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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 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 self-esteem 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 substance-related 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 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 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 full-time 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 State-defined and Federal time limits (60 months) without employment cites some female-specific, but similar, disadvantages.

These disadvantages include being under age 22 when receiving first welfare check, never being married, not having a high school diploma, having little or no work experience, and having a child under the age of 3 (Duncan et al., 1997).

An important distinction to make is that clients may face different obstacles in acquiring or improving marketable skills, securing jobs, and maintaining employment. For example, a client may have difficulty securing a job if he has poor interviewing and job-seeking skills, no clear vocational goals, and a distorted perception of his skills, the job requirements, and the compatibility between these. Once on the job, he may encounter difficulties with supervisors and coworkers if he cannot accept criticism or direction, has poor work habits, fails to report problems, or is frequently late or absent from work without an adequate reason (Schottenfeld et al., 1992). Counseling and vocational services must be tailored to each individual and to his stage of employment or job readiness.

Further distinctions may be made between limitations to employment that are temporary and those that are chronic, and between those that can be resolved and those that cannot be changed. Some substance users, for example, have transitory memory or psychological problems (e.g., depression, anxiety, panic disorders) that improve spontaneously as recovery progresses or with specific medication. On the other hand, cognitive functioning may be permanently damaged as a consequence of long-term and excessive alcohol use or as a result of traumatic brain injury from a motor vehicle accident, or it may not ever have been within normal range as a result of birth trauma or other unknown causes. Some skill deficiencies may be resolved with additional training or education if the client is willing and capable of pursuing these remedies. All of these factors must be considered in deciding what remedies can be applied, by whom they can be applied, and with what likelihood of success they can be applied using the resources available (Wolkstein and Spiller, 1998).

Vocational Issues

Vocational Needs

Persons with histories of substance abuse will have varying vocational histories, ranging from being chronically or permanently unemployed to being continuously employed. It is important to note that the severity of the client's substance abuse does not necessarily correspond to substance-use-related problems, employment status, or the need for vocational services. For example, the chief executive officer of a large corporation may have serious alcohol use problems that may not yet be directly affecting his job performance.

Substance users may be classified into a range of categories according to their functional limitations and related needs for vocational and other types of rehabilitative services (Wolkstein and Bausch, 1998; Wolkstein and Spiller, 1998). Clients with a strong work history require different forms of vocational services than those who have never worked and have a lifetime history of substance abuse and dependency.

Figure 1-2 provides strategies for promoting employment for individuals throughout the employment continuum (Nightingale and Holcomb, 1997).

Availability of Vocational Services

Even though vocational and employment services are needed and wanted by clients with substance abuse disorders, help of this type is generally not part of the substance abuse treatment package (Platt, 1995; Schottenfeld et al., 1992). Researchers from the Drug Abuse Treatment Outcome Study (DATOS) reported that there was a widening gap between clients' need for support services beyond substance abuse treatment and the availability of those services (National Institute on Drug Abuse [NIDA], 1997). These services included vocational services. The focus of substance abuse treatment has become more comprehensive in recent years, with some assessment of employment history and vocational functioning typically a part of the intake process (e.g., Addiction Severity Index) and often demanded by managed care and welfare reform. However, the provision of vocational services by substance abuse treatment programs still should be expanded.

Some of the major reasons for the lack of vocational services in treatment programs include the current emphasis on briefer forms of treatment (usually outpatient) that satisfy cost-efficiency concerns, the very short time many clients actually spend in treatment, and a treatment philosophy that is not vocationally driven. Although the effectiveness of treatment depends on meeting clients' multiple medical and social needs related to substance use, many programs have cut back on the services they offer. In a survey of 481 outpatient substance abuse treatment units, researchers found significant decreases between 1988 and 1990 in all services examined--physical, medical, and mental health care; special treatment for multiple substance use; and employment, financial, and legal counseling (D'Aunno and Vaughn, 1995). Of 24 methadone maintenance treatment programs surveyed in 1990 by the General Accounting Office, only four had onsite vocational services, and the clients were not required to use them (French et al., 1992). A similar comparison of resources available to clients in community-based treatment in the Treatment Outcomes Prospective Study (TOPS) and in DATOS (Ethridge et al., 1995) found a marked decrease over a decade in both the number and variety of services provided. The study participants reported that substance abuse counseling alone did not address their wide-ranging service needs.

