incorporate the development of a detailed personal plan may wish to encourage formal presentations where the client describes his plan to selected peers and staff and receives feedback from the group. This "approval committee" can also include outside professionals involved with the client, such as a probation officer or a child welfare worker. For clients from particular ethnic groups, the approval committee might also have representatives of the community to which the client is returning at discharge. The presentation can be done in a formal way that symbolizes a passage from the exploration and information gathering that characterize the early stage of the treatment to action. The committee evaluates the client's plan, makes suggestions, and, by approving it, endorses the plan and gives the client permission to carry it out.

Medium- and Low-Structure Treatment Programs

According to the model developed by the American Society of Addiction Medicine (ASAM), clients in intensive outpatient treatment spend from 9 to 20 hours a week in the treatment program, and clients in standard outpatient treatment spend less than 9 hours a week (ASAM, 1996). Lengths of stay vary widely but can be 6 months or longer in outpatient treatment. Lengths of stay in short-term residential treatment have declined in recent years because of pressure to contain costs, from typical 28-day programs to programs as brief as 10 to 14 days. Clearly, the range of vocational services for clients in medium- and low-structure programs is narrower than the services offered in high-structure programs. However, even 1 hour of rehabilitation services a week for 24 weeks, or 1 hour a day for 14 days, can be a significant level of attention for clients with serious vocational needs.

Most substance abuse treatment is provided in outpatient settings--generally in the lowest intensity modality (i.e., less than 9 hours a week). Thus, finding innovative ways to address the needs of clients in these programs, for which funds are often limited, is critical. As noted earlier, the Consensus Panel recommends that outpatient programs either hire a VR counselor or obtain such services through a VR consultant.

The time devoted to VR issues in outpatient programs can be used in several ways; some are described below. (Vocational activities that can be undertaken by methadone maintenance programs, halfway houses, and short-term residential treatment programs are described in a separate section.)

Education about work and job seeking

A brief introductory presentation and a question-and-answer session on work, jobseeking, and daily living skills can be completed in an hour. Many topics related to the world of work may be helpful to discuss with clients. These include what work is, work values, career exploration, résumé development, job searching, job interviewing, the workplace, workers' and employers' rights, discrimination, and maintaining employment. A series of presentations could be developed, with one session devoted to each of these topics.

If staff time for these presentations is limited, the outpatient program should look to organizations in the community that can send volunteers to address client groups, such as the local Chamber of Commerce, the State employment service, or the State VR system. Private Industry Councils and local Workforce Investment Boards also have career counselors who could address client groups about the availability of education and training opportunities, local employment opportunities, and job readiness issues. For example, the director of human resources of a large corporation can provide a group with valuable information about how to make a good impression during an interview. Employers with whom the program has placed clients can be guests. In addition, alumni of the program who have unusual or interesting jobs or who have completed training courses for particular occupations (e.g., mechanic, electrician, beautician) can talk about what they do and the obstacles they faced in achieving their goals. Local entrepreneurs who have been successful at starting their own businesses often have motivational stories to tell. The emphasis at these presentations should not be on recruiting clients into specific occupations but on how ideas and motivation can be transformed into action to achieve desired goals.

Another tactic is for counselors to give homework assignments related to work issues. For example, clients can be asked to bring in five employment ads from a newspaper that describe jobs that appeal to them. Another homework assignment might be for the client to register with a local job search agency or visit the local library to explore references about career options.

Vocational assessment

During the intake interview, outpatient programs typically collect information about the client's vocational needs using various assessment tools. An example used by substance abuse treatment programs is the Addiction Severity Index (ASI) (McLellan et al., 1980, 1992), one domain of which assesses the client's education and employment skills, sources of financial support, and severity of problems at work. However, this is not an adequate substitute for an assessment done by a VR counselor.

Assessment tools that clients can use independently can be an efficient use of resources. For example, Holland's Self-Directed Search is an instrument that clients can complete themselves, and the results can be viewed as a form of vocational self-assessment (Holland, 1985a). A client may learn from the process that she likes to produce a tangible product and does not like to deal with more process-oriented tasks that involve "shuffling papers" and "crunching numbers." This information can also be highly useful from a clinical standpoint in addressing work-related stressors and substance use triggers. Clients can be encouraged to discuss in a group setting what they have learned, as well as concerns they face about maintaining a job, returning to a job, or seeking a job while stabilizing in recovery.

Incorporating vocational issues into group counseling

Although many traditional outpatient programs are based on an individual counseling model, groups can be an effective way for clients to address work-related issues. Problems that clients have on the job may become more conspicuous in the context of the group than in the individual counselor's office. Group members who have job interviews can be helped by the group to role-play any problems they anticipate in the interview, such as questions about their substance abuse or criminal history. Group members who are working can provide valuable advice about on-the-job behavior.

