Integrating Substance Abuse Treatment and Vocational
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, L.C.S.W., J.D., C.C.A.S., served as the CDM TIPs project director. Other CDM TIPs personnel included Raquel Ingraham, M.S., project manager; Jonathan Max Gilbert, M.A., former managing editor; Susan Kimner, editor; and Cara Smith, former production editor.
Special thanks go to consultant John J. Benshoff, C.R.C., Ph.D., for his considerable contribution to this document. Special thanks also go to Vivian Brown, Ph.D., and Margaret K. Brooks, Esq., for their valuable contributions to Chapter 8.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse disorders, provided as a service of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http:// www.samhsa.gov/csat/csat.htm. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Integrating Substance Abuse Treatment and Vocational Services, presents a fundamental rethinking of the importance of integrating vocational services into substance abuse treatment planning. The goal of this TIP is to show how employment can play a key role in recovery from substance abuse disorders. In the wake of legislative reforms and limited resources, the TIP discusses establishing a referral relationship with other agencies to better meet client needs. Not only will clients receive services in areas outside the alcohol and drug counselor's area of expertise, but active referrals may help the client stay in treatment, and agencies can also share resources and funding to provide services more efficiently. Policy and funding issues also are discussed, as are legal issues.
This TIP represents another step by CSAT toward its goal of bringing national leaders together to improve substance abuse treatment in the United States.
Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
Karen Allen, Ph.D., R.N., C.A.R.N.
Professor and Chair
Department of Nursing
Berrien Springs, Michigan
Richard L. Brown, M.D., M.P.H.
Department of Family Medicine
University of Wisconsin School of Medicine
Dorynne Czechowicz, M.D.
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Linda S. Foley, M.A.
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Abuse Directors
Treatment Improvement Exchange Project
Wayde A. Glover, M.I.S., N.C.A.C. II
Commonwealth Addictions Consultants and Trainers
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
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
James G. (Gil) Hill, Ph.D.
Office of Rural Health and Substance Abuse
American Psychological Association
Douglas B. Kamerow, M.D., M.P.H.
Center for Practice and Technology Assessment
Agency for Healthcare Research and Quality
Stephen W. Long
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Richard A. Rawson, Ph.D.
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
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Sidney H. Schnoll, M.D., Ph.D.
Division of Substance Abuse Medicine
Medical College of Virginia
Nancy K. Young, M.S.W., Ph.D.
Children and Family Futures
Leslie Chernen, Ph.D.
Rhode Island Public Health Foundation
Providence, Rhode Island
Sidney Gardner, M.P.A.
California State University - Fullerton
Center for Collaboration for Children
Margaret K. Glenn, Ed.D., C.R.C.
School of Allied Health Professions Counseling
Virginia Commonwealth University
Gale Saler, M.Ed., C.R.C.-M.A.C., C.P.C.
Deputy Executive Director
Terry Soo-Hoo, Ph.D.
Counseling Psychology Department
University of San Francisco
San Francisco, California
Diana D. Woolis, Ed.D.
Senior Research Associate
National Center on Addiction and Substance Abuse at Columbia University
New York, New York
Judith Arroyo, Ph.D.
University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions
Albuquerque, New Mexico
Yvonne F. Bushyhead, J.D.
Vocational Opportunities of Cherokee
Cherokee, North Carolina
Alfanzo K. Dorsey, M.S.W.
State Treatment Director
Social Rehabilitation Services
Kansas State Alcohol and Drug Abuse Services
Eduardo Duran, Ph.D.
Gallup, New Mexico
Paul Ingram, M.S.W.
PBA, Inc. - The Second Step
Tim Janikowski, Ph.D., C.R.C.
Rehabilitation Counselor Training Program
Southern Illinois University
Gloster Mahon, M.S.
Illinois Jobs Advantage Project
Angela G. Rojas-Dedenbach, M.A.
Michigan Jobs Commission Rehabilitation Services
Alex Trujillo, M.S.
Counseling and Therapy Services
University of New Mexico Student Health Center
Albuquerque, New Mexico
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse disorders by providing best practices guidance to clinicians, program administrators, and payors. 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 client advocates debates and discusses its particular areas of expertise until it reaches 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 bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
Nelba Chavez, Ph.D.
Substance Abuse and Mental Health Services Administration
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
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
Unemployment and substance abuse may be intertwined long before an individual seeks treatment. Although the average educational level of individuals with substance abuse disorders is comparable to that of the general U.S. population, people who use substances are far more likely to be unemployed or underemployed than people who do not use substances. According to the U.S. Census Bureau, employment rates for the non-substance-using population ranged from 72.3 percent in 1980 to 76.8 percent in 1991. However, employment rates of the population with substance abuse problems before admission or at admission to treatment have remained at relatively stable, low levels since 1970, ranging from 15 to 30 percent. Most of the research on the employment rates of persons with substance abuse disorders has focused on opiate-dependent persons (usually heroin), and employment rates for other substance users may vary. The data clearly indicate the need for interventions to improve employment rates among this population in treatment and recovery.
Two major reform efforts have affected the substance abuse treatment field: health care reform and welfare reform. Both of these reforms highlight the role of vocational training and employment services in substance abuse treatment. Under the cost-saving initiatives of health care reform (i.e., managed care), treatment providers face demands to reduce length of care and still produce cost-effective, positive outcomes. Treatment providers must also attempt to match a client's individual needs to an appropriate level of care. Recent welfare reform efforts, which limit benefits and impose strict work requirements, stress vocational rehabilitation for people with substance abuse disorders in an effort to move clients off welfare and into work.
Treatment providers will need to learn how to operate under the imperatives of these two major reform efforts. Because of their increasing emphasis on efficacy and outcomes, welfare and health care reforms promise to enhance the availability and provision of not only substance abuse treatment services but also necessary supporting services, including vocational rehabilitation. Substance abuse treatment that is cost-effective and shows verifiable positive outcomes is the ultimate goal. However, this goal cannot be achieved unless all the client's service needs are met, and this will occur only through the integration of treatment and wraparound services, including vocational counseling and employment services. Vocational counseling is an effective way to refocus substance users toward the world of work. Employment subsequently serves as a means of (re)socialization and integration into the non-substance-using world.