Effectiveness of Vocational Services For Substance Abuse Clients

While research has been conducted on the effectiveness of vocational services and on substance abuse treatment, few studies have addressed the effectiveness of vocational services in substance abuse treatment settings. A few large-scale collaborative efforts and more focused client-specific interventions have been mounted over the last 20 years to increase clients' employment levels. These have included supported work demonstrations, job-seeking and placement services, personal competency and skill-building programs, and other vocational supports. Most have exhibited moderate success, but few have been widely replicated, primarily because of cost factors and ties to federally sponsored job-training activities. Many of these programs did not demonstrate much long-term effect and did not decrease substance use, although the supported work efforts did decrease dependence on public assistance and increase employment (Hall, 1984). The mixed results from these studies are partly attributed to difficulties of research in this area and the lack of a standard methodology. As one researcher noted (Platt, 1995),

  • There are different definitions of employment (i.e., point-in-time or period-of-time).
  • The followup periods are varied.
  • The case mix of the populations studied is not always defined.
  • The components of the vocational services offered are not adequately explained.
  • It is not clear how well client needs were matched to services offered.
  • Study participants were mainly from publicly funded clinics that serve lower socioeconomic groups and did not include the full continuum of individuals with substance abuse disorders.
  • In general, the research methodologies used in the large-scale studies were not rigorous. The treatment protocols were vague and changed over time and from site to site, and large dropout rates may have compromised random assignment (Hall, 1984).
  • In general, there is a scarcity of research on the vocational services and employment needs of substance-using women, the variables that differentially affect racial and ethnic groups, the effects of parental modeling, the predictors of employability, and the determinants of who cannot benefit from vocational services.

Traditional vocational services emphasize esteem building, adjustment to social conditions, comprehensive assessment, skill building, and basic education. However, today's focus on work first and quick employment, which try to prevent clients from being left without financial support when public assistance ends, overlooks these traditional emphases. This strategy helps unemployed, low-skilled clients find work rapidly but does not help these individuals advance into higher paying and more satisfying jobs. Investigators are discovering that a combination of quick-employment strategies (also known as "rapid attachment") and basic education and training produces the best long-term impacts on continuing employment and advancement for low-skilled workers (Hanken, 1998). However, it is the intent of funding sources, such as the Welfare to Work Block Grant, to make available not only job retention support services but also training and other services to help clients advance to higher level employment (see Chapter 6, Funding and Policy Issues, for more information).

Treatment and Employment

A review of the literature on the impact of substance abuse in the workplace concluded that employees who abuse substances are costly to employers. This is because people who abuse substances

  • Have twice as many lengthy absences as other employees
  • Use more sick days and benefits
  • Are tardy three times more frequently
  • Are five times more likely to file workers' compensation claims
  • Are more likely to be involved in accidents
  • Are more inclined to steal property belonging to the employer or other employees
  • Work at approximately 75 percent of their productive capability

Another literature review (Comerford, 1999) examined the similarities in the self-efficacy roots of substance abuse disorders and vocational dysfunction, along with the benefit of providing vocational services in conjunction with substance abuse treatment. Based on this review, Comerford recommended using client functionalities and level of care as a guide for vocational services, closely monitoring working clients, and providing long-term counseling to ensure that clients' developmental gains are not lost.

The misuse of psychoactive substances often compromises a person's work performance or in many cases becomes such a preoccupation itself that continued employment is impossible (Wolkstein and Spiller, 1998). A study from the Urban Institute found that welfare recipients who have substance-abuse-related problems are just as likely to work as other recipients (63 percent worked at some point during the current or previous year compared with 58 percent of those without substance use problems), but those with substance-abuse-related problems work less steadily--only 15 percent work full-time and year round compared with 22 percent of all recipients (Strawn, 1997).

Many studies have found that substance abuse treatment does increase employment rates, although the magnitude of the gains varies widely, and the results are mixed. These gains in employment have been reported for heroin addicts in methadone maintenance programs and therapeutic communities, for polysubstance users in outpatient substance-free clinics, for male and female clients in residential programs, for alcohol users in private hospital-based programs, and for White and Hispano/Latino individuals with substance abuse disorders in California. However, no readily identifiable factors are consistently associated with or predictive of these increases in employment (Platt, 1995).

Some of these studies (Pavetti et al., 1997; Young, 1994; Young and Gardner, 1997) have cited improvements in employment rates as great as 60 percent among certain groups as a result of treatment for California residents with substance abuse disorders, and 136 percent among Missouri clients. A study in Ohio found a 60 percent decline in absenteeism among working clients who were in treatment and a 15 percent reduction in the number of clients receiving public assistance (Johnson et al., 1998).