Some outpatient treatment programs for substance abuse may hesitate to develop groups specifically for vocational rehabilitation because they receive reimbursement only for substance abuse treatment services. In the climate of welfare reform, they may be successful in convincing funding sources that VR issues are key to clients' recovery and to bringing Temporary Assistance to Needy Families (TANF) and welfare-to-work resources to the substance abuse treatment site (see Chapter 6 for more information about funding). However, even if funding is not available, a VR group can be set up with volunteer presenters and experts from the community.

Short-Term Residential Treatment

As noted previously, stays in short-term residential programs, formerly known as 28-day programs, have been greatly reduced. Typically, the focus is to stabilize the client and initiate recovery before discharge to outpatient care. Because of their limited timeframe, such programs are the most difficult in which to integrate VR services, and they probably do not have a VR counselor on staff. Historically, the alcohol and drug counselor sometimes helped clients find jobs, but financial squeezes on these programs make current staff involvement or vocational assessment unlikely.

However, staff members in short-term residential programs can do a vocation-oriented interview after program entry that includes some type of screen for vocational problems. Discharge planning around vocational issues is encouraged, as are referrals to outpatient VR services. The program staff should develop a knowledge of community resources for referral. Another way to incorporate vocational issues into these programs is to use self-report instruments, such as Holland's Self-Directed Search or Vocational Preference Inventory, because these involve little staff time (see Appendix B for information about these instruments).

Educational programs about work can also be woven into the curriculum of the short-term residential program. Typically, these programs are education-oriented and based on a revolving curriculum of modules about clients' substance abuse and the consequences of not arresting the addiction process. With a minimal level of consultation from a VR counselor, it should be simple for programs to build in a module about vocational issues and what vocational rehabilitation involves. This module could be targeted to the needs of the majority of clients in a given program. It should motivate clients to seek VR services upon referral to ongoing outpatient treatment and other community-based services.

Vocational Strategies for Different Types of Services


Detoxification facilities, which typically provide stabilization, will not be able to provide VR services. Because most programs will gather some information about the client's work history through a psychosocial interview and the administration of the ASI or similar assessment, it is recommended that detoxification facilities address vocational needs as part of the discharge plan. In this way, the recovery program to which the client is referred will have information that gives a snapshot of the client's potential vocational issues.

Methadone maintenance programs

Some methadone maintenance programs have introduced vocational services. In a demonstration project sponsored by the National Institute on Drug Abuse, a vocational readiness screening instrument was developed for methadone maintenance clients that measured five dimensions: the client's vocational status, level of motivation, level of social support, ancillary needs, and barriers for vocational activity (Dennis et al., 1994; Karuntzos and Dennis, 1994). In this demonstration project, the screening instrument was administered by a VR counselor, but an alcohol and drug counselor with some vocational expertise could be trained to use it. An alcohol and drug counselor was trained to provide vocational counseling and build positive work attitudes and behaviors. The project hired a case manager to deal with barriers to employment such as transportation and child care. The project funded some clients' return to school and purchased tools for other clients pursuing vocational goals. One key program component--creating relationships with employers--was identified as a critical aspect of success.

The Opioid Maintenance Program of the University of New Mexico's Center on Alcoholism, Substance Abuse, and Addictions is developing the position of a transitional agent. The case manager is part of a multidisciplinary team whose approach is designed to be harmoniously inclusive of basic living needs. A networking system within the community provides referrals for vocational training, educational opportunities, employment resources, and housing needs. Welfare to Work is also coordinated through this resource.

A key component of these kinds of programs is teaching clients job readiness skills. For example, the frequent visits required (especially in the early stages of treatment) can be scheduled on an appointment basis, as opposed to a drop-in basis, to address punctuality, time management, and personal responsibility issues. For more information about methadone maintenance programs, see TIP 20, Matching Treatment to Patient Needs in Opioid Substitution Therapy (CSAT, 1995c).

Utilizing a vocational case manager can help greatly when the primary counselor is very involved in the vocational counseling aspects of the client. A specific person who is responsible for trying to reduce barriers that could prohibit clients from job training, continuing education, job placement, aftercare, and so forth is essential. The primary counselor may not have enough time to deal with those issues.

Halfway houses

Halfway houses or other reentry facilities are an important element in the continuum of care. To be eligible to live in most halfway houses, clients must be in a training program or a job during the day. Most halfway house residents are trying to stabilize themselves in many aspects of their lives, including work, before they move out to live on their own. Thus, a support group for maintaining both sobriety and employment is appropriate in this setting. Such a group, meeting in the evening, could address issues related to helping residents keep their jobs and become more effective employees. The staff can help group members recognize triggers in the work environment that alert them to a risk of relapse. It is most helpful when staff members in halfway houses see a client's job not as a "given," but as a set of newly acquired skills that need strengthening.

A halfway house or group of halfway houses can hire a VR counselor as a consultant to conduct group sessions or hold educational seminars for staff. Community volunteers, including individuals who have completed the halfway house program, can be important resources for helping residents maintain employment and stabilize their recovery.