This Treatment Improvement Protocol is intended for providers of substance abuse treatment services. However, it can also be of use to vocational rehabilitation (VR) staff, social service workers, and all who are involved in arranging for and providing vocational and substance abuse treatment services. The TIP introduces vocational issues and concepts and describes how these can be incorporated into substance abuse treatment. While the alcohol and drug counselor is not expected to achieve complete mastery of vocational counseling, she should acquire at least rudimentary skills in providing vocational services and be able to recognize when her client should be referred to a VR counselor.
The Consensus Panel for this TIP drew on its considerable experience in both the vocational rehabilitation and substance abuse treatment fields. Panel members included representatives from all aspects of vocational rehabilitation and substance abuse treatment: VR specialists, alcohol and drug counselors, academicians, State government representatives, and legal counsel.
The TIP is organized into eight chapters. Chapter 1 provides an overview of the need for vocational services and discusses how employment and substance abuse treatment are interconnected. Challenges to employing clients in substance abuse treatment and strategies for promoting employment are discussed. The chapter also contains an overview of Federal and State legislative reforms and trends that have a deep impact on substance abuse treatment and the need for integrating employment services into substance abuse treatment.
Chapter 2 introduces the elements of vocational programming, such as screening and assessment tools, vocational counseling, prevocational services, training and education, and employment services. The roles of the VR counselor and vocational evaluator are discussed. A section on resources provides an overview of the vocational resources that are available for substance abuse treatment clients.
Chapter 3 focuses on the clinical issues related to integrating vocational services into substance abuse treatment. This chapter helps the alcohol and drug counselor incorporate vocational components into a treatment plan for the client and actively involve the client in his rehabilitation by assessing strengths and interests, setting goals, and finding and maintaining employment. The chapter also discusses legal and social challenges to securing employment. Three case studies are presented to illustrate the concepts discussed in the chapter.
Chapter 4 provides information about integrating onsite vocational services into substance abuse treatment programs. The main premise is that the substance abuse treatment program should not operate alone but should be part of a collaboration of agencies that provide various services to clients. Information is provided about models, staff development and training, integrating services, and, depending on the type of program (e.g., high-structure program, low-structure program), outcomes assessment, and uniform data collection.
Chapter 5 discusses setting up a referral system among agencies. Counselors are introduced to the authentically connected referral network, which is an integrated system where agencies function as equal partners to best serve the various needs of their clients. In an authentically connected network, a holistic view of the client is adopted. Barriers to collaboration, finding potential collaborators, the elements of effective referrals, and building an authentically connected network are discussed.
Chapter 6 offers guidance to administrators who are navigating in the new, unfamiliar funding environment created by recent Federal and State reforms. Funding strategies and sources are provided, and the steps for adapting to the new funding and policy climate are reviewed. Future considerations regarding Single State Agencies, flexible funding mechanisms, accountability and resource redirection, and the role of the Federal government are also discussed.
Chapter 7 provides an overview of legal and ethical issues for alcohol and drug counselors who are providing vocational services directly or through referral. Part I discusses discrimination, Part II discusses welfare reform, and Part III covers confidentiality issues.
Chapter 8 presents information on the impact of increased law enforcement activity on clients with substance abuse disorders. The chapter provides some specific strategies to help clients who are making the transition from incarceration to the community find needed employment.
The TIP also contains several appendices, including source information for various screening tools, Web sites, and other useful resources; a version of the Addiction Severity Index; a list of State employment agency addresses and Web sites; Federal and State funding sources; and a sample copy of an Individualized Written Rehabilitation Program.
Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, it will be used to denote both substance dependence and substance abuse. The term does relate to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders as described by the DSM-IV.
The recommendations that follow are grouped by chapter. Recommendations that are supported by research literature or legislation are followed by (1); clinically based recommendations are marked (2). To avoid sexism and awkward sentence construction, the TIP alternates between "he" and "she" in generic examples.
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.
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).
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).
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).
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.
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),
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).
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
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.
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.
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:
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.
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.
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 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 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, 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 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 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.
Awareness is growing about the importance of, and in most cases, the necessity of work in the recovery process. Work is central to the existence of adult functioning; in addition to providing the funds needed to live, work supplies status and security for an individual. In most substance abuse treatment models, recovery involves a shift away from substance abuse or dependence behaviors, attitudes, and beliefs to a focus on the establishment of positive life activities and attitudes. Traditionally this involves abstinence, reshaping the personality and cognitions, and developing a strong support network, all aimed at maintaining a recovery process free of relapse. Loss of or failure to adopt a positive vocational identity is a risk-laden situation for most individuals and often leads to depression, poor self-image and self-esteem, and relapse for many.
In addition to the obvious psychological implications of employment, legal and survival implications have emerged for many individuals. Welfare-to-work reforms at the State and national levels now mandate participation in gainful employment for nearly all adults; consequently, most individuals entering recovery must be prepared to seek and obtain employment. This can be a daunting task, both for individuals and substance abuse treatment agencies, many of whom may turn to vocational rehabilitation (VR) services for support and assistance.
This chapter introduces the field of vocational rehabilitation to alcohol and drug counselors and describes the services VR counselors are trained to provide, such as screening and assessment, vocational counseling, referral for training and education, and placement assistance. The chapter lists State and community resources that are useful in placing clients in jobs. In the absence of a VR counselor, the alcohol and drug counselor may have some ideas about what types of resources to use in providing vocational assistance to clients. Chapter 3 discusses issues in vocational rehabilitation from the clinical side.
Vocational rehabilitation counseling focuses on the process of improving an individual's functioning in primary life areas based on the person's values, interests, and goals. The VR counselor is trained to provide a wide range of vocational, educational, supportive, and followup services (Wolkstein and Spiller, 1998). These services include five essential functions (Schottenfeld et al., 1992):
VR counselors are professionals who have earned a master's degree in VR counseling in a rehabilitation counselor training program offered at nearly 100 universities and colleges across the country. They are trained as counselors with specialization in disability and vocational areas, and they work in a wide spectrum of school- or community-based VR programs. The VR field has long recognized the importance of its involvement in the treatment of substance abuse disorders. Consequently, in addition to their core studies, a significant percentage of rehabilitation counselor training programs include specialty studies in substance abuse disorders as an elective sequence in their programs (Benshoff et al., 1990).