These investigators also noted that substance abuse treatment is not similarly successful for everyone with respect to employment gains. Evidence indicates that substance abuse disorder treatment increases both employment and earnings (Legal Action Center, 1997b; Young, 1994). The National Treatment Improvement Evaluation Study (NTIES) (CSAT, 1997b) reported an 18.7 percent increase in employment of 5,700 study participants in the year after treatment. In Oregon, clients increased weekly earnings from $154 to $278 in the 3 years after treatment; in Minnesota, full-time employment of clients in the public treatment system increased by 18.1 percent in the 6 months after treatment compared with the 6 months before treatment. In these studies, the welfare rolls were reduced (resulting in substantial savings), cost offsets were produced for other health care (e.g., hospitalizations, drug overdoses, detoxification, mental health admissions to psychiatric hospitals, treatment of in utero substance-exposed infants), and substance use also decreased.

Other data from Minnesota, Colorado, Florida, and Missouri reveal increases in employment rates for welfare recipients who completed a substance abuse treatment program. A study in Kansas showed that earnings for clients were 33 times higher after completing treatment, compared with before treatment (Young, 1996). A similar study in Oregon found that clients who completed treatment earned 65 percent more than counterparts who terminated prematurely (Young, 1996).

Substance abuse treatment also improves job-training effectiveness, according to a report issued by the Miami Coalition for a Safe and Drug Free Community (Rector, 1997). Because many participants in Federal job-training and skill-development efforts in this city were found to be using crack, three Job Training Partnership Act (JPTA) programs added specially developed Training Assistance Programs (TAPs) to their activities from November 1994 to November 1995. All three sites saw increases in effectiveness (i.e., the percentages of adult and youth trainees completing training and their job placement rates) after incorporating TAPs that focused on preventing and reducing crack use.

If work is to be sustained and enduring lifestyle changes made, the vocational services provided must focus on pathways into careers, on job satisfaction, and on overcoming a variety of barriers to employment, as well as on the skills necessary for maintaining employment.

National Trends Affecting Employment

A number of changes affect today's workforce and 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. Particularly noteworthy are shifts from a manufacturing to a service economy and advances in communications and other technologies that make computer literacy a valued and necessary skill.

Job growth has occurred in two areas at the opposite ends of the occupational spectrum: high-wage, high-skill technical and professional occupations, and low-wage, low-skill service jobs without many opportunities for advancement (Hanken, 1998). The greatest number of new jobs that have been generated pay $80,000 per year or more--or $15,000 a year or less. Few middle-income jobs have been created in recent years, and this overall wage inequality has been increasing in the United States for both men and women since the mid-1970s. Real wages in terms of buying power have fallen substantially for workers with the fewest skills, education, and experience, whereas those of professionals at the top of the pay scale have skyrocketed. Wages for entry-level jobs are low and declining; moreover, they are likely to decrease further as more unskilled work is conducted in foreign labor markets and as more welfare recipients are required to enter the labor force (Burtless, 1997).

In the U.S. economy, poorly paid, entry-level service work is widely available, although this varies enormously by locale, by skill or specialty area, and by transportation access to jobs (Burtless, 1997). In many places, new immigrants, unskilled and undereducated workers, and ethnic minority groups face daunting challenges. In making vocational decisions, these clients, unless counseled otherwise, may have widely discrepant expectations about what is desired and what is possible. These discrepancies can lead to treatment and job failure, especially if the client underestimates or overestimates his abilities, is not realistic about costs of employment and the challenges of financial independence, and is not prepared for ongoing work and additional training beyond the immediate satisfaction of having a job.

Moreover, in today's work world, few employees can expect to remain with one company for a complete career. Low-wage workers are particularly vulnerable in this new world of work as other publicly funded safety nets weaken. Going back and forth between work and welfare or other subsidies is no longer a long-term option for the chronically underemployed (Hanken, 1998). Lack of financial security can produce anxiety and substance use relapse unless clients are trained to be flexible and assertive in regard to work. Because most workers will change jobs and occupations several times in the course of a career, retraining and adaptability are critical. Work must be seen from the perspective of developing and advancing personal goals. Vocational counseling and guidance can play a vital role in defining one's career path and making difficult work-related decisions.

Federal and State Reforms

Welfare reform and changes in child welfare laws

The combined effect of the new welfare reform requirements and changes in the child welfare laws greatly pressure parents involved with child protection service agencies to quickly comply with multiple demands for compliance with public system requirements. To avoid losing parental rights to their children, parents may be required to enter substance abuse treatment and achieve sobriety as well as meet other expectations of the child welfare system, all within a limited time period. At the same time, under Temporary Assistance for Needy Families (TANF), welfare authorities may impose work requirements and sanction those who fail to comply.