The measurement of treatment outcomes is no longer just a research issue. In the current health care environment and with recent reforms in the welfare system, all treatment programs must demonstrate to payors and other funders that clients are achieving the goals to which the program is dedicated--the goals by which the program defines "success." Demonstrating the program's success is also important for recruiting new staff members and for maintaining or improving the morale of the existing staff.

For many years, abstinence was the only successful outcome recognized by most substance abuse treatment programs. However, treatment programs have begun to recognize the many different criteria that can be used to define success. Examples of criteria include (but are not limited to)

  • Abstinence or decreased substance use
  • Decreased involvement with the legal system
  • Success in employment
  • Success in education or training
  • Improved family relationships
  • Enhanced psychological functioning
  • Removal from welfare rolls
  • Return or maintenance of child custody
  • Improved physical health (e.g., decrease in emergency room visits)

A similarly flexible approach should be considered in defining a successful vocational rehabilitation outcome. Outcomes must be defined and measured within a realistic framework. For clients with significant disabilities and who have strong family support, doing part-time or volunteer work may be a realistic goal. In the case of a single woman with young children who has minimal social supports and will soon lose welfare benefits, achieving gainful employment is an important goal, but perhaps harder to achieve.

What, then, should be called a successful outcome in terms of vocational rehabilitation? Some vocational measures include

  • Number of hours worked per week (or per month, or in the past 6 months)
  • Entry into and/or completion of an educational or training program
  • Temporary or permanent job
  • Earning level and/or level of benefits
  • Employment evaluations, promotions, raises
  • Duration of employment
  • Job satisfaction
  • Return to school to pursue long-term vocational goals

As described in TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (CSAT, 1995a), all programs must have mechanisms in place to ensure the ongoing collection of reliable data. For example, one State has enhanced a version of the ASI so that it assesses 10 domains and is more relevant to Native American populations and other groups. This and other assessment instruments that are administered at intake should be periodically readministered and linked to outcomes.

It is best to conceive of a continuum of outcomes, from part-time to full-time work, from volunteer work to full-time homemaker, all of which may be considered successful depending on what was realistic at baseline for the client. The personalized vocational goals that clients articulate in their rehabilitation plans may not fit the program's measurement categories. However, helping clients attain these goals may represent a significant investment of staff energy, and programs will find ways to measure and report these outcomes.

More data are needed on employment outcomes across the array of substance abuse treatment modalities. Until recently, research has tended to focus on clients in methadone maintenance programs and has used mostly simple outcome measures (e.g., job versus no job). Building databases on employment outcomes from treatment programs is critical to future understanding of the dynamic connection between these two areas. In general, the field has focused on whether substance abuse treatment results in improved employment. However, it is also important to determine whether implementing vocational services and focusing on clients' vocational needs result in better substance abuse treatment outcomes. Important work also remains to be done in identifying treatment-level and client-level variables (such as clients' satisfaction with services) that are related to good employment outcomes. Accurate outcome data can also support future funding requests to legislative and other decisionmaking bodies and help ensure the fiscal viability of integrated treatment and vocational services.

To understand long-term employment outcomes, it is important for programs to obtain followup data after clients leave treatment. Vocational outcomes can be better during the posttreatment period, when clients are farther along in the recovery process and can focus more energy and attention on job performance. Outside of formal research studies, followup data are often difficult to obtain because many clients are lost to the program when they complete treatment. One program that has a high rate of success in contacting clients for followup interviews makes sure that at discharge it obtains the names, addresses, and telephone numbers of two significant others in the client's life who are not in the same household. The program should have the client update his address and telephone number before leaving.

The program should also have the client sign an authorization for followup that allows the program to contact the significant others whose names the client provided. 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. There are many variations of employment success, including obtaining and maintaining a full-time job, one or more part-time jobs, seasonal jobs (in which clients are unemployed for part of the year), or sheltered employment making or selling hand-crafted goods.

Figure 4-3 provides information about a client outcomes initiative developed by CSAT.

Uniform Data Collection

It is not uncommon for different funding agencies to require substance abuse treatment programs to report different types of data or to report the same data but in different forms. Program administrators are beginning to call on agencies to standardize reporting categories, not just to ease the programs' reporting burden but to facilitate comparisons among data sets. Another significant problem is that funders generally ask for aggregate data that are not broken down by the severity of clients' substance abuse disorders or VR needs.

Interpretation of such data is difficult, and reported results can be misleading, especially when the outcomes of two programs with different case mixes are compared. However, Federal minimum data sets do require pre- and posttreatment status reports concerning client employment, and such data can currently be analyzed concerning client characteristics, type and intensity of substance abuse treatment, and the like that lead to success in the employment domain. Substance abuse treatment agencies involved in providing vocational services must lobby strongly to have outcome indices related to employment inserted in such uniform data packages.

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