Graduates of VR counselor training programs are eligible to become Certified Rehabilitation Counselors (CRCs) through the national certifying body, the Commission on Rehabilitation Counselor Certification (CRCC). The CRCC is the oldest counselor certification program in the United States, and in 1996 the connection between VR counseling and substance abuse disabilities was given more emphasis. In that year, the CRCC created the Master Addiction Counselor (MAC) certification, which is available to those who are already CRCs. As a result, universities often work with substance abuse treatment programs to cross-train with their students. Accredited rehabilitation counseling programs require their students to complete a minimum of 640 hours of supervised fieldwork under the supervision of a CRC. Students seeking a specialization in substance abuse counseling often complete practice and internships in substance abuse treatment settings.
Vocational evaluators are rehabilitation professionals specializing in assessment, vocational evaluation, and work adjustment, including prevocational readiness. Vocational evaluators may become certified as Certified Vocational Evaluators (CVEs), a national certification offered by the Commission on Certification of Work Adjustment and Vocational Evaluation Specialists (CCWAVES). To earn this certification, individuals must demonstrate proficiency in such areas as vocational interviewing, vocational assessment, and individualized vocational evaluation and planning. A bachelor of science degree in rehabilitation is the minimum qualification for a CVE, although many earn a master's degree in vocational evaluation, thus gaining preparation to provide more specialized services. In addition to learning about assessment, these professionals have studied such topics as assistive technology; group and individual counseling; counseling theories; case management; job analysis; types of disabilities; career planning; job placement techniques, testing, and evaluation; and rehabilitation issues related to particular disabilities, including substance abuse disorders.
Figure 2-1 illustrates how one agency combined vocational services with substance abuse treatment services in a residential treatment facility.
Both the Rehabilitation Act of 1973 and its Amendments and the Americans with Disabilities Act (ADA) of 1992 offer protections and eligibility for benefits and services to individuals with substance abuse disorders. For example, the ADA considers individuals who are in recovery from dependence on alcohol or who are in recovery from illicit drug use to be individuals with disabilities who are entitled to the protections of the Act (Feldblum, 1991). Within certain limitations, these Federal laws entitle those with substance abuse disorders to receive VR services funded by Federal and State governments. (See Chapter 7 for a more detailed discussion.)
Developing a vocational plan for a particular client begins with screening and continues, as necessary, with further assessment. Vocational screening is usually performed during the initial intake process and can be performed by an intake counselor, an alcohol and drug counselor, or a VR counselor. Screening is intended to provide a rough picture of the client's vocational history and potential. It includes a brief vocational and educational history, touching on employment experiences of the individual, including legal and other-than-legal employment, military history, and special skills possessed by the individual. Many individuals with substance abuse histories lack a legal, easily verifiable employment history, but they may have worked in jobs that paid "under the table" and have developed certain job skills in consequence.
In addition to background information, the screening should assess the client's psychological willingness and readiness to enter the workforce. Many individuals who are thrust into employment by welfare reform fail, but not because of poor work skills. More often they fail because they have a poor understanding of workplace rules, regulations, or behaviors. Their failures are traced to absences, tardiness, or an inability to get along with supervisors and coworkers. In some cases, screening will reveal individuals with a positive work history and an ability to enter the workforce; in most other situations a more in-depth vocational assessment may be required. In either situation, the alcohol and drug counselor may wish to consult with a VR counselor in the development of the vocational portion of the treatment plan.
Vocational assessment is a longer, more intensive process aimed at identifying the most optimal vocational outcome for the individual (Power, 1991). It incorporates more in-depth evaluative procedures and examines the complex social, emotional, physiological, and vocational factors contributing to the individual's vocational potential. Vocational assessment should be performed by a trained VR counselor or a vocational evaluator.
When the findings from the screening and assessment process are analyzed, the services the client needs to gain "successful employment" can be identified. The meaning of successful employment is different for each client; it can mean anything from part-time to full-time employment or even volunteer work or vocational skills training. The clinician should not make assumptions and should work closely with the client to develop a treatment plan that includes a vocational component appropriate to the client's needs and abilities. For the plan to be successful, the client must be an active partner in establishing and maintaining the recovery process and must be accountable for his actions and behaviors.
As treatment progresses, the client's abilities and life circumstances can change. These changes can affect the client's capacity for employment, need, or eligibility for resources and her attitude toward employment. The vocational component of the treatment plan is a dynamic process and should be periodically evaluated to determine if (1) the stated goals are still viable and appropriate, (2) further assessment is needed, and (3) any consequent adjustments to the plan are needed. 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 when necessary. Key clinical issues related to the development of vocational treatment are discussed in Chapter 3.
Screening allows the alcohol and drug counselor to determine the kinds of vocational services the client needs and to develop an appropriate vocational component to the treatment plan. Screening should accomplish the following (although not to the degree of detail that would be provided through a followup assessment or counseling by a VR counselor):
In most intake or screening processes, an important task is to review the client's medical records. If the client has not had a recent medical or psychiatric examination, these should be arranged as part of standard intake procedures since medical information has considerable relevance to a client's employability. These examinations can identify a client's limitations that are not otherwise apparent, such as visual and hearing impairments, mental health problems, and hidden coexisting disabilities. It is important to remember that information from a medical or psychiatric examination is confidential and may not be shared with other providers without the client's written consent. See Chapter 7 for a discussion of confidentiality issues.
An initial screening for vocational issues can be completed by the alcohol and drug counselor. Figure 2-2 contains a sample of the kinds of vocational information that the counselor can gather during this initial screen. Publicly funded alcohol and drug treatment providers are required to use the Federal Minimum Data Set (MDS), also called the Treatment Episode Data Set (TEDS), as part of their intake and discharge procedures. The MDS contains the minimum amount of data that States are required to submit to the Substance Abuse and Mental Health Services Administration (SAMHSA) each time a client enters or leaves publicly funded substance abuse treatment. The TEDS asks about the client's education and employment status.