Those with substance abuse disorders, minimal work experience, and dubious parenting skills may feel overwhelmed by all these demands. Maintaining sobriety, by itself, is a difficult achievement for many. Complying with work requirements and parenting responsibilities at the same time may seem impossible. For some people, the response may be to deny that "the system" has changed. Others may be overcome by a feeling of hopelessness and the inclination to give up. Still other parents will relapse into substance abuse.

As welfare reform and changes in child protection laws are implemented, alcohol and drug counselors will see increasingly stressed parents in need of supportive counseling and services. Providing support while conveying to clients the urgency of their attaining or maintaining sobriety will be the challenge in the years ahead.

There are several laws in this area with which alcohol and drug counselors should be familiar:

  • 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

These laws must be monitored closely because they signal time periods when financial support will be terminated for clients and delivery of vocational and employment services will be drastically modified. These changes will heighten the urgency for integration of treatment and vocational services as a means to provide clients with maximum opportunity for full rehabilitation. These laws are discussed in detail in Chapter 7; see also the TIP, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT, 2000a) for discussion of these laws.

Medicaid and managed care programs

Although Medicaid has not been a major source of funding for substance abuse treatment, many States have negotiated coverage for screening services, inpatient detoxification, intensive outpatient day treatment, and some medical, methadone maintenance, counseling, and therapy services (Strawn, 1997). Most States now require that Medicaid recipients enroll in State-directed managed care programs. However, in many places, moving Medicaid reimbursements to managed care programs has created new obstacles to financing substance abuse treatment.

A primary tenet of managed care is based on "continuum of care" principles in substance abuse treatment. This concept argues that treatment needs change over time, often in a predictable fashion. Managed care plans typically require the use of a comprehensive program having several levels of care, such as detoxification (inpatient, outpatient, or residential), hospital rehabilitation, nonhospital residential rehabilitation, structured outpatient rehabilitation, and individual or group outpatient rehabilitation (Anderson and Berlant, 1995). Matching the proper intervention with current patient needs should lead to more effective and cost-efficient service delivery.

Although the emphasis on cost efficiency is commendable, there is concern that the emphasis on savings might curtail treatment effectiveness. A focus on improved fiscal outcomes that ignores more satisfactory and enduring client outcomes could be counterproductive (Young and Gardner, 1997). Treatment barriers imposed by managed care programs under Medicaid in some States include refusal to approve appropriate treatment placements, failure to accurately diagnose substance abuse, referral to geographically inaccessible facilities, and retroactive denial of benefits (Legal Action Center, 1996). Providers should remain abreast of changes in Medicaid rules and regulations in order to access such financial reimbursements for their clients.

An existing Medicaid requirement has also complicated reimbursements for residential care for substance users. The Medicaid rules prohibiting reimbursement for residential services provided in a facility with more than 16 beds to anyone between the ages of 22 and 64 years have often discouraged special residential treatment for women and their dependent children.

Populations Most Affected by Legislative Changes

There are numerous concerns regarding the effects of the aforementioned legislative and policy changes on several populations. These populations include women on welfare, their children, noncustodial parents, former Supplemental Security Income (SSI) beneficiaries, and clients in the criminal justice system.

Women on welfare

Women on welfare have been the primary targets of reform efforts (particularly at the Federal level), which reflect changing societal attitudes about the expanded roles of women, their place in the workforce, and their capabilities for self-reliance. The sudden changes and multiple roles that women are expected to assume are a difficult balancing act. Without adequate support, women who are living in poverty with their children find it more difficult to assume full responsibilities as the head of the household and become productive outside the home. Unfortunately, the new emphasis on women does not necessarily consider the many disincentives and loopholes in the work requirements, such as lower wages from work than from welfare, lack of child care, and loss of Medicaid benefits after certain periods of work.

In response to welfare reform efforts, substance abuse treatment programs must address the vocational needs of women and offer them a full range of vocational services. A recent study of an experimental TEP for methadone clients in three facilities in the United States found significant variations in the types of vocational services offered to male and female clients (Karuntzos et al., 1994a). The women in the TEP were less likely to be involved in vocational activities or employed at admission compared with males. These women were also less likely to have received job preparatory services than male counterparts, who received more job support, job development, and job placement services. Although the investigators argued that differences in the vocational services provided reflect gender differences in vocational pressure and readiness, women who are expected to enter the job market in the near future will need a comprehensive range of vocational services that are delivered intensively, as well as child care. Women on the TANF rolls must be alerted to the law's realities and the urgency to demonstrate work readiness and find employment rather than exhaust temporary benefits.

Indications are that the Welfare Reform Act has apparently stimulated a dramatic 37 percent overall drop in welfare rolls--with decreases in all States (Archer, 1998; U.S. Department of Health and Human Services [DHHS], 1994a). Some welfare offices are now functioning as job placement centers. However, a current survey indicates that the numbers on the welfare rolls are declining in part because applicants are being diverted from enrollment by one-time cash payments, requirements to exhaust all assistance from relatives and charitable organizations before getting TANF benefits, and additional stipulations to engage in immediate job search activities and to provide evidence of a predetermined number of job applications as a condition of TANF eligibility. States are also discovering that necessary and appropriate services for hard-to-place welfare recipients are not available and are investing more resources in providing ancillary services, such as transportation to existing jobs and in developing day care for children (National Governors' Association [NGA], 1997).

Children of women on welfare

Children of women on welfare are affected by the requirement that their mothers rapidly enter the workforce, especially if their mothers take low-paying jobs. This is not a minor consideration because children are the largest group on the welfare rolls, representing approximately two-thirds of the recipients. Some mothers will not be able to provide basic necessities of food, shelter, clothing, and adequate day care if these items are costly in the local economy, if relatives are not nearby and cannot help, and if other government or charitable assistance is not forthcoming. These material hardships may increase the incidence of child abuse and neglect (DHHS, 1999a). Access to health care also may be jeopardized if employers do not offer adequate insurance protections or if preexisting conditions are not covered. Although eligibility for Medicaid is still available for these children, most States rely on managed care efforts to keep Medicaid costs down, which may restrict available medical services. New funds, however, are now available from the Child Health Insurance Partnership (see Chapter 6) to provide insurance to children who are not eligible for Medicaid and not covered by private insurance.

High-quality child care often is unavailable at a reasonable cost for mothers with low-paying jobs. Employed mothers also have less time to spend with young children, and jobs may require lengthy commuting times, resulting in children's spending up to 12 hours a day or more in day care. As more mothers with infants begin to work, child care arrangements will affect these children's learning environments and responses, for better or worse. While there has not been much research, there is some that indicates that maternal employment does not harm and can help the development, maturation, and cognitive functioning of school-age children (Larner et al., 1997). A lack of adequate supervision, by contrast, could exacerbate behavioral problems in children and contribute to a punitive and dysfunctional family environment. Also, it is important to note that children with a parent or parents with substance abuse disorders are at higher risk of developing these problems themselves.

Noncustodial parents

Noncustodial parents, usually fathers, may need substance abuse treatment and vocational services as they try to become better providers. New policies in the TANF legislation also require that States try to collect child support from absentee parents who have abandoned their families; this has contributed to an increase in child support payments retrieved by State and Federal government (Office of Child Support Enforcement, 1999). The mechanisms in place to identify fathers and garnish their wages can be punitive but, more important, are ineffective unless these fathers are working and paid enough to meet child support requirements.

Some investigators estimate that working noncustodial fathers could contribute as much as 40 percent of the amount previously received by mothers during the 18 years of Aid to Families With Dependent Children (AFDC) benefits while a child is dependent (Larner et al., 1997). Minnesota, Missouri, and Nevada are already implementing strategies to improve the earnings of noncustodial parents, usually by court-ordered referral of unemployed fathers to vocational and training services and threatened sanctions such as revocation of their drivers' licenses (NGA, 1997). These strategies could also include treatment for those identified as having a substance abuse disorder.

Former SSI beneficiaries

Former SSI beneficiaries who previously qualified for cash benefits because of substance- abuse-related disabilities are no longer eligible for this assistance or for food stamps unless they have another qualifying physical or mental health disability. Hence, comprehensive vocational services integrated into substance abuse treatment will be necessary now more than ever for this population. CSAT currently is funding studies on the impact of this benefit loss on this population.

Criminal justice system clients

Criminal justice system clients with drug-related felony convictions are no longer eligible for TANF benefits or food stamps unless States modify or opt out of this prohibition. This group is another target for vocational services and employment. In addition, clients in treatment as a condition of probation or parole may lose eligibility for TANF, food stamps, SSI, and public housing if they are found to be violating conditions of release during the period they received such funding, or have absconded. The definitions of violation and of duration of ineligibility must be defined, as must the procedures for reporting between welfare offices, treatment programs, and the criminal justice system. However, because a large percentage of substance abuse treatment clients have been criminally adjudicated, this legislation may be another avenue for termination of their financial support.

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