The processes and instruments used for assessment are tailored to the needs of the individual client and should be administered by a trained VR counselor or vocational evaluator. They are based on established career development theories, and the instruments should be able to provide evidence of validation. They also vary according to the following:
Functional assessment is necessary to match clients with work they can perform successfully. Going beyond traditional models of diagnosis or client classification, functional assessment incorporates a broad range of assessment strategies. It aims to identify existing capabilities and limitations, along with the sociocultural or environmental conditions that impede or enhance success for the client. Sound treatment planning dictates that all of the assets and liabilities of the client be considered to develop a holistic plan. Functional assessment provides a more objective measure for evaluating client behaviors and for examining treatment planning outcomes. It is well documented that relapse and recovery failure are linked to vocational and educational failure. Functional assessment is a strategy designed to maximize success and minimize failure; it is not simply a tool to provide a diagnosis or a classification.
The term functional capacities denotes the job readiness of the individual, including skills such as the ability to read, write, relate well to supervisors and coworkers, or use a computer. Functional limitations are those deficiencies that should be addressed by a recovering person and VR counselor when planning to meet short- or long-term vocational goals. Identifying these limitations is important because the extent to which an individual's limitations are a barrier to employment depends in part on her work and living environment. For example, an individual with impaired mobility or who has a visual impairment may not drive and must travel to work by public transportation. But if the client's area is not served by public transportation, then this limitation presents a more serious barrier. Public VR services may assist individuals with impaired mobility or impaired vision to procure transportation for employment, including providing funds to purchase vehicles or convert existing vehicles to make them accessible.
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.
A functional assessment evaluates the client's performance of key functions in five areas: living, managing finances, learning, working, and interacting socially. Interventions can then be planned to help the client develop or apply the needed skills.
People in recovery commonly have significant functional limitations, some as a result of substance abuse and some associated with coexisting disorders. These limitations can be physical, psychological, or social, and the categories may overlap.
A limitation in any of these areas can be considered a challenge to employment or a vocational challenge if it affects the individual's capacity for successful employment.
The areas of assessment have been further refined into a six-realm classification system for functional limitations and capabilities (Livneh and Male, 1993). Assessments using this sophisticated system should be performed by a trained VR counselor. The system can be used to identify and conceptualize limitations, consider remedial strategies, and help the client make an enlightened and appropriate career choice. The six realms are as follows:
Substance abuse can be a direct cause or a result of functional limitations in each of these realms. Because substance abuse is often a coexisting disability, the clinician should be aware of the possibility of impairment in any or all six realms and ensure that adequate assessment has been done to identify such limitations. Because these areas require more comprehensive evaluation of a client's strengths and limitations in several specific functional areas, a trained psychological or VR counselor is needed to make these assessments.
A number of assessment instruments are available to gather more in-depth information related to vocational skills, interests, and aptitudes (see Figure 2-3). However, special training in the use of some of the instruments is needed to correctly administer the tests and interpret findings. Descriptions of some of the most commonly used and helpful instruments follow. See Appendix B for information about obtaining these resources.
A number of instruments are available to assist in determining vocational preferences and interests. These instruments are based on different theoretical approaches to career counseling. The following are commonly used and can be administered by alcohol and drug counselors to engage the client in the vocational exploration process. See Appendix B for information about where to obtain these resources.
The following tests generally are administered by a trained VR counselor or vocational evaluator because of their complexity of administration or interpretation.
Assessment approaches abstracted from actual job tasks can be performed to complement psychometric testing. Psychometric tests "are close simulations of actual industrial operation, no different in their essentials from what a potential worker would be required to perform on an ordinary job. Through performance on a work sample, tentative predictions about future performance can be made" (Power, 1991, p. xiv). A number of such systems are available, and they all measure performance across a range of basic job tasks.
An especially useful assessment approach is a computer-based system called the Microcomputer Evaluation Screening and Assessment System (MESA) (Brown et al., 1994; Valpar International Corporation, 1984). The MESA System is designed to "assist in identifying those individuals who are job or training ready, those who are in need of remediation, or those who may need a more comprehensive assessment" (Valpar International Corporation, 1984, p. 67). The MESA System was introduced in 1982, and the full and short forms of the system have been sold to thousands of rehabilitation facilities, schools, private practitioners, Federal programs, and other rehabilitation-related facilities in the United States. Thus, MESA System scores frequently are available to rehabilitation counselors whose clients have completed formal vocational evaluations.
After assessment, individuals need counseling about setting vocational goals and creating short- and long-term plans for achieving those goals. To develop a plan with a client, the factors to consider include (1) the results of assessments, (2) existing training resources in the client's field, (3) employment opportunities in the local area, (4) the feasibility of alternative goals when full-time employment is not an option, and (5) client empowerment to make the necessary decisions.
Client empowerment is a fundamental premise of rehabilitation; it implies an ability to shift away from dependence to independence, a notion consistent with recovery. The very notion of empowerment suggests both the availability of opportunity and the ability to move toward that opportunity through a sequential, developmental process aimed at creating further opportunity. Empowerment is not a foreign notion to drug and alcohol treatment and recovery. The peer self-help movement empowers individuals by focusing on control of what can be controlled and recognition and acceptance that some things (i.e., drugs, alcohol) cannot be controlled. In addition, it empowers clients by creating a mutual support system and by a philosophy of moving away from learned helplessness to taking responsibility for one's own actions and behaviors.
From a rehabilitation perspective, disabilities that disempower individuals are created by attitudes, beliefs, stereotypes, and actual physical barriers in the social, vocational, or personal environment of the individual and are not intrinsic to the person. Truly empowered individuals are as independent as possible across physical, psychological, intellectual, social, and economic dimensions. From a recovery perspective these individuals might be conceptualized as having learned strong recovery skills around impulse control and delayed gratification, self-advocacy, and assertiveness. Empowered individuals are capable of going beyond manipulation of systems and people to an open, honest style aimed at securing and enjoying basic entitled rights.
A five-step approach to career counseling has been described this way (Salomone, 1988):
VR counselors are trained to assist clients through these or similar steps to determine vocational goals and plans.
VR counselors are required to develop an individual plan for employment with each client. Formerly called the individualized written rehabilitation program (IWRP), this plan specifies the goals and objectives agreed to by the client and the agency and spells out the services the State agency will provide (see Appendix G for a sample IWRP). It is a formal document within the VR system and essentially represents the contract between the agency and the client. The principle of free choice strengthens the development and implementation of the plan--the client is presumed to have the ability to choose appropriate, realistic objectives and goals in concert with the VR counselor and is expected to meet specific and reasonable criteria for plan continuation. Consequently, a client enrolled in an educational program may be required to attend a specific number of classes and maintain a passing grade point average; a client enrolled in a vocational training program may be required to attend training regularly and on time. However, clients with substance abuse disorder-related disabilities may encounter policies or regulations not encountered by individuals with other disabilities. These dictates may be formal or informal (i.e., not contained in the agency administrative regulations) and may be operationalized at the State, regional office, or individual counselor level. For example, some agencies may require an individual to demonstrate a period of abstinence prior to eligibility for service, a regional office may require an individual to participate in counseling at a particular counseling center, or a counselor may require participation in a specified number of Alcoholics Anonymous meetings during the rehabilitation process. While these policies and regulations are usually well intended, they often pose a bureaucratic barrier to rehabilitation services. Clients who feel they are being denied services or forced into unneeded service by unreasonable or unfair policies are guaranteed the right to appeal. Each State agency has established an impartial hearing process to resolve cases in dispute.
Other legal or regulatory factors may affect participation in employment plans and treatment plans. Some clients may be required or mandated to perform certain activities by the courts or probation and parole. Welfare-to-work regulations may impose other conditions the client must fulfill. Depending on legal or regulatory factors, alcohol and drug counselors and VR counselors may need to adopt specific strategies to support, guide, and encourage clients as they seek to comply with and meet the demands of the employment plan and external forces.
Prevocational services are those that are typically provided before an individual begins the job-seeking process (see Figure 2-4 for examples of prevocational counseling activities). Although some clients already have work-related skills that need to be recovered, updated, or refined through a training process (or rehabilitation), others have no job skills and need to develop them for the first time. Some clients need training in basic life skills, such as how to organize themselves to engage in learning, before they can benefit from vocational training. The term habilitation describes the process of helping these clients acquire the basic skills needed to perform effectively in the workforce. There are several types of services, including life skills training programs, job readiness, work adjustment, and mentoring.
Life skills training prepares clients who have never lived independently to manage the requirements of daily life. Residential programs or halfway houses offer opportunities to gain social and life skills such as cooking, cleaning, time management, money management, grocery shopping, and general household planning. Occupational therapists are frequently the professionals who provide life skills training, when they are available. Otherwise, community support workers or other team members can supply the training.
Job readiness programs help individuals gain the specific skills, attitudes, and motivation needed to obtain and maintain employment. For example, clients learn how to interview for a job and make a positive impression on an employer, how to apply for a job in writing, how to dress, and how to prepare a résumé or work history. These services are provided through job clubs, VR agencies (e.g., Goodwill Industries, State VR agencies), nonprofit or community agencies, federally funded job training programs, or consultants.
Work adjustment is a prevocational support program for people who have never had a job and who need help learning how to work effectively. Clients perform tasks in a simulated work environment with regular evaluations. A work adjustment program should be of limited duration, with a goal of eventual competitive employment. Such programs teach clients new skills and help them learn to tolerate criticism and work well with peers and supervisors. Most work adjustment programs are designed for clients who are mentally retarded, and they have been criticized for frequent failure to lead to competitive employment. Some VR programs also provide specially trained job coaches to assist clients with work adjustment. Work adjustment needs of individuals with substance abuse disorders may be similar to the needs presented by individuals with other types of disabilities, but many substance abuse disorder clients may be offended by or resistant to participating in work adjustment programs. This is especially so if they perceive themselves as having been placed in a setting or with a disability group that is below their operational level. Both VR counselors and alcohol and drug counselors must be sensitive to these feelings in recommending a particular work adjustment site.
Many clients can only meet their employment goals through appropriate education or training. Some perhaps lack literacy. They may have dropped out of high school. Some have a history of chronic underemployment, and others have long-term plans that require advanced knowledge and skills.
The terms education and training are sometimes used interchangeably; however, providers of these services commonly make a distinction between the two. These services, or the referrals for them, are available through State employment services commissions, one-stop centers, schools, employers, VR centers, and colleges and universities.
In general, an educational program provides information and sometimes skills that the participant can use in a variety of settings; there is no clear and specific vocational application. At the end, the participant has learned a subject and may also have developed or honed skills--such as the ability to make a well-reasoned argument--that can be applied in many contexts. For example, a college program leading to a bachelor of arts degree in history is an educational program.
In contrast, a training program, such as the Job Corps, shows the participant how to perform a task and in the process provides information to give the instruction a context. For example, a course where the individual learns to repair computers or to build a database using a particular kind of software is considered training.
It is possible to envision a continuum from "pure" education that has little to do with a particular job (e.g., history) to training that builds skills that can be applied in a variety of jobs (database development) or that is specific to the needs of a particular job (how to use custom-designed software to build a database for a specific job application). Which type of program is most applicable to meeting the client's needs will, of course, depend on the client's goals, timelines, and aptitude for engaging in learning under given conditions. Most secondary school and adult education programs provide a combination of educational and training activities.
This section describes several of the most common kinds of training and education programs that are available to clients. These resources include school-to-work transition programs, on-the-job training, apprenticeship programs, technical schools and colleges, community-sponsored adult education, and colleges and universities.
School-to-work transition programs provide opportunities for students to broaden their educational, career, and economic opportunities. These programs build on and expand other existing programs of several types, such as technical preparatory, cooperative education, youth apprenticeship, career academics, and schools within schools. These programs have several components:
Most local school systems are directed to provide career exploration and support for all students, beginning in elementary school.
Some employers offer their employees opportunities to gain the necessary skills for a specific job task in a supervised setting. On-the-job training, when available, clearly benefits the employee by providing useful training at no cost; it also benefits the employer by ensuring that the employee is familiar with the company's particular way of doing things.
Through networking with employers and tapping into the knowledge of employment professionals, the clinician can learn which employers in the area train their new employees and under what terms, and then make helpful suggestions to clients. Programs are sometimes available to assist in organizing these experiences, subsidizing the salary through the training period, or providing a tax credit. Alcohol and drug counselors should consult the Job Training Partnership Act (JTPA) and welfare-to-work agencies in their area to see if on-the-job training relationships have already been developed with local employers.
Apprenticeship programs offer a structured process for mastering a particular profession, such as carpentry or plumbing. Individuals work side by side with a skilled person. All apprenticeship programs require some classroom work as well.
These programs are organized through unions and employment commissions. State agriculture departments often have apprenticeship programs suitable for farm and greenhouse management positions. An individual must meet certain criteria and often is required to take aptitude and interest tests upon application. It is important for the applicant to have references and experience in entry-level jobs in the field. Of course, a critical component is the employer's willingness to make a commitment to train the individual.
Some schools and colleges offer vocational training in which participants develop and practice the skills needed to meet the requirements of a particular job. Some examples of jobs include computer operator or repairperson, business manager, automotive service technician, nurse's aide, emergency medical technician, beautician, chef, welder, plumber, and veterinary assistant. Usually, technical colleges and vocational schools serve specific groups of occupations, such as technological or human services.
Some schools offer 2-year degree programs that lead to an associate's degree, 1-year diploma programs, or certifications that require less than 1 year. The degree programs often combine technical classes with general education requirements that focus on oral and written communications skills, math skills, research and computer skills, and social/interpersonal skills.
All technical colleges and schools operate under an admissions policy that outlines the requirements for attendance. Some require a high school diploma or general equivalency diploma (GED), whereas others offer remedial education that allows a person to obtain a GED. All such programs require tuition, paid by either the student or another funding source. Some offer financial aid and provide staff members to assist students in the pursuit of such funding. Referring a client prematurely to a technical school can be harmful if the client embarks on the program without the financial support to complete it successfully and defaults on the loan.
Some city or county school systems use public schools on evenings and weekends to deliver a range of programs for adults, recent graduates, and young persons who dropped out of school. Many regions have accessible, well-staffed community colleges. These programs often are attractive to young people who do not have enough money to enter extensive training programs. Public schools sometimes offer preparation for GEDs, remedial education programs, and basic courses for adults. Some community programs offer courses in word processing, graphic design, and other skills.
Programs available through community schools and community colleges are often reasonably priced and likely to be accessible by mass transit services. Alcohol and drug counselors should become familiar with the public educational opportunities provided by local schools to assist clients in using these resources.
Colleges and universities offer programs that provide general knowledge and skills that are applicable to many different professions. State-supported schools are likely to have lower tuition fees and generally give priority to State residents.
Some clients who want to attend a college or university have poor academic records because of previous substance abuse or learning problems. Students who are unsure of their academic skills may want to take some courses on a pass/fail basis or register as special students rather than as degree candidates taking a full-time course load. For those who want to demonstrate their qualifications as students to a college or university before applying, taking courses at a less competitive school and doing well in them, then transferring, is a good strategy. Note, too, that clients may wish to pursue a 2-year associate's degree if it is difficult to commit to a 4-year program.
Colleges and universities are required by law to provide support services to students with disabilities, including learning disabilities. This might mean providing accommodations such as assistance in taking class notes or special arrangements for taking tests. However, to receive such services, the student must present documented evidence of a disability requiring the need for the accommodations requested.
The following sections review some of the most commonly used employment and vocational services that could benefit clients recovering from a substance abuse disorder who are seeking employment.
Some clients will need help learning how to secure employment because they have never looked for a job, are seeking a different kind of job, or have special problems to address in the job search (e.g., how to handle the existence of a criminal record). Many of the providers identified in this chapter offer assistance in numerous areas, such as the following:
Job clubs, which use a behaviorally based, group-oriented approach, are another source to help jobseekers (see Chapter 4 for more information about job clubs). Meeting daily or weekly, jobseekers help themselves and each other develop and pursue job leads, practice interviewing skills, and receive encouragement. These approaches have proven effective in helping many people achieve their job goals.
Another valuable source for jobseekers is the Internet. Figure 2-5 describes America's Job Bank (AJB), a Web site maintained by DOL in conjunction with State employment offices.
Effective job development generally requires the VR counselor to provide multiple services, such as networking with employers, establishing relationships with them, and assembling information about employment opportunities for clients. The counselor locates jobs and also provides information to the employer about the client (within the confines of confidentiality). This addresses potential barriers to employment that result from biases and discrimination. VR counselors also conduct outreach to area employers to publicize the availability of individuals with the requisite skills for the job. Participating employers can receive certificates, publicity, or other recognition.
Job development also requires the counselor to become familiar with the local labor market to better guide clients about the types of employment that are available locally. For many States this information is available online. DOL regularly identifies the professions that it projects will expand in the future on its Web site (www.dol.gov) and in its annual publication, Occupational Outlook Handbook. AJB (www.ajb.dni.us) has links to State employment databases, and the Career InfoNet Web site (www.acinet.org) also provides occupational growth projections. This information allows the client to make decisions about a career that will be viable both in the present and in the future.
In the act of job placement, the VR counselor can intervene with the employer on behalf of the jobseeker. The intensity of the placement services varies from case to case, depending on such factors as the client's level of motivation, openness on the part of the employer, and the status of the economy. It requires a skilled professional with the knowledge and abilities to counsel both the client and the employer effectively, as well as to understand the intricacies of recruitment, human resources issues, and job satisfaction (Parker and Szymanski, 1998). Research also indicates that when a job placement plan is developed separately (i.e., in addition to the primary substance abuse treatment plan), counselors are more likely to successfully place their client in a job (Zadny and James, 1977). This may be because separately developing a vocational plan places more emphasis on employment.
Job placement can be completed by an individual consultant or through a program or agency. Also, a number of national computerized services exist to help individuals identify prospective employment suitable to their skills (see Figure 2-5). Most States have online systems that work in a similar way: Employers post job openings, and respondents place résumés and cover letters on file for employers to review.
Supported employment enables people with disabilities who have not been successfully employed to work and contribute to society. The locus of vocational rehabilitation in supported employment shifts from that of a sheltered setting to a real-world job setting. This approach is appropriate for clients with coexisting disorders (e.g., mental retardation, chronic mental illness, traumatic brain injury) that are so severe that they cannot maintain employment without intervention. Common forms of supported employment service delivery include the following:
This arrangement is relatively easy for a residential treatment facility to arrange if the same employers hire clients from the facility. Mentoring can be extremely effective when linked to self-help support groups.
Typically, they pay up to one-half the employees' salary for the first 90 days of a job.
Figure 2-6 provides an example of a rehabilitation facility that offers supported work.
Once a client has a job, a different set of issues arises. The client needs assistance in identifying relapse triggers that exist on the new job and in resisting the impulse to celebrate by drinking or using drugs for having secured employment. If the client has a disability in addition to a substance abuse disorder, VR counselors may need to help him identify any reasonable accommodations and assistive devices needed to perform required job functions. Individuals sometimes find they need additional education to help them manage their paycheck and household budget or to address other life changes and responsibilities that occur as a result of employment. Counselors should encourage clients to take advantage of their employer's employee assistance program as needed. Treatment programs need to accommodate their newly employed clients by having evening counseling hours and providing onsite child care while clients attend treatment programs.
Some kind of support for the long term must be built into VR programs so that the client avoids boredom, takes advantage of opportunities to advance, and manages crises at work. In addition, today's job market demands that clients be prepared for the possibility of job loss. VR counselors can inoculate clients against the attendant dangers of despair and relapse by working with the clients to develop a career network that identifies alternative strategies and pathways clients can use in the event of job loss or new openings. (See Chapter 3 for additional discussion of clinical aspects of job retention and advancement.)
For referral purposes, it is important for the clinician to be familiar with the local resources available to clients. Some clients will need only education and training to help them prepare for a career or enhance existing qualifications. Others will require a variety of rehabilitation services in addition to training or education. Some will need counseling to help them choose an employment situation that will make the best possible use of their skills and satisfy their own criteria for "successful employment."
The following sections discuss the variety of resources and services that may be available to clients. There will be considerable differences from one region to another in what resources are available, how they are structured, and whom they serve.
However, this discussion is intended to suggest avenues that could be explored to find new sources of vocational assistance.
On August 7, 1998, President Clinton signed P.L. 105-220, the Workforce Investment Act of 1998, into law. This legislation consolidates more than 60 Federal programs into three block grants to States for employment, training, and literacy. This reform measure replaces programs currently under the Job Training Partnership Act, the Stewart McKinney Act, the Carl Perkins Act, and the Adult Education and Family Literacy Act. Statewide and local Workforce Investment Boards (WIBs), which will replace Private Industry Councils (PICs), are required to provide employment and training activities to help youths and adults facing serious barriers, such as disabilities (including substance abuse disorders). The activities of the WIBs include disseminating lists of service providers and establishing one-stop delivery systems for the following services:
These programs provide job training and other services that are intended to increase employment and earnings, increase educational and occupational skills, and decrease reliance on welfare. Alcohol and drug counselors should be aware of the eligibility requirements and locations of these programs in their areas and refer clients to these services as appropriate. (See Chapter 7 for further discussion of the Workforce Investment Act.)
A network of State employment agencies is funded by DOL to offer a variety of services to persons who are eligible to work in the United States. The agency names vary (see Appendix E for a list of the agencies in all States). A central office is usually established in the State capital, and field offices are dispersed in communities to serve people in specific geographic areas.
Typically, they offer the following types of services to those looking for jobs and to employers:
These State agencies work closely with local government and private employers. Some have WIBs and Employer Advisory Committees. Employer Advisory Committees are local conglomerates that have a function similar to WIBs and are charged, usually by "one-stop" legislation such as the Workforce Investment Act of 1998, with planning, coordinating, and implementing all public economic development and employment services. As a consequence, these organizations also often provide direct links to available Federal, State, and local government jobs. Two government-run case management programs are described in Figures 2-7 and 2-8. Figure 2-9 describes an employment program for ex-offenders in Texas.
The Rehabilitation Act of 1973, as amended, authorizes the allocation of Federal funds to establish State VR programs to assist individuals with disabilities in preparing for and securing employment.
Priority is given to people with the most severe disabilities. To be eligible for VR services from a State agency, a person must
This type of agency exists in all States and Territories. Each agency has a central office, which is usually located in the State or Territory capital, and field offices throughout the State or Territory. Counselors may be assigned to specific geographic locations, particularly to ensure coverage in rural areas. Some specialize in providing certain services, such as job placement, or work with a specific population (e.g., those with substance abuse disorders or brain injuries).
State VR offices provide a wide range of services, including vocational counseling, planning, training, and job development and placement. The alcohol and drug counselor can refer a client to a State VR office after the initial assessment phase is completed and the client is ready to benefit from these services. Before accepting the client, the coordinating counselor arranges for further assessments to determine the client's readiness for rehabilitation.
The primary case management and counseling services for the State agency are provided by a rehabilitation counselor. The rehabilitation counselor's responsibilities include (1) assessing the client's needs, (2) developing programs and/or plans to meet identified needs, and (3) providing or arranging for the services needed by the client, which may include job placement and followup services (Parker and Szymanski, 1998).
Once a client is accepted by the agency, rehabilitation legislation mandates the development of an individual plan for employment (IPE)--also known in some States as the IWRP--to identify goals and objectives for employment, as well as a timetable for achievement. It is important for the alcohol and drug counselor to review the plan with the VR counselor to support the client in achieving these goals and identifying potential difficulties. The vocational plan should reinforce the substance abuse treatment plan and make the interagency linkage work as well as possible for the client.
Before referring clients to this type of service, the clinician should first develop a relationship with the assigned VR office, which is likely listed in the phone book in the State government section. Because many VR staff members will need cross-training in substance abuse treatment, each office should have a supervisor who can help determine which counselor should receive the referral.
Clients referred to a State VR agency must call to make an intake appointment. It helps to have psychological and medical evaluations ready, as obtaining documentation of disability is the second step of the process and often the most cumbersome. These evaluations must be signed by appropriate professionals and indicate the type of disability and limitations. Also, any information about a client that is divulged to another agency must be accompanied by a release form signed by the client (see Chapter 7 for a detailed discussion on confidentiality issues). State VR agencies can place clients in precontracted job training programs or provide funding for eligible clients to attend technical or college programs. This funding can enable indigent clients to receive the higher education services that would have eluded them without this support.
Two recent pieces of legislation will strongly influence the ways that treatment programs seek and secure funds to meet their clients' vocational needs. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 dramatically transformed the means by which public assistance is provided (see Chapter 7 for details on this legislation). The Balanced Budget Act of 1997 provided additional resources to support the goals of the 1996 welfare reform legislation by authorizing DOL to provide welfare-to-work grants to States and local communities. These grants are to be used for transitional employment assistance to move hard-to-employ recipients of Temporary Assistance for Needy Families (TANF) into unsubsidized jobs offering long-term employment opportunities; clients with substance abuse disorders are specifically targeted. The program is mobilizing the business community (largely through local WIBs) to hire welfare recipients and is working with civic, religious, and nonprofit groups to mentor families leaving welfare for work.
Funds can be used by States, PICs, WIBs, and other entities to move eligible individuals into long-term jobs by a number of means, including job retention and supportive services such as substance abuse treatment. Although TANF (and therefore welfare-to-work) funds cannot be used for "medical services" such as detoxification under the care of a physician, a range of substance abuse treatment services can be provided under this funding. In some States, TANF block grant funds have been allocated for substance abuse treatment services, including assessment, residential treatment, and less intensive outpatient programs.
The welfare-to-work legislation is implemented differently in each State, and there is a complex web of political and financial forces that must be understood to access this funding effectively. Scanning the environment to determine the relationships among the welfare agencies, PICs, WIBs, State substance abuse agencies, and other community-based organizations is critical. It is in this context--a complex landscape of shifting ideas about treating substance abuse disorders, changing funding streams, and the blurring of roles and responsibilities between public and private sectors and between Federal and State governments--that substance abuse treatment programs must seek to secure the funds that have been set aside to help chronically unemployed welfare recipients obtain and maintain work.
Program planners should look to the future and budget for one-time expenditure items that will improve vocational outcomes for clients. Such items might include a computer with a package of vocational assessment software. A VR library can be budgeted as a one-time expense although some updating is periodically needed (see Figure 2-10). Additional information on securing funding for expanding current programs and hiring is provided in Chapter 6.
When eligible dependents and survivors are included, nearly one-third of the U.S. population is entitled to veterans' benefits (U.S. Department of Veterans Affairs, 1997). The huge job of administering these benefits belongs to the Veterans Benefits Administration (VBA). The VBA's mission, in partnership with the Veterans Health Administration, is to provide benefits and services to veterans and their families in a responsive, timely, and compassionate manner in recognition of their service to the nation. The benefits include compensation and pensions, housing loans, insurance, and vocational or educational counseling and training. The VBA's educational services have two objectives:
Vocational Rehabilitation and Counseling Service programs (VR&C services) primarily serve veterans entitled to benefits under 38 U.S.C., §3100 et seq. VR&C services administer vocational training to certain nonservice-connected veterans awarded disability pensions and educational and vocational counseling to specified classes of beneficiaries (veterans, service members, spouses, widows, and children of disabled veterans). Alcohol and drug counselors should be aware of those clients who are entitled to these benefits and how to access these services. Persons eligible for veterans benefits must apply through the local or regional Veterans Administration office, which can be located through the Federal government pages of the telephone book.
Almost every community has a host of agencies that provide VR services. They offer a variety of services, from job-seeking assistance to employment in a sheltered or supported environment. In some States these agencies are State-certified and funded. In other States they are funded and operated by counties or cities. In many instances, the agencies are private, nonprofit groups funded from a variety of sources to serve a specific group of clients. Eligibility for the services varies according to the policies established by the specific organization and its funding sources. Some serve persons with disabilities who are unable to work in a competitive environment, whereas others focus on youths who are at risk for dropping out of school or need a second opportunity because they already dropped out. Particular populations, such as those in a public housing community, could also benefit from rehabilitation programs targeting their needs. The key is that these services are designed to meet the unique needs of the community.
These organizations receive funding from a number of funding streams--Federal, State, and private (including foundations). The Neighborhood Funders Group is a national association of grantmaking institutions. It has more than 150 member foundations that seek to improve the economic and social fabric of low-income urban neighborhoods and rural communities. Many of their programs fund employment projects that vary from community to community. The local social services agency is a starting point to learn more about these programs.
Community-based rehabilitation centers offer a range of medical, social, psychological, and technological services to persons with disabilities. They serve a locality, allowing people to undergo rehabilitation and build supports in their own community. They receive funding from State agencies, insurance companies, and nonprofit agencies (e.g., Goodwill Industries). A community-based rehabilitation center's target population varies according to the center's mission but might include persons with a traumatic brain injury, spinal cord injury, and learning disabilities, among others. Referrals to this type of center require coordination with the funding source.
Some local mental health agencies have designed vocational services as part of their continuum of care for eligible clients. These services vary and require coordination through the mental health care center or office. Persons who have a mental illness and require supportive services to obtain and maintain employment may be eligible. Some examples of typical programs include job club programs as part of day treatment programs, job coaching for obtaining and maintaining appropriate work behaviors, and supportive employment onsite in a work setting. Alcohol and drug counselors have numerous avenues for finding out about local VR services: