There are many compelling reasons for vocational components to be part of the substance abuse treatment plan for clients in recovery. For example,
This chapter discusses clinical issues related to the incorporation of vocational components into the substance abuse treatment plan and how to counsel clients to address their vocational goals and employment needs. Exploring options for appropriate training or education, finding and maintaining employment, and coping with environmental and legal challenges also are discussed. The chapter then addresses how to develop a treatment plan and at the end presents case studies using the principles discussed throughout the chapter.
To successfully incorporate vocational services into substance abuse treatment, the alcohol and drug counselor must first acknowledge that vocational training, rehabilitation, and employment compose an important area of concern for clients. How clients handle work often is closely related to how they handle other aspects of their lives; therapeutic concerns such as poor self-esteem, feelings of inadequacy, hypersensitivity to criticism, and issues with authority tend to manifest themselves in relationships at work. Therefore, gainful employment can be a measure of a client's successful adjustment, social functioning, and community reintegration (Schottenfeld et al., 1992). Research also suggests that the occurrence and severity of relapse tend to be lessened in individuals who can develop positive self-images and raise self-esteem through employment (Arella et al., 1990; Deren and Randell, 1990). Employment also can help decrease criminal behavior and substance abuse (Schottenfeld et al., 1992). Realistically speaking, clients must be able to support themselves financially. These findings confirm the therapeutic importance of including employment as part of the substance abuse treatment process.
Clinicians can best address vocational issues by considering their relevance at every stage in the client's treatment, including their incorporation into individualized treatment goals. Preliminary information on vocational needs should be collected and assessed at intake. When the client's situation is stable, the vocational element of the treatment plan should be more fully developed. Additional assessments should be conducted if necessary, with referrals to vocational services as appropriate.
The Consensus Panel believes, based on its collective experience, that three key elements are essential to effectively address the vocational needs of clients in the recovery process. They suggest that clinicians
These recommendations are discussed in more detail below, except for screening and assessment, which are discussed in Chapter 2.
Regardless of the client's employment situation--employed, looking for better work, or unemployed--it is appropriate for the treatment plan to have a vocational component that specifies objectives developed jointly with the client. Goals should be set that can be achieved through counseling (such as improving relationships with coworkers, handling anger or stress appropriately in the workplace, improving attendance), or the client may require referral to vocational rehabilitation (VR) counselors. The following are situations in which a clinician should refer the client for vocational services:
Research suggests that counselors can help clients progress by focusing on what clients feel is most important (Jongsma and Peterson, 1995; Linehan, 1993; Meyers and Smith, 1995). For many clients, employment is the primary concern. For women with children, their care is of primary concern, and employment is the means to obtain that goal. For clients coming from incarceration, employment may be a condition of their parole. For others, work may seem unrelated to their current needs and desires as they perceive them. Still, exploring vocational goals can help these clients attain other goals, such as increased financial independence or a more satisfactory living arrangement. By helping the client appreciate the benefits of work, expressing optimism about the client's ability to obtain work, and preparing the client for the work environment, the clinician can foster positive change in the client's sense of worth, increase hope for the future, and positively affect many other areas. Figure 3-1 presents a list of early-stage vocational issues to explore with clients.
Many persons in recovery share common internal and external challenges in regard to employment. These include out-of-control feelings, coexisting disorders or disabilities, low self-esteem and self-efficacy, poor work histories, fear of failure, fears and anxieties severe enough to block needed actions, deficiencies in life skills such as financial planning, and poor problemsolving or coping skills. As these challenges become clinical issues, the clinician should address them in an empathic but motivational style, building rapport and trust and practicing reflective listening skills. A solution-focused approach can be used to help clients recognize that although it feels as if there are no alternatives, they can choose from among a range of options. The timing of the introduction of elements of vocational services depends on a number of factors, which are presented below in the section on developing the treatment plan.
A treatment plan for substance abuse ideally includes professionals from a number of disciplines. This multidisciplinary approach is discussed in greater detail below. The roles assumed by two of the players--the alcohol and drug counselor and the VR counselor--differ from one program to another and sometimes even within programs from one client to another. If the alcohol and drug counselor is the only person addressing employment issues, this clinician's tasks will be different from the case where the client is engaged in a formal vocational program.
The clinician--either the alcohol and drug counselor or VR counselor--has important responsibilities in (1) activating and supporting the client's desire for change, (2) motivating the client to take the risk of seeking new or better employment when appropriate, (3) helping the client learn to anticipate and solve problems, and (4) referring the client to community resources that can provide support at various points on the employment continuum.
Appropriate therapeutic goals in the realm of employment include the following:
It is also important to have an understanding of the client's cultural and family values and beliefs about work. For example, many Asian Americans are likely to focus heavily on returning to work because of the strong work ethic within their culture and the shame associated with being out of work. Family members are likely to be pressuring the client (possibly not with great sensitivity) to return to work. However, the client may be reluctant to explore the reasons for job loss or to identify the specific steps needed to make a change.
In such cases, the clinician should validate and support the cultural value placed on the importance of work and acknowledge the client's sense of being pressured to return to work. In addition, it is sometimes helpful to frame the treatment as a rebuilding process similar to the body's healing and reconstruction after an injury.
It is important to recognize that all clients, not simply those who belong to cultural and ethnic minorities, approach work from a particular cultural framework. However, the clinician should beware of making assumptions about how clients' cultural backgrounds affect their perceptions and experience because individuals can differ significantly from the norms of their culture.
In addition, the clinician should maintain an awareness of his own values, attitudes, and biases that affect the view of work-related decisions and challenges and how these can negatively affect the client's ability to progress. The clinician who does not see in work the possibility for growth and a way to enhance recovery will inevitably communicate to the client a poor attitude regarding work.
Clinicians often play a mediating role between clients and employers, helping each understand the other's point of view. The clinician's grasp of the employer's view is essential to ensuring the client's smooth transition to the workplace. Clinicians should also take advantage of opportunities to educate the employer on substance abuse disorder issues and how to address them in appropriate policies. A service partnership or close collaboration with a VR counselor is especially valuable in mediating and facilitating client-employer relations. VR counselors work regularly with employers in their communities and are trained to negotiate win-win situations with clients and employers.
As clients move toward planning for future work or addressing challenges in their current workplaces, many opportunities for personal growth and accomplishment arise. Competency areas applicable to clients in recovery who are concerned with vocational issues include
The clinician should explore the client's developmental history and other pertinent facts in each competency area, including relevant life experiences and their positive or negative consequences. This section discusses these competency areas and addresses the clinical challenges that commonly arise in each area.
As clients envision the possibility of a vocation--purposeful work that is meaningful to them--they also have an opportunity to address important therapeutic goals such as increased self-sufficiency, self-trust, and a sense of efficacy in the world. Although employment accepted for the purpose of gaining money also addresses these goals, the sense of choice that is implied by the term "vocation" is especially powerful. Because of this, the clinician will want to help the client distinguish between short-term employment strategies and long-term strategies for developing a vocation. In guiding the client to address this important topic, the clinician should use appropriate pacing and timing and avoid a confrontational approach. A realistic vocational goal should be part of a positive and compelling life vision that truly belongs to the client.
If the client has a negative work history, the clinician can activate a positive self-image by asking the client about areas in her life in which she has been successful (e.g., helping parents or other family members, participating in a religious group or other community organization). The idea that skills acquired in one setting are often transferable to another is sometimes new and reassuring to many clients.
To assist the client with vocational planning, the alcohol and drug counselor or VR counselor will need reliable information about the client's life experiences, especially past work and educational experiences, as well as his knowledge, skills, and abilities. If available, the clinician should review prior employment and vocational skills assessments and the results of prior aptitude testing. (Information relayed by the client about educational or VR agencies that have previously worked with the client should be verified and records obtained to ensure the accuracy of details.) With a work history, the counselor can perform a "transferable work skills analysis." Typically, this process involves the following steps:
Salomone states that transferring skills from one job to another requires the assessment of (1) the worker-specific vocational preparation that classifies work as unskilled, semiskilled, or skilled; (2) the physical demands of previously performed jobs; (3) a medical determination of the client's current physical and mental status and ability; and (4) the identification of specific jobs that the client could perform given the three factors noted above (Salomone, 1996). There are computer-based programs such as the EZ-DOT, CAPCO, and RAVE (Brown et al., 1994) that can be used to assist the counselor in this process.
The client's work history will reveal the skills the client already has. However, some clients may have forgotten parts of their employment history, and many will not be able to articulate the knowledge, skills, and abilities they possess. To elicit this information, the clinician can ask about specific activities the client has done, such as using a jackhammer or cooking, as well as about the client's use of spare time. Hobbies and interests sometimes suggest possible career directions, as well as natural talents. To assess clients' vocational interests, the clinician can use the easy-to-administer Self-Directed Search, mentioned in Chapter 2. The results of this scale can then be discussed with the clients to determine realistic vocational choices to explore.
As previously noted, vocational issues are ideally introduced when the client is relatively stable, although there are situations where the need for employment is so compelling that it must be addressed immediately. Whenever this issue is raised, the counselor should tailor the strategy to the client's stage of "readiness to change." A well-known model of change, developed by psychologists James Prochaska and Carlo DiClemente, is relevant (Prochaska and DiClemente, 1982). This model envisions the process of change as a wheel in which the individual moves from a stage of not thinking seriously about change (precontemplation) to seriously contemplating the possibility of change, determining to undertake change, acting to make the desired change happen, maintaining the new behavior, dealing with possible relapse, and then around the circle from contemplation once more. Different skills are required on the part of the clinician when the client is at different stages (Miller and Rollnick, 1991; see also TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999c]). As the client progresses through the cycle of change, it becomes possible to address new and more challenging dimensions of long-term planning.
Clients who are at a precontemplation stage in regard to work may need motivation to help them develop a positive attitude toward the prospect of work. Applicable clinical strategies include encouraging positive "self-talk" and exploring both the benefits and the disadvantages associated with work in a motivational style that elicits "self-motivational statements" (Miller and Rollnick, 1991). The clinician can build on the client's desire to stay "clean" and show how work can support that objective by providing a legal means of income as well as the potential for developing relationships that support a substance-free lifestyle.
Some clients who have clear and pressing reasons to find work are nevertheless in denial about the necessity to make a transition. This condition may present itself as avoidance: "I'm doing 12-Step and that's it--I'm in recovery, and I just can't handle anything else." Some clients enjoy the sharing and social contact that a group offers so much that they want to make it fill their lives; finding or staying in jobs may seem a distraction from what feels most important. The challenge for the clinician is to help them appreciate the realities of the situation and envision the consequences of their decisions, while maintaining the primacy of recovery. Clinicians should be careful not to foster a belief in their clients' fragility that could lead to their being denied useful services. If clients are genuinely unsure of where they stand (e.g., in regard to welfare-to-work requirements), then accurate information should be provided to them, or the clinician should make relevant referrals as appropriate.
For many clients, the transition to work seems a daunting leap from their present situation. Some are used to thinking in terms of getting through 24 hours at a time, and the thought of how to plan for a year or more can be overwhelming. Such clients can benefit from encouragement and from a focus on short-term, specific, manageable goals within the context of a longer term strategy. Clinicians can help clients envision each step and prepare them to overcome the obstacles that each step presents. For clients who lack work experience, a positive framework for considering work issues needs to be built. It should be explained to them that work is sometimes difficult and may require sacrifice but that it offers the satisfaction of achievement. For some clients, a period of temporary work in a supervised and controlled setting is necessary to prepare them for more permanent full-time work. Certain residential programs, for example, have clients engage in mechanical work under the auspices of the program in order to ease the transition and build a positive work history (see Chapter 2).
Clients who must for the first time accept menial employment will have understandable difficulty with the transition to work. Reorienting their values and framing the new work world positively is usually a long-term and difficult task. The clinician will need to help clients develop reasonable job expectations given their skills and environment. It will also be important to emphasize the nonmonetary rewards of work such as no more fear of arrest for selling or using illegal drugs and the esteem from family for having "gone straight."
Clients must also learn to envision a ladder to more prestigious employment and accept a reasonable pace of progress. Use of metaphors that are meaningful to the client helps to illustrate stages of growth leading to the goal. For example, sports superstars start out by practicing, learning, developing, and demonstrating their talents before they can build a reputation. Or, the clinician might compare the injury caused by the substance abuse, and the recovery afterwards, to the time and effort needed to rebuild the strength in an arm or leg after a serious wound or fracture. These analogies can be effective with clients who relate more readily to physical symptoms than to psychological concepts.
Even for clients who are currently employed, a reconsideration of vocational goals is often advisable as part of the recovery process. Some employed clients in recovery should consider a transition because their job exposes them to alcohol or drug use on the job. For example, a construction worker whose crew drinks or smokes pot at lunchtime or after work may not be able to maintain a substance-free life.
In defining the client's educational needs and exploring available resources to meet them, it is important to recognize that the client's past experience with the educational system may strongly influence work-related decisionmaking. For example, the client may have had an undiagnosed learning disability and may have experienced repeated failure within the educational system, or the client may have had poor experiences with teachers. Some clients are illiterate, although they may have concealed this fact even from some of their closest associates. Clients who are not native English speakers may have experienced difficulties from the language difference that have affected their education. It is important for the clinician to be aware of the client's history in these areas and to help the client recognize and reframe the impact of a negative learning history on the present situation.
To support the client in obtaining successful employment, the clinician should be able to answer the following questions:
The clinician can learn the answers to some questions indirectly by noticing cues from the client, assessing writing skills on the basis of the intake forms, and observing the client's patterns of communication. Other questions are best addressed by asking the client directly at an appropriate time in the treatment process. Typically, the clinician makes a preliminary estimate of the client's educational abilities at the outset, then refers the client to other resources as necessary for a more thorough assessment. Counselors working with clients who are ex-offenders also should be familiar with the educational resources available to those clients through the prison system so that appropriate referrals can be made if necessary.
When the clinician has the information about the client's educational history, needs, and interests, the clinician can then assist the client with identifying career goals and determining the education required to meet those goals. The clinician should help the client recognize when his goals may be either too high or too low. However, it is important to be sure the process is client-driven, emphasizing the client's responsibility for decisionmaking.
As the client demonstrates a capacity to engage in education and becomes more employable, the clinician can support the client by raising the bar of expectation and encouraging the client to take on more challenging educational and vocational objectives. It is important, however, that the pace of progress not exceed the client's ability to experience success and handle whatever disappointments occur.
The process of finding a job provides an opportunity for clients to grow in many areas important to recovery. It provides an opportunity to practice goal-setting and recognize achievement. Through a successful job search, the client can acknowledge the potential for positive change and movement in a direction of her own choosing.
To be successful, clients may need to grow in a number of different ways. Common growth areas include the following:
Once the client has found employment, the work setting itself will present challenges and provide opportunities for growth. It provides an opportunity to learn appropriate boundaries and appropriate self-protection. The client may need help discerning when self-disclosure is appropriate and when it is not. Recovering clients who are newly employed--particularly those with criminal records--should be careful of being in vulnerable positions in which they could be accused of stealing or other illegal behaviors (e.g., avoid closing up a store alone). Work will also provide an opportunity for some to recognize and accept responsibility.
Workplace conflict is to be expected, and persons in recovery may find such conflicts powerful triggers for relapse.
The workplace may evoke associations with the family of origin, intensifying and potentially distorting the client's sense of what is at stake in conflict situations. The clinician, alone or through a therapeutic group, can help the client get the distance needed to perceive the situation accurately. The therapeutic process will help the client become conscious of associations and better able to separate past and present issues. Impulse control, problemsolving skills, stress management, and conflict resolution skills may all require development. In addition, the client may need help recognizing the legitimate options open to her in the situation--for example, getting help from the human resource department or requesting a transfer.
Many persons in recovery experience problems with authority that can become clinical issues as they enter the work environment. Some mistrust authority and experience a great deal of stress when dealing with their supervisors. They may have an excessive fear of being fired or a too-quick response to perceived mistreatment. Some fail to manage anger and can explode when the boss is critical or inflexible. The clinician can help the client distinguish between appropriate and inappropriate behavior on the part of the supervisor, and, if this is a problem, help the client separate emotional reactions to the supervisor from feelings about a parent or other authority figure. Clients can work on seeing "the boss" as a person. In addition, clients should learn to recognize their personal power in dealing with the supervisor and notice opportunities to negotiate. These issues can be dealt with successfully in individual or group therapy, or the client may be referred to community resources for training in pertinent job and behavioral skills such as anger management.
Some clients have medical and psychological needs and limitations that can affect the type of employment for which they are best suited. The clinician can help them consider how to present these needs and limitations to an employer and acquaint clients with their legal rights concerning accommodations.
Clinicians should receive basic information on the client's medical and psychological condition at intake. The Addiction Severity Index (ASI) can provide a brief history and description of the client's medical needs (See Appendix D). If a more in-depth vocational assessment is needed it should be done by a VR counselor or a vocational evaluator (see Chapter 2). Also, a physical examination is usually part of the intake procedure; the clinician should identify acute and chronic medical needs and identify a process to address them. In particular, clients should be screened for substance abuse-related disorders such as sexually transmitted diseases, HIV/AIDS, and hepatitis, at the initiation of the treatment process so that these disorders may be treated and stabilized prior to the client's vocational training or employment endeavor. The screening should include determining what accommodations might be necessary for a client with medical dysfunction in training or employment settings.
Similarly, at intake or as soon as possible thereafter, clinicians should determine whether the client has coexisting psychiatric disorders. ASI has a psychiatric domain that may be helpful. The client may have problems such as depression, anxiety, anger control, memory deficits, concentration deficits, or more severe symptoms such as hallucinations. In that case, the client should be referred to a psychiatrist for further evaluation and to determine whether medication is necessary (or if current medication is effective). Such disorders have implications for vocational planning and for the kinds of support the client needs from the clinician when actively seeking or trying to maintain employment. Keep in mind that diagnosis of a psychological disorder is impossible if the client is still using. The psychoactive effects of drugs or the manifestations of withdrawal may mimic the symptoms of mental conditions. Generally the client must have abstained from drugs for an extended period of time (6 to 12 months) before a differential diagnosis can be made.
Special issues arise for clients who are either reliant on opioid maintenance therapy (i.e., methadone) or dependent on prescribed medications. If a client is taking methadone, then she may fail drug tests mandated in some places of employment unless she has disclosed the fact to the employer's medical review officer. It can be beneficial for a methadone patient to transfer to treatment with LAAM (levo-alpha-acetyl-methadol) as LAAM cannot be detected in urine drug screens except for thin layer gas chromatography and gas chromatography/mass spectrometry. See TIP 22, LAAM in the Treatment of Opiate Addiction (CSAT, 1995d). Similar problems can arise with certain prescription drugs (see Chapter 7 for a discussion of associated legal issues). The clinician or another knowledgeable specialist should help the client manage appropriate self-disclosure in advance of the drug test so that his right to confidentiality is protected.
Medications can generate a variety of other work issues that, whenever possible, should be anticipated before the client seeks or accepts employment. Some psychotropic medications, for example, can cause side effects such as lethargy, dizziness, and nausea. It is essential that these side effects be considered when determining appropriate work situations for clients so that they are not placed in a dangerous situation or one that will ultimately lead to failure. The timing and conditions under which the medication must be consumed should also be taken into account. Some medications leave the body through sweat, reducing their effectiveness; clients in jobs involving physical exertion, such as construction, should make appropriate adjustments for this. In other cases, a job coach or other monitoring may be needed to help the client cope with coordination problems resulting from medication.
The clinician should also ensure that clients (particularly those with comorbid medical or psychiatric disorders) recognize the importance of finding a job with health insurance. A good number of clients will obtain jobs without benefits or with benefits that phase in after a probationary period. Those involved in treatment should coordinate their efforts to ensure the most positive blend of resources and services possible to assist clients. In addition, counselors should educate clients about their right to confidentiality and accommodation for disabilities (see Chapter 7; see also TIP 29, Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities [CSAT, 1998c]).
Many clients must overcome logistical challenges to securing and maintaining work. The clinician can play an important role in helping clients identify the most effective approaches to addressing these difficulties. The Consensus Panel suggests using solution-focused strategies, building on coping skills the client has already demonstrated, and applying them to new contexts. Clinicians should encourage the client to identify resources used to accomplish other objectives and determine how these strategies might be useful in negotiating work-related issues. The clinician also should know about community resources, particularly in the frequently troublesome areas of housing, transportation, and child care. Progress and difficulties in meeting employment goals should be discussed regularly.
The clinician should be aware of the client's basic living situation and be able to refer the client to community resources if needed. Is the client coming from a residential treatment setting? Is he homeless, just out of the hospital, or in a group home with substance users? The client's living arrangements will have implications not only for the availability of support during recovery, but also for the availability of job-related resources such as access to an answering machine or a reliable message taker. Clients can also be referred to one-stop career centers or employability centers for assistance. Clinicians should be familiar with what housing options are available, such as through local housing authorities and the U.S. Department of Housing and Urban Development (HUD).
Many clients have transportation issues such as suspended or revoked driver's licenses, lack of public transportation, or geographic isolation. For people with children, long hours on public transportation and the ability to get to a sick child greatly influence the ability to stay employed. If transportation is known from the beginning to be a problem, the client should only explore job opportunities accessible by public transportation. Clinicians can help them review how they have arranged transportation in the past (e.g., to get to a methadone clinic), and brainstorm about alternatives, including carpooling. VR services, medical assistance programs, and public transportation systems often provide free or low-cost transportation for eligible clients.
Locating suitable, convenient, and affordable child care is a common problem. For clients involved with child protective services or welfare agencies, child care vouchers are available both for child care centers such as the YMCA and local Boys and Girls Clubs and for family day care arrangements. These programs are usually licensed and provide safe and developmentally appropriate services for children while parents are at work. Head Start and early intervention programs are also available for low-income families through local schools, religious organizations, and social service agencies. Some child care voucher programs are initiated when employment begins. The resources clients used to care for their children when they were using substances are probably not the safest or best alternatives. However, the clinician can expand the client's repertoire of possibilities by making suggestions--for example, sharing caretaker responsibilities with friends or relatives who work different hours. Again, being familiar with local child care agencies and resources will allow the clinician to provide appropriate referrals in this area.
For some clients, eligibility for work can be affected by criminal records or by issues related to their immigrant or residency status. Clients are sometimes barred from specific jobs (such as child care worker) on the basis of prior convictions. In addition, many have records so complicated they are actually unaware of outstanding warrants; it is not unknown for a client to have rebuilt her life and be gainfully employed, only to be arrested for a crime committed some years ago. See Chapter8 for more information about working with ex-offenders.
Recent immigrants often need assistance in collecting the documents needed to work and in accessing reliable information about legal requirements. The clinician should direct such clients to community resources for help in applying for legal residency, getting a work permit, or learning the process for becoming a U.S. citizen. Clients not familiar with the U.S. Immigration and Naturalization Service and State requirements will need help distinguishing between realistic concerns and those that should not be a deterrent in seeking and maintaining work (see Chapter 7).
The first task in helping a client move toward employment is motivating the client to want to join society rather than be on its fringes. Work is an opportunity to advance the client's progress toward this important goal. The newly employed client can practice effective communication skills in a new environment, including learning how to talk to persons in authority, manage anger, and raise issues effectively. Developing confidence in appropriate self-expression, especially when it leads to the desired result, can enhance the client's sense of self-efficacy. Researchers have demonstrated that when people believe that they are capable of performing a new behavior (i.e., have efficacy expectations) and know that the new behavior will get them what they want (i.e., have outcome expectations), they are likely to persist and be successful in their attempts for change (Bandura and Adams, 1977).
Clients returning to work, or those attempting to maintain employment for the first time after a period of withdrawal from society, may be deficient in the basic skills needed to function within an organizational culture, manage resources, and gain social acceptance. Specific skills that may be needed include
Although some transition skills may be effectively gained through referrals to other community resources, it is the clinician's responsibility to assure the client of the necessity for change and to engage the client in mastering the social skills that will support recovery. The clinician can use the group therapy format to give clients an opportunity to role-play responses in difficult social situations and receive feedback from the group. If the client is employed at a work site that pressures him to drink, the client may need help avoiding or managing ostracism--or finding a healthier work environment.
For clients moving into the work environment for the first time or after an extended period of withdrawal, family members' behaviors toward the client around work issues can either help or hinder the client's progress. It will be useful for the clinician to have some information on how family members are responding to the client's employment situation.
An understanding and encouraging family can provide much needed emotional support to the client. Unfortunately, however, many families may have covert reasons for not wanting to see the client recover fully in the area of work. For example, clients may fear losing disability benefits if they recover sufficiently to work or a wife may be ambivalent about her husband's return to work because she has grown accustomed to being the sole decisionmaker in family matters while her husband was disabled by his substance abuse. If these issues are not addressed, then family members might not support the client's attempts to return to the job market. In fact, the family members might actually sabotage the client's efforts to return to work, viewing work as competition. For example, a client's child may begin acting out at school to get his attention. Recognizing and dealing with family resistance to work is a complex and continuing task with some clients.
Losing a job, which can trigger a profound sense of failure and self-doubt, has been highly correlated with relapse (Platt, 1995). Yet, few persons in this era can expect to retire from the job at which they first started work--either through their own choice or their employers'. As a result, the client is likely to have more than one opportunity to exercise job-seeking skills. Today, the "contract" between employer and employee is "short-term and performance based," and "the company's commitment to the employee extends only to the current need for that person's skills and performance" (Hall and Mirvis, 1996, p. 17). Because of this philosophy, the clinician should help prepare clients for the need to change and grow throughout their work life. Either directly or through referral, the clinician should help clients envision the next steps they might take after leaving their present job. This kind of preparation can make each job, regardless of its duration, a learning experience rather than a failure. Some job counselors envision an employment "web" in which the client can move laterally, up, or down to accomplish strategic objectives. Clients should be prepared to show resilience and exercise choice in their work lives.
As discussed previously, job-seeking and employment present an opportunity for growth and stabilization that can support recovery. However, the process can also be stressful and present many potential triggers for relapse. For example, if a client witnesses substance abuse on the job, should he report it or try to be "one of the guys?" General assistance in managing stress effectively should be provided. Even if the client can find employment that provides good support for a substance-free lifestyle, the workplace will almost inevitably present challenges that could trigger renewed use. The clinician should be alert for the presence of triggers that have affected the client in the past and help the client recognize and cope with them. For example,
To achieve therapeutic goals in the domain of employment, the clinician should develop a treatment plan that addresses the client's vocational training, rehabilitation, and employment needs. Typically, such plans cover a period of 90 days (although some treatment episodes do not allow for this length of time). The case studies at the end of this chapter illustrate how vocational rehabilitation is integrated into treatment plans. Consensus Panel members suggest envisioning the clinical treatment process as intertwined with the client's cultural background and the client's "work identity." Work identity denotes the specific meaning of the concept of work to the individual client. This includes
The client's goals can include the attainment of good pay, interesting work, job security, opportunity to learn, interpersonal relationships, variety in tasks, autonomy, opportunity for advancement, and other considerations (England, 1991). These motivational considerations will obviously influence the career path chosen. They are also integral to the treatment process, a way for the individual with a background of substance abuse to begin to create an identity as a person in recovery.
The following considerations, discussed in this section, are key to the formulation of a treatment plan:
To provide adequate support to the client in gaining successful employment, multidisciplinary participation is often needed. The case manager, whether the clinician or another person, should identify people from a range of professional disciplines who are able to supplement the clinician's skills and meet the client's needs. Most should be involved at the time of intake, then consulted afterward as needed. The group will most likely not come together as a team, but members should recognize that they each have significant responsibilities toward the client. Because of their ability to help clients meet therapeutic goals in their domain of employment, the group frequently includes the following members:
Some clinicians would include the client's new employer or a representative of the client's school as a member of the treatment recovery team. Advantages to this approach include the potential for educating this person, as a representative of an institution that will play a key role in supporting recovery, to understand potential triggers for relapse in the workplace and increase the likelihood that the client will receive appropriate support. However, even assuming the client's informed consent, issues related to confidentiality, boundaries, and stigma should be carefully considered. Conflicts of interest could arise. The employer or educator may treat the client differently and project a bias, consciously or unconsciously, that affects the individual's employment experience.
Unless a client needs time for detoxification or adjustment to sobriety, some aspects of prevocational counseling can begin in the early stages of treatment. If the client has an immediate need for employment and is capable of managing it successfully, the timetable can be accelerated to encourage the client to accept an available entry-level job.
Although treatment initially focuses on use issues, a brief discussion of long-term treatment goals, such as work, will lay groundwork for later therapy. The client should have, in the back of his mind, the notion that work will be an important component of recovery, and although not addressed directly at first, vocational issues will play an important role in his treatment. The time for introducing vocational services must be paced according to the client's specific situations. Among the factors that must be considered are
It is important to coordinate treatment services to avoid conflict with the client's current job or educational pursuits because both of these may be helpful in stabilizing the client and supporting a substance-free lifestyle.
Vocational plans will differ according to the client's stage of substance abuse and recovery. The client's commitment to work and the appropriate type of work can only be projected on the basis of thoughtful analysis of his specific situation. This includes considerations related to the specific substance or substances the client has used, his pattern of use, the amount of time in recovery, relapse triggers, and the social and other support systems available to assist in his recovery. If ongoing effects from substance abuse are evident, the clinician should assess the level and nature of dysfunction the substance abuse is causing (or has caused). Clearly, the client's level of functioning will affect the type of work he can undertake successfully (see Chapter 2 for further information on functional assessment).
If the client does not have medical complications or withdrawal, or if the client has used a substance that does not have long-term effects that continue into the period of initial withdrawal, vocational planning issues can be addressed earlier in the treatment process. Vocational issues should be discussed whenever the opportunity arises. Even if a client's prospects for obtaining employment in a competitive market are slim, volunteer or supported work activities can be an important adjunct to traditional treatment and can give structure and meaning to the individual's life.
Individuals with short-term substance dependency are likely to have less severe functional limitations and therefore a potentially wider range of job options (if they are unemployed). They may have a positive work history and may even have maintained a job. If they do need employment, they usually will have fewer difficulties in gaining it. If other factors are equal, these individuals are generally capable of achieving higher goals.
Some individuals with chronic substance dependency (dependence for 2 years or more) can be employed, but the longer the dependency has continued, the more likely it is that the individual has lost her job and has experienced functional loss and other difficulties that will make her more difficult to employ. These individuals generally have more medical problems or issues. Also, as masked symptoms emerge, the clinician may encounter coexisting disorders such as depression and anxiety that will have ramifications in the workplace. These clients usually have fewer resources and may have burned more bridges during their period of dependency.
A special class of chronic users includes functional alcoholics, whose relatively ingrained dependency is usually time limited. These individuals have learned to abstain for short periods--long enough to maintain employment--then binge. In setting goals for individuals with chronic dependency, enough time must be allowed for the individual to adjust to abstinence. As use decreases, vocational challenges can be increased.
Clients who have been abstinent for 90 days or less are at the greatest risk for relapse. Because of this, modest vocational goals are more appropriate. However, some individuals have significant cognitive dysfunction and have difficulty making plans and structuring time. It is generally best to limit stress and make only gradual changes in life activities, keeping the client focused on the recovery process and the "here and now." If it is essential to address vocational goals prior to 90 days of abstinence, then strong supports will be needed to maximize the individual's chance of success.
Individuals who have maintained their abstinence for more than 3 months have a diminished risk of relapse and, in general, a greater success rate for engaging in new activities and tolerating stress. Their family lives and sense of self have moved toward stability, and they have an increased capacity for long-range planning and problemsolving. They are often ready to engage in active job seeking or to begin work toward long-term vocational goals by acquiring new skills and knowledge. The treatment provider should ensure that the vocational plan provides that resources will be in place should a crisis occur, with adequate aftercare and followup treatment.
The type of substance or substances the client has used also has implications for employment planning or work toward long-range vocational goals. Although each client's situation will have unique elements, the following generalizations suggest common concerns that should be taken into account.
Because alcohol is a legal substance, clients who use alcohol have generally experienced more social acceptance and are less likely to have criminal records than persons who use illegal drugs. These clients may, in general, have greater functional ranges, fewer personality disorders, and less of an "up and down" cycle than those dependent on illegal substances. As a consequence, there tend to be fewer obstacles to employment, and the client may have succeeded in maintaining a job through the period of dependency.
Even when a client in treatment is employed, there can be obstacles in the vocational area. These clients are more likely to have coworker encouragement to use alcohol. For example, going out for lunch with others may be a trigger for use, or employees may get together at a bar after work on Fridays. As part of the "methods" section of the treatment plan, the clinician and client will want to consider how to change work-related habits that have encouraged alcohol use in the past; for example, the client may find a lunchtime 12-Step program meeting or take a book to lunch, following the standard process of changing "people, places, and things" associated with use.
It is usually possible to detoxify the client's system in a relatively short time, even for clients who have used alcohol intensively. It is important to consider the implications of detoxification for employment and manage the issue of work leave in the manner most likely to protect the client's job. The client's workplace may have an employee assistance program that can help with this task. Ideally, the client will have sick leave or annual leave that may be used to provide the time needed without endangering employment.
For clients whose alcohol use has affected their attendance at work and who have a negative reputation for reliability, the plan may appropriately include a quantitative objective, such as attending work for 28 out of the next 30 days. Pharmaceutical help may be available to the alcohol-dependent employee. Naltrexone (ReVia) is approved by the Food and Drug Administration as a treatment for alcoholism. Although its cost is prohibitive for some, naltrexone appears to reduce craving in many abstinent patients and block the reinforcing effects of alcohol in many patients who continue to drink. The latter effect often enables patients who drink a small amount of alcohol to avoid full-blown relapse and lessens the likelihood of their return to heavy drinking. The mechanism of naltrexone's effect in alcoholism has yet to be conclusively demonstrated, but there is hope that combining this drug with "talk therapy" (i.e., cognitive-behavioral treatment) will reduce relapse and improve outcomes of traditional alcohol dependency treatment. For more information about naltrexone, see TIP 28, Naltrexone and Alcoholism Treatment (CSAT, 1998b).
Depending on the length of time the client has used amphetamines, a longer period of abstinence may be required before vocational rehabilitation can begin in earnest. Long-term use may result in psychosis, making short-term employment impossible. Other common coexisting disorders include depression, anxiety, and panic attacks--all of which raise the possibility of relapse. Problems maintaining attention and concentration are also common. These difficulties, which should generally be dealt with through appropriate referrals, usually suggest the need for a relatively long period of abstinence before symptoms are controlled and vocational issues can be addressed.
Amphetamine users typically are excitement seekers who are used to performing when "up" and then crashing. During the "down" part of the cycle, they may have experienced a high rate of absenteeism from work. Therapeutic objectives can address the client's need to keep a steady pace throughout the day. Healthy nutrition, energy management, and sleep are all likely to be important areas in which behavioral changes are needed in order to sustain productivity.
In setting vocational objectives, a sensible balance is needed between jobs that require high levels of risk-taking behavior and those that offer too much sameness and predictability. High-excitement jobs feed the "up-and-down" cycle associated with amphetamine use and also may offer daily association with others who may use amphetamines, resulting in a high potential for relapse. Monotonous, clerical work is likely to result in relapse because of boredom; jobs that require creativity, flexibility, and movement are usually more successful. For example, an intelligent former amphetamine-using individual with computer skills might do well at designing computer games.
There is no pharmacological substitute for cocaine, as there is for heroin, and an intense subculture helps to maintain the cocaine-using lifestyle. During the period of active use, the user will typically have a spotty record of work attendance, sometimes leading to job loss. It is not uncommon for cocaine abusers to have borrowed against their next paycheck. This behavior should be addressed with arrangements to repay the company. Long-time users may have brain damage (neurochemical changes) and functional loss (Gawin and Ellinwood, 1988). Whether the client has used crack or powder cocaine, it is important to consider work that will help the client maintain the sober lifestyle because it is easy to become readdicted. Coexisting depression and anxiety disorders must be addressed with cocaine-dependent clients (as with other recovering substance users) because these negative emotional states readily lead to relapse.
It is important to have a plan for rapid intervention and excellent aftercare. Potential relapse may also be reduced by asking the employer to directly deposit paychecks into the employee's bank account. As with any recovering substance user, jobs that are especially likely to trigger relapse should be avoided--all night shifts at factories, routine jobs, unsupervised jobs such as late-night guard, or jobs in industries that contain a high percentage of users (Budney and Higgins, 1998; Carroll, 1998). For more information on the treatment of cocaine, see TIP 33, Treatment of Stimulant Use Disorders (CSAT, 1999b).
For recovering heroin users, an adequate period for detoxification before resuming work is critical. Clients experiencing withdrawal symptoms will be too ill to concentrate in a structured environment for any length of time. Intravenous injection of this drug can cause related medical problems that must be addressed before these clients can work. Such problems may include hepatitis, endocarditis, fatigue, and ulcers. Many clients will not be able to do a great deal of walking or handle physically demanding jobs during the recovery period.
As previously noted, clients who are in opioid maintenance therapy (i.e., methadone, LAAM) should have a plan to address the possibility of failing a urine test. It is also important to take the job requirements into account when the dispensing schedule is organized. Because work will mean relearning the rituals of maintaining relationships and acting appropriately within the work culture, the treatment plan may also include objectives related to reacquisition of social skills and their application in the workplace.
Some clients use prescription drugs, including narcotics, to self-medicate to mask anxiety, depression, or pain. The treatment plan should include a process for addressing these underlying conditions. For example, national pain management organizations can perhaps suggest alternative ways to manage pain. In vocational planning, the clinician should bear in mind that pain saps energy, and individuals who suffer from chronic pain are unlikely to be able to manage high-energy jobs.
Individuals who have been polysubstance users may have cognitive impairments such as hyperactivity and concentration deficits that will limit their potential for employment. They may also have more complex triggers for use. The clinician should assess these triggers and, based on findings, identify comfortable, incremental steps that can be successfully achieved. Although difficult, it will be helpful to identify work environments that provide as few of the individual's primary triggers as possible.
Clients who are required to have a job in order to maintain eligibility for welfare, or who are losing welfare support, may have to start work earlier in the recovery process than would ordinarily be advisable. Under these circumstances, the client should be assured that the job he has accepted, for which he may be overqualified, is a temporary choice that is appropriate to meeting the immediate need. In addition, the client's initial job may provide a forum for acquisition of job skills, social competencies, and recommendations requisite for higher education or employment.
With individuals for whom child custody is an issue, whatever is required to regain or maintain custody is likely to be the client's top priority. The timelines and requirements related to this external constraint should be reflected in the vocational plan.
In treating clients who lack funds for basic expenses--food, shelter, clothing, transportation, child care, and health care--the clinician's role is to help the client find community resources and social services to help meet these basic needs. An entry-level job may be appropriate for meeting the immediate crisis. Therapeutically, the client's need for financial support may be a powerful motivator for positive change.
Participation in the work world is, unfortunately, influenced by many factors other than an individual's interests and abilities. Segments of the labor market may be less accessible for some because of gender, race, ethnicity, culture, and disability. These differences are due to societal factors such as discrimination and unequal educational resources allocated to schools in lower income communities (Szymanski et al., 1996).
The clinician should maintain a realistic attitude when addressing clients' specific situations, ensuring that their goals are achievable and that they understand legal antidiscrimination protections. A number of legal protections exist to protect people from workplace-related discrimination (see Chapter 7 for more information on these protections). It is important to acknowledge the reality of discrimination that some clients face, while concurrently nourishing a drive to succeed and channeling it in promising directions.
When clients return to work, they are exposed to a number of potential relapse triggers (Rehabilitation Research and Training Center on Drugs and Disability, 1996). These include
The treatment plan should provide for effective management of all relapse triggers that are relevant to the individual. The plan should establish a proactive strategy to avoid the loss of newly won ground. It is useful to consider in advance the possibility of job loss or demotion and to consider the moves that would then be open to the client. This will help to reduce the likelihood that either event will lead to despair and relapse.
The following case studies represent either particular or composite cases familiar to Consensus Panel members. They are intended to illustrate several ways in which clinicians have helped clients in recovery from substance abuse disorders achieve appropriate vocational goals consistent with the recovery process.
Kay was referred to outpatient substance abuse treatment 4 months ago by the criminal justice system when she and her boyfriend were convicted of possession with intent to sell illegal drugs. Her drugs of choice were cocaine and amphetamines. She has past convictions related to drugs and prostitution.
Kay is 22 years old and the mother of two young children who are living with her mother, an employed waitress. Kay's therapeutic goals include becoming economically self-sufficient and regaining custody of her children. Vocational concerns have become a large part of her focus in both individual and group counseling sessions. Kay consistently insists that "any job will do." What is important to her is to be employed so that the criminal justice system does not put her in jail and thereby prevent her from regaining custody of her children. However, in planning for her to become economically self-sufficient, the clinician recognizes that she must have a job that provides enough income to support two children. In addition, the job should have health benefits.
The clinician learns at intake that Kay attended school only through ninth grade. She dropped out when she gave birth to her first child. Her educational records show that she repeated first grade; she says this was because the teacher felt she wasn't mature enough and because she could not focus on her work. Her attitude about returning to school is that it is not an option "because I am dumb." However, her records include the results of recent aptitude testing that suggest that she is capable of pursuing her education beyond high school.
Kay has a very spotty work history. Her primary places of employment were fast food restaurants and nightclubs. The counselor learns that requirements of the probation and parole system pushed her into employment in at least two instances. None of her jobs lasted more than 4 months, and Kay does not believe she is capable of holding down a job. She reports being fired for not showing up to work when she overslept or had been out partying the night before. She also has been reprimanded for not grasping the work tasks quickly enough and for having poor customer relations skills. She was fired from one job when a customer told the nightclub manager that she had a criminal record. She feels inadequate in many ways; for example, she is concerned about her ability to read and to manage numbers, count change, and so on.
Therapeutically, it is important that Kay find employment that supports her recovery lifestyle; however, the pressure she is under to locate a job must also be acknowledged. In the group sessions, the clinician finds that Kay identifies with another woman who admits to being terrified to go to work. Exploring this, Kay reveals that her fear is associated with having to tell an employer about her criminal record and what she has done to get drugs, as well as her past employment experiences.
In summary, Kay presents a self-image of failure supported by her past experience in academics and work. Her options are limited by her lack of a high school diploma or general equivalency diploma (GED), yet she needs to obtain a job that provides an adequate income and includes benefits in order to provide a foundation for her children. She has no knowledge of what types of jobs are available beyond restaurants and other service-oriented industries, nor does she currently have the skills for many occupations.
The first step in responding to Kay's vocational needs was to identify who should serve on her team. In addition to the treatment staff, the team included a State VR counselor, her probation officer, a social worker, and a representative from the State employment service. She was referred for a vocational evaluation to assist her in making employment decisions. Kay's vocational evaluation included a series of interest inventories, aptitude tests, and other assessments. At the exit interview with the evaluator, Kay reported not being able to remember anything except that she could complete the requirements for a GED, if she wanted to do so. A followup meeting was scheduled with her VR counselor, social worker, and drug and alcohol counselor. By this time, a written report was available, and they reviewed it with Kay in detail. Her reading and math skills were both at the fifth-grade level. She showed the aptitude to complete her GED and pursue vocational training. The recommendations for an immediate employment objective included positions in the restaurant and hospitality industries or in a clerical position such as receptionist, file clerk or other entry-level position. Certain positions for which she had an aptitude were ruled out because of her criminal record.
During the discussion of vocational alternatives, Kay leaned toward choosing a job in a restaurant because that was the type of work she had done previously. In the joint counseling session, however, it was pointed out that the hours associated with this type of work and the environment would be likely to trigger a relapse. Kay's lack of interpersonal skills was another concern. Kay also received guidance about the problems frequently associated with some entry-level jobs: Coworkers are often younger and are inclined to "party," the hours are irregular, and alcohol is readily available. There was also a discussion about what her course of action would be if confronted with situations that might cause her to relapse.
Kay's final decision was to pursue employment in an office clerical position. She was nervous that she would be rejected if employers discovered her criminal past and that she would not fit in with the other workers. Because Kay lacked effective job-seeking and maintenance skills, it was decided that she would participate in a program that taught these skills and would address the concerns about interpersonal relations at the office, as well as how to handle issues related to her criminal past. The VR counselor also arranged for her to start in the Job Club program. The program provided assistance in completing applications, looking for job openings, developing interviewing skills, and writing a followup letter. She was told she could use the rehabilitation center's facilities to look for work because they had access to the State Employment Commission's job-opening database, maintained posted job announcements, subscribed to the newspaper, and provided job placement counselors to assist in the process.
Kay obtained a job in a company that had hired a number of persons with disabilities. Because the VR counselor had experience with the employer, he told Kay about the work setting and the benefits and support programs that were available. One of those was an employee assistance program. He explained that they could help if she felt that she was having problems that would interfere with her job (e.g., stress or transportation difficulties) or that were related to her recovery. The company also had medical benefits and paid vacations.
The company's human resources director was concerned about Kay's lack of skills and educational history. She thought Kay would be a good employee but would need extra training. To assist with this, the State VR Agency arranged an on-the-job training program. In exchange for the employer providing the extra training, the agency paid a portion of her salary for a preset period.
The alcohol and drug counselor and the VR counselor worked out a daily plan with Kay. They discussed transportation to and from work, lunch, breaks, and how to fit in her Narcotics Anonymous meetings, counseling sessions, and meetings with her probation officer. They also helped her plan a budget that would allow her to save money for an apartment. In the meantime, she would continue living in the supervised housing run by the substance abuse treatment program.
Kay also expressed concern about fitting in with her coworkers. She owned mostly T-shirts and jeans and did not have suitable office clothing. A local program that helped women going back to work provided her with enough outfits for one week of work. With her clinician, she role-played possible conversations with coworkers and what she would do if approached to go for drinks after work.
She started working and was successful. Her performance evaluations were good, but her supervisor indicated she needed to work on being assertive and asking questions. In her regular counseling sessions, the clinician talked to her about daily work-related issues that arose. The supervised housing provided a setting that allowed her to talk with other people in recovery. The support group helped her identify solutions and options to problems, which included her continuing difficulty in adhering to a budget.
Kay developed a long-term plan with her social worker and alcohol and drug counselor. She would continue to adhere to a daily recovery plan, and visits with her children would be allowed. If she continued to progress in recovery, she would be able to petition for custody. At the end of the on-the-job training period, Kay continued to work with the company. Her case with the VR agency was then closed, with the understanding that followup support could be provided if necessary. She continued in aftercare and met with her probation officer on a regular basis. Once her housing and work stabilized, Kay planned to pursue a GED.
Young-Hwa, a 40-year-old Korean male, had immigrated to the United States 15 years ago without proper documentation. He had a hard life because, despite his training as a chef in Korea, he had difficulty finding a well-paying job without proper documentation. After many years as a kitchen assistant and then as an assistant cook, he finally was hired as a chef in a Korean restaurant.
During his long quest for suitable employment, Young-Hwa used alcohol to handle the stress and feelings of frustration and disillusionment. The many years of hardship put a strain on his marriage and he had many arguments with his wife. He progressively increased the amount of alcohol he used. During these heavy drinking episodes he became verbally abusive to his wife and two young children. After 3 years of continued alcohol use and verbal abuse, his wife and children left him. One year later, he was fired from his job for being drunk at work.
Over the next 3 years, he became depressed and continued to drink heavily. Finally, he was arrested for driving under the influence of alcohol and was ordered by the court to an alcohol residential treatment program.
In treatment, the clinician helped Young-Hwa by activating his desire to have contact with his children as motivation for recovery. The clinician supported the idea that his children needed a caring, loving, and competent father. In addition, the counselor focused on Young-Hwa's strengths as a competent chef for many years and engaged him in a discussion of how he could regain that level of functioning.
The clinician referred Young-Hwa to an Asian American legal services organization, which helped him apply for the immigration residency amnesty program in effect at the time. This step would grant him legal residency status.
In the meantime, Young-Hwa needed to find employment as quickly as possibly, both to satisfy requirements for probation and to support himself. There was no separate VR counselor on site; also, the client was suspicious of non-Asian counselors and resisted the idea of a referral to State or county rehabilitation agencies. Because of this, the Korean clinician performed some of these tasks. The clinician guided him in exploring job opportunities in the Korean community and recommended that he begin at a lower level than full chef. The client resisted this idea initially, but later agreed that he needed to rebuild his level of competence in a step-by-step fashion.
He found a job as an assistant cook. Because he was very interested in boxing and was a boxer when he was in high school in Korea, the clinician used that sport as an analogy. He reminded Young-Hwa that for a boxer to come back from an injury, he needed to rebuild slowly. This rebuilding involves a step-by-step process until he finally can become a "major contender" again.
Julia is a 27-year-old Italian American female. She was referred to a specialty residential program by the child protective services agency because her daughter was born with a toxicology screen that tested positive for heroin, cocaine, and marijuana. In order to keep her baby, she was required to participate in this program with her infant daughter. Julia was administered a battery of assessment measures during her intake interview for residential treatment. These measures included the ASI (which measured her functional status in seven domains) and the Self-Directed Search (which determined her vocational interests and skills).
Julia is an only child. She lives with her mother, a nurse, and her father, an electrician. Her parents were given temporary custody of her daughter while she was waiting for placement at the residential program. The clinician learned, however, that she and her parents have had several physical fights recently, of which the child protective services agency was not aware.
Julia has had 13 years of education. She had been a nursing major at the local community college 5 years ago but dropped out when she could no longer manage school due to her polysubstance use. Julia has been drinking to intoxication on Friday, Saturday, and Sunday since the age of 15. She has also injected heroin regularly (about three times per week over the last 5 years) and has been smoking or snorting cocaine on weekends. She often used more than one substance per day--usually cocaine and alcohol--when she could not get heroin.
Julia has been arrested for assault, breaking and entering, and robbery. However, she was not convicted and has never been incarcerated. Julia usually got her money for drugs by stealing or by giving sexual favors. Julia has several close male and female friends who are also using drugs. She has had serious conflicts over the last 30 days with her parents, sexual partners, and friends. She reports that her current sexual partner, who sells drugs and is the father of her child, has physically and emotionally abused her.
Julia has been hospitalized twice for suicide attempts. She says that periodically she becomes severely depressed, can't eat or sleep, cries a lot, can't sit still, and has trouble getting out of bed. She is easily irritated when she is depressed and sometimes has difficulty controlling her anger. Julia also has panic attacks and is, at times, fearful of crowds, stores, classrooms, and restaurants where she does not know people. She is also afraid they will see her having a panic attack and think that she is crazy. Julia has been prescribed imipramine (Tofranil), lithium (Lithonate), and diazepam (Valium), but none of these medications seem to help. She finds it easier to get herself out of bed after she has used heroin or cocaine. Julia admits that her drug use may be a form of self-medication because she "feels better" after she uses.
Julia's ASI composite scores reveal that she is most in need of treatment in the areas of alcohol and drug use, employment, social relations, and psychiatric problems. Julia herself rates her need for treatment in the areas of alcohol and drugs and in psychological functioning as extreme, but she views her need for employment and social counseling as slight.
Julia's result from the Self-Directed Search matches her vocational dream of becoming a nurse (like her mother). Julia was surprised to learn that her summary code was also consistent with dietician, physical/occupational therapist, and psychiatric technician. She was particularly interested in the physical and occupational therapy fields because she thought these occupations would limit her access to drugs and thus eliminate the temptation to steal them, while still allowing her to work with people in a medical setting.
When Julia was approached about further vocational exploration, she said that the thought of going back to school made her highly anxious and that she did not think she could ever see herself getting up to go to work or performing adequately on the job. She felt that she had been using drugs too long and "hanging out" so long with other users that she did not even know how to talk to "straight people." She also felt humiliated about all her arrests and about "doing nothing with her life" all these years, so she couldn't imagine filling out an application to go back to school or interviewing for a job.
Aware of the close-knit structure of Italian American families and Julia's desire to move back with her parents when she leaves the residence, Julia's counselor initiated family sessions with Julia and her parents to deal with the family violence. Julia was also referred to a psychiatrist to evaluate her depression and anxiety. The psychiatrist prescribed the antidepressant fluoxetine hydrochloride (Prozac), which has just begun to help her feel somewhat more comfortable. Julia has begun to learn relaxation and coping skills so that she can manage her panic attacks more effectively and not continue to avoid public settings. Julia is also participating in an anger management and social skills group, in which she is learning the internal and external triggers for her anger. She has been role-playing new ways to cope with these anger triggers and learning how to express her feelings more effectively.
Julia has also been discussing her life plans and goals. She would one day like to marry and have a father for her child and work with people in a medical setting. In the meantime, Julia has been gathering information about potential careers in physical or occupational therapy. She has gone to the career section of her local library to find information about the specific duties and requirements for each job. Armed with this information, Julia developed a plan with her VR counselor concerning the next steps to take and how she will accomplish them. These steps included selecting and applying for school, finding the money for tuition, arranging for child care, and finally, starting the program.
A key purpose of this TIP is to help treatment programs rethink their philosophies and restructure their services around the belief that productive activity (work) is crucial to the health and long-term recovery of clients. One way to ensure that clients receive the necessary vocational services is to provide them in-house as an integral part of the substance abuse treatment program, rather than by referral to outside agencies. Each program must decide to what extent it wants to and can provide onsite vocational services. This chapter is designed to guide programs in this important decisionmaking process. Even those programs that cannot offer a full range of vocational training and employment services within their program setting can benefit from the information in this chapter. The chapter also describes how programs in various treatment modalities, from therapeutic communities to low-intensity outpatient treatment, can begin to address the vocational needs of their clients.
Employment and vocational services need to be a priority in every treatment program and should be addressed as a goal in treatment plans. The Consensus Panel recommends that if possible, a substance abuse treatment program should add at least one vocational rehabilitation (VR) counselor to its staff. Should the size of the program or other fiscal shortcomings prevent this, arrangements should be made to have a VR counselor easily accessible to the program. No matter the treatment modality or level of service, inclusion of a vocational specialist who is cross-trained in or at least sensitized to substance abuse disorder issues will create a new dynamic in the program. Through both formal and informal interactions, this staff member will begin to raise the awareness level of other treatment staff members about vocational issues. The vocational specialist can identify ways in which the staff members are already addressing vocational issues but simply not thinking of their efforts in vocational terms. For example, when one therapeutic community hired a VR specialist to help its treatment counselors provide vocational services to residents, she pointed out that many aspects of the program already addressed clients' vocational needs. She demonstrated how the job assignments given to residents emphasized the development of prevocational skills and explained that they were really operating a work adjustment training program. However, a VR counselor can provide more intensive and specific counseling, assessment, resource development, and treatment planning.
Unfortunately, some programs do not have the resources for such a staff specialist. However, a consortium or network of programs may sometimes be able to share a specialist as a consultant who provides training and other staff development activities on an occasional basis and guides work with particular clients. At the same time, it must be acknowledged that even the most comprehensive program cannot meet the treatment and vocational needs of all clients. Welfare reform, health care reform, and other funding pressures can overwhelm treatment programs because they must meet the vocational needs of all clients with less support and in shorter periods of time. Referrals to outside vocational service agencies are necessary for many clients.
Every treatment program should consider itself part of a collaborative interagency effort to help clients achieve productive work. For the purposes of this TIP, the onsite integrated services model is discussed separately from the integrated services through referral model (discussed in Chapter 5). In reality, most programs exist on a continuum with onsite programs making fewer referrals, but where referrals continue to be a key part of providing services to all clients.
Any decision to integrate vocational services into a substance abuse treatment program must be supported by the board of directors, the administrative staff, and the alcohol and drug counselors. This level of support is necessary to effectively change the existing "culture" of the treatment program and ensure that vocational services are a core part of treatment and not just a supplementary service.
To effect this change, the mission statement should be modified to encompass vocational goals and to ensure that all staff members embrace these goals (see Figure 4-1). An important philosophy to articulate in the mission statement is the belief that work is crucial to the health and long-term recovery of clients and that implementing vocational services is in itself therapeutic. As discussed later in this chapter, outcome studies must consider employment as one of the key variables in measuring program success. It is important to be aware that work in the competitive market may not be possible for all clients. Moreover, people often seek to contribute to their community, either by volunteer work or by some other type of educational or similarly productive involvement with the larger world that enriches their interactions with others and their sense of self-worth. Thus, the concept of employment "success" may need to be broadened when the outcomes of substance abuse treatment programs are evaluated.
The treatment program must decide the parameters of what it can offer clients in terms of vocational services. Many factors will enter into this decision. To begin the decisionmaking process, the program must addressseveral questions:
The most important factors in choosing a program model are (1) the modality of the substance abuse treatment program and the intensity of services provided, and (2) the specific needs of clients. Treatment programs vary from the least intensive level of outpatient treatment to highly structured residential programs, such as therapeutic communities. The degree to which the program can structure the client's daily life and the length of time spent in the program significantly dictate the range of onsite vocational services that can feasibly be offered. A therapeutic community in which clients generally reside for several months can offer a much wider range of vocational services than a short-term (14- to 28-day) residential program whose main objectives are to stabilize clients and initiate the recovery process before discharge.
The vocational needs of the majority of the program's clients, as well as other client-related factors such as their values and the realities they face in finding employment, are other key factors to consider in deciding the parameters of the onsite services offered. The important issue of cultural competence is discussed more fully in Chapter 5. Suffice it to say here that programs must ensure that staff members have a thorough knowledge of the diverse populations represented in their treatment program and the particular challenges that different groups face in securing and maintaining work. It is also important to understand various cultural attitudes toward work.
In any program, clients' ability to work will vary greatly. Some clients who have never worked or who are chronically unemployed will need habilitative and prevocational training. Others with more regular work histories may need help learning new job skills, finding work, or recognizing work-related relapse triggers. Some programs treat a large number of clients with a high level of coexisting disorders (e.g., serious mental illness). Clients with extensive or special needs outside the program's vocational capacity should be referred to collaborating agencies. Collaboration is discussed in Chapter 5.
One approach to evaluating the vocational needs of the client population is to survey clients who are currently in the program. A series of focus groups is an effective way to understand the particular needs of a program's client population. In these groups clients can discuss their needs and support each other in articulating their problems, gaining confidence about themselves, exploring employment goals, and preparing for finding and maintaining work. Another approach is to follow up with former clients to document their current vocational status and ask them which services they received at the agency were most and least helpful, and what services they would have wanted.
As noted previously, hiring or contracting with a VR counselor familiar with substance abuse treatment issues is an effective strategy to begin addressing the vocational issues, awareness, and training needs of program staff. Another option is to collaborate with State VR agencies that offer inservice training on vocational issues to alcohol and drug counselors. Joint training of alcohol and drug counselors with VR specialists should be encouraged, when appropriate. Key resources for such training and education are State and Federal VR authorities, which are found in every State, as well as the Rehabilitation Research and Training Center (RRTC) on Drugs and Disabilities. Other resources include university-based rehabilitation continuing education programs located throughout the country. Whether an agency is large and multiprogrammed or smaller, appointing someone as case manager can help ensure efficient collaboration, both intra- and interagency.
Another strategy for bringing VR expertise into the program is to form linkages with undergraduate and graduate programs in VR counseling and to offer the treatment program as a training site for internships in which students in these programs can be cross-trained in substance abuse treatment issues--provided that supervision and support are adequate and appropriate.
Integrating vocational services and ensuring that all staff members share the program's values and mission will involve examining and changing job descriptions to recruit staff with vocational experience and training. Advertising and recruiting efforts can be broadened to include journals and programs of interest to VR counselors. Again, linking with a university to provide an internship site is a highly effective strategy for recruiting permanent staff members who possess the necessary skills. As part of their professional service obligations, university faculty should be open to providing inservice training programs on VR topics for the agency's staff. In turn, treatment staff may be able to help university faculty by offering to give guest lectures on substance abuse issues, becoming a resource for the university's employee assistance program, or helping with student intervention services.
A key aspect of incorporating vocational services into a program is to develop relationships with both large and small local employers. Many mutual benefits can result from ongoing relationships with employers because programs develop an understanding of the types of workers these employers are seeking and employers begin to perceive the program as a good source of job applicants. In geographic areas where there are multiple treatment programs, consideration should be given to a collaborative effort to develop relationships with potential employers. A centralized clearinghouse can also lead to better matches between jobs and the applicants for them.
The VR field has developed several approaches to initiating and maintaining such relationships. Becoming familiar with a particular employer, researching its products and human resources, and using a businesslike approach (e.g., professional dress, business cards, promptness) can be effective approaches (Vandergoot, 1984). Another approach offers an employment service or pool of qualified potential workers to employers as an incentive for establishing an ongoing relationship (Shafer et al., 1988). Documents describing these approaches can be obtained from the National Clearinghouse of Rehabilitation Training Materials (see Appendix C, "Published Resource Materials").
In addition, many large employers have on-the-job training programs. For example, a large hotel chain offered on-the-job training for entry-level positions as front desk clerks, housekeepers, and laundry and kitchen personnel that allowed them to advance in their chosen job areas. Large employers also usually provide some level of employee benefits, such as medical leave, insurance, and access to child care. Relationships with small family-owned businesses can also be an important source of ongoing employment for clients. One program placed a client several years ago in a family-owned carpet business as a warehouse worker. That individual is currently the warehouse supervisor and hires many of the program's clients, giving them a chance to return to or enter the workforce in a supportive work environment. Clients who have completed treatment and are successfully working are excellent resources for information about job opportunities and prospective employers.
Some cities have business advisory groups that assist with return-to-work programs. Another good resource may be the Welfare to Work Partnership, a nonpartisan, nationwide effort designed to encourage and assist private sector businesses with hiring people on public assistance. This network of both large and small employers is committed to hiring individuals with multiple barriers and little work history. The partners are committed to working with many social service agencies to find solutions and promote a healthy workforce. See their Web site, www.welfaretowork.org, for more information.
Ex-offenders are one group for which it is often particularly difficult to find job placements; therefore, treatment programs that involve job placement activities will need to make a special effort to locate employers for this population. Providers should be proactive when possible, in order to convince potential employers of the reliability of their clients. It will take time to develop strong and lasting relationships with employers willing to hire ex-felons, and providers working with this population should not expect immediate success. Once relationships with employers are formed, providers should exert effort to maintain these relationships and ensure that employers are satisfied with clients they hire.
Programs should inform potential employers about any financial benefits for which they may be eligible if they hire an ex-felon. For example, under the Tax and Trade Relief Extension Act of 1998 (P.L. 105-277) employers who hire ex-felons from low-income families are eligible for a tax credit of up to $2,400. Funds are also available for States from the Federal government under the Job Training Partnership Act (29 U.S.C. §§201-206) as amended by the Workforce Investment Partnership Act of 1998 (P.L. 105-220), which States can use for a variety of services including on-the-job-training. Ex-offenders are one of the groups specifically covered in this legislation. These latter funds are distributed through the States, and individual State departments of labor should be contacted for more information on the funds available. There are also Federal funds, distributed through State employment services (also known as One-Stop Career Centers), to pay for bonding for ex-felons and people in recovery from substance abuse disorders. This bonding service is provided free-of-charge to employers who are willing to hire ex-felons.
The specific procedures that a program develops will depend on the scope of vocational services it decides to incorporate into its treatment protocol. However, in an integrated program, vocational services are regarded as therapeutic, and a client's attitudes toward work, work skills, work history, and work goals are clinical issues that have an impact on recovery. Even if clients pass through the program very quickly, vocational concerns can be introduced and addressed in individual or group counseling, through brief screening in the form of work-related questions as part of an intake interview, or as part of relapse prevention in discussing work-related triggers.
Once the treatment program has decided to integrate vocational services, the degree to which the program can structure the client's daily activities while in treatment and the length of time the client spends in the program dictate the range of onsite vocational services that can feasibly be offered. The following section describes three levels of treatment programs and the types of vocational services that can be incorporated into each setting. The three levels of programs include high-structure programs (therapeutic communities and day treatment programs), which can offer the broadest range of services; medium- and low-structure programs (intensive outpatient treatment, standard outpatient treatment); and short-term residential programs (programs shorter than 30 days). Strategies for other kinds of programs, such as detoxification programs, opioid management programs, and halfway houses, are also discussed.
Clients in therapeutic communities both live and work in these facilities, and their daily lives are highly structured by the ground rules and operations of the program. The length of stay in these programs varies widely, ranging from 10 days to 1 year or more. Clients in day treatment programs may spend about 6 hours a day at the program facility. Compared with a therapeutic community, the length of stay in day treatment programs is generally shorter, ranging from 4 to 6 weeks to several months. Interactions among staff members and clients and their peers are potent aspects of these high-structure programs, in which clients tend to seek the approval and respect of other members of the circumscribed and structured community.
Many clients in high-structure programs have little or no work history. Many lack education, are not competitive for training or career-track positions, and lack the financial skills to handle a paycheck or control impulse spending. Few have experience in setting and achieving personal goals or successfully completing treatment for their substance abuse. Many have a personal or family welfare history, and many have a criminal record. Clients' low self-esteem and lack of appropriate role models, combined with distorted expectations and ideas of "success" and the lack of a positive vision for their lives, all strongly contribute to their difficulty in obtaining and maintaining stable employment.
Therapeutic communities and day treatment programs are ideal sites in which to establish vocational services based on a classic rehabilitation model (Rubin and Roessler, 1995; Wright, 1995). Such a model includes the following components:
Some of these vocational components and ways they can be integrated into high-structure programs are discussed in more detail below.
Work adjustment training, as described in Chapter 2, uses work in a structured environment to teach accepted employment practices (i.e., education about work--the workplace, employer expectations, etc.). Therapeutic communities provide a wide range of internal work adjustment opportunities in the form of chores or job functions that support the day-to-day operations of the program and facility. Day treatment programs also can create such opportunities by establishing client-operated departments or services that are important to the operation of the program.
In a work adjustment environment, clients are assigned various jobs after they enter the program. Early work assignments are designed to enhance clients' strengths and build self-esteem by helping clients "discover" skills they did not realize they had. These work assignments focus clients on the importance of completing a task, working as a team member, and developing a sense of pride and personal satisfaction in a job well done. Early work assignments usually are less complex, guarantee initial success for most clients, and offer an opportunity for advancement to more responsible positions in the structure. Later, as clients demonstrate a commitment to their treatment goals and an ability to handle work positions of increasing responsibility, assignments become more complex and are designed to address behavioral areas clinically identified as essential to progress in recovery.
Other work skills emphasized in work adjustment training are attention to details, successful task completion, frustration, tolerance, and accountability.
In addition to acquiring supervisory skills, clients learn how to handle on-the-job advancement and how to model appropriate work behavior for newer members of the program. For many clients in these programs, a key work-related issue is understanding and dealing with authority in constructive ways that will not jeopardize their job.
When vocational rehabilitation and treatment for substance abuse are integrated in this way, clients not only work at various tasks with peers but also encounter these same peers in substance abuse disorder group counseling. Thus, work-related issues are addressed by clients in clinical groups, and clinical themes arise in vocational activities. Substance abuse disorder recovery and "vocational recovery" are synchronized, and clients are afforded opportunities for insights into problems and the interrelatedness that occurs when services are so thoroughly integrated.
High-structure programs can establish groups that focus on job issues addressing positive workplace behavior such as appropriate grooming, dress, and proper socializing on the job, as well as self-defeating and negative behavior in the workplace. Work-related triggers for relapse, such as disappointments and frustrations, can also be addressed in recovery in vocationally oriented group and individual counseling and in work adjustment training. Financial management skills can be provided on both an individual and a group basis. Efforts to improve skills in activities of daily living should also focus on social supports: making friends, having hobbies, networking for job-related information, and structuring leisure time. The importance of a client's hearing the same messages in all aspects of her treatment and from both alcohol and drug and vocational staff members should not be underestimated.
Work adjustment training involves bringing all clients to a basic level of work readiness before actual job-seeking activities begin. All programs should establish specific criteria that a client must meet before beginning formal vocational counseling. These criteria will define the point in the treatment process when a client will begin receiving formal vocational services, which is dictated in part by the length of a given treatment program. Formal vocational services provided at this point can include assessment, counseling, planning, résumé and interview preparation, and teaching other job-seeking skills, as well as job placement and monitoring. These services are described in detail in Chapter 2. A comprehensive vocational program would also include a vocational library that both staff and clients could use as resources for vocational planning and job placement. Figure 4-2 provides information about job clubs.
Developing and implementing a personal plan for change is another key aspect of vocational rehabilitation. The client develops the plan in consultation with vocational and treatment staff. The plan lays out the direction in which a client wishes to go and demonstrates that the client understands the steps necessary to achieve his goals. The plan can address vocational, educational, social, familial (including children), and housing goals, as well as relapse triggers and ongoing needs for substance abuse treatment. It generally requires the client to anticipate obstacles and develop contingencies or alternative strategies for coping with them.
The idea of the plan may be introduced to clients early in the treatment process so that they can begin to think about it. However, clients in high-structure programs may not be ready to actually develop a plan until they have learned about the effects of substance abuse on all aspects of their lives and have learned about the world of work and their vocational strengths and deficits. The length of the individual's proposed treatment is again a factor, and clients in shorter term treatment programs may be encouraged to develop plans that are more focused on specific, immediate vocational goals. Plans can also be used effectively in counseling groups because "going public" with a plan often enhances the client's commitment to it.
Counselors should evaluate the client's plan to determine whether the vocational goals the client sets are realistic (not too high or too low) and whether achieving the goals will allow the client to make a sufficient living and support continued recovery. In many ways the process of developing the personal plan is more important than the actual content of the plan. Situations and goals change, but once clients have mastered the process, they can create new plans on their own as their future situations require. In any case, it should be emphasized that the plan will be most useful if both the goals and the timeframe for achieving them are as specific as possible.
High-structure programs that incorporate the development of a detailed personal plan may wish to encourage formal presentations where the client describes his plan to selected peers and staff and receives feedback from the group. This "approval committee" can also include outside professionals involved with the client, such as a probation officer or a child welfare worker. For clients from particular ethnic groups, the approval committee might also have representatives of the community to which the client is returning at discharge. The presentation can be done in a formal way that symbolizes a passage from the exploration and information gathering that characterize the early stage of the treatment to action. The committee evaluates the client's plan, makes suggestions, and, by approving it, endorses the plan and gives the client permission to carry it out.
According to the model developed by the American Society of Addiction Medicine (ASAM), clients in intensive outpatient treatment spend from 9 to 20 hours a week in the treatment program, and clients in standard outpatient treatment spend less than 9 hours a week (ASAM, 1996). Lengths of stay vary widely but can be 6 months or longer in outpatient treatment. Lengths of stay in short-term residential treatment have declined in recent years because of pressure to contain costs, from typical 28-day programs to programs as brief as 10 to 14 days. Clearly, the range of vocational services for clients in medium- and low-structure programs is narrower than the services offered in high-structure programs. However, even 1 hour of rehabilitation services a week for 24 weeks, or 1 hour a day for 14 days, can be a significant level of attention for clients with serious vocational needs.
Most substance abuse treatment is provided in outpatient settings--generally in the lowest intensity modality (i.e., less than 9 hours a week). Thus, finding innovative ways to address the needs of clients in these programs, for which funds are often limited, is critical. As noted earlier, the Consensus Panel recommends that outpatient programs either hire a VR counselor or obtain such services through a VR consultant.
The time devoted to VR issues in outpatient programs can be used in several ways; some are described below. (Vocational activities that can be undertaken by methadone maintenance programs, halfway houses, and short-term residential treatment programs are described in a separate section.)
A brief introductory presentation and a question-and-answer session on work, jobseeking, and daily living skills can be completed in an hour. Many topics related to the world of work may be helpful to discuss with clients. These include what work is, work values, career exploration, résumé development, job searching, job interviewing, the workplace, workers' and employers' rights, discrimination, and maintaining employment. A series of presentations could be developed, with one session devoted to each of these topics.
If staff time for these presentations is limited, the outpatient program should look to organizations in the community that can send volunteers to address client groups, such as the local Chamber of Commerce, the State employment service, or the State VR system. Private Industry Councils and local Workforce Investment Boards also have career counselors who could address client groups about the availability of education and training opportunities, local employment opportunities, and job readiness issues. For example, the director of human resources of a large corporation can provide a group with valuable information about how to make a good impression during an interview. Employers with whom the program has placed clients can be guests. In addition, alumni of the program who have unusual or interesting jobs or who have completed training courses for particular occupations (e.g., mechanic, electrician, beautician) can talk about what they do and the obstacles they faced in achieving their goals. Local entrepreneurs who have been successful at starting their own businesses often have motivational stories to tell. The emphasis at these presentations should not be on recruiting clients into specific occupations but on how ideas and motivation can be transformed into action to achieve desired goals.
Another tactic is for counselors to give homework assignments related to work issues. For example, clients can be asked to bring in five employment ads from a newspaper that describe jobs that appeal to them. Another homework assignment might be for the client to register with a local job search agency or visit the local library to explore references about career options.
During the intake interview, outpatient programs typically collect information about the client's vocational needs using various assessment tools. An example used by substance abuse treatment programs is the Addiction Severity Index (ASI) (McLellan et al., 1980, 1992), one domain of which assesses the client's education and employment skills, sources of financial support, and severity of problems at work. However, this is not an adequate substitute for an assessment done by a VR counselor.
Assessment tools that clients can use independently can be an efficient use of resources. For example, Holland's Self-Directed Search is an instrument that clients can complete themselves, and the results can be viewed as a form of vocational self-assessment (Holland, 1985a). A client may learn from the process that she likes to produce a tangible product and does not like to deal with more process-oriented tasks that involve "shuffling papers" and "crunching numbers." This information can also be highly useful from a clinical standpoint in addressing work-related stressors and substance use triggers. Clients can be encouraged to discuss in a group setting what they have learned, as well as concerns they face about maintaining a job, returning to a job, or seeking a job while stabilizing in recovery.
Although many traditional outpatient programs are based on an individual counseling model, groups can be an effective way for clients to address work-related issues. Problems that clients have on the job may become more conspicuous in the context of the group than in the individual counselor's office. Group members who have job interviews can be helped by the group to role-play any problems they anticipate in the interview, such as questions about their substance abuse or criminal history. Group members who are working can provide valuable advice about on-the-job behavior.
Some outpatient treatment programs for substance abuse may hesitate to develop groups specifically for vocational rehabilitation because they receive reimbursement only for substance abuse treatment services. In the climate of welfare reform, they may be successful in convincing funding sources that VR issues are key to clients' recovery and to bringing Temporary Assistance to Needy Families (TANF) and welfare-to-work resources to the substance abuse treatment site (see Chapter 6 for more information about funding). However, even if funding is not available, a VR group can be set up with volunteer presenters and experts from the community.
As noted previously, stays in short-term residential programs, formerly known as 28-day programs, have been greatly reduced. Typically, the focus is to stabilize the client and initiate recovery before discharge to outpatient care. Because of their limited timeframe, such programs are the most difficult in which to integrate VR services, and they probably do not have a VR counselor on staff. Historically, the alcohol and drug counselor sometimes helped clients find jobs, but financial squeezes on these programs make current staff involvement or vocational assessment unlikely.
However, staff members in short-term residential programs can do a vocation-oriented interview after program entry that includes some type of screen for vocational problems. Discharge planning around vocational issues is encouraged, as are referrals to outpatient VR services. The program staff should develop a knowledge of community resources for referral. Another way to incorporate vocational issues into these programs is to use self-report instruments, such as Holland's Self-Directed Search or Vocational Preference Inventory, because these involve little staff time (see Appendix B for information about these instruments).
Educational programs about work can also be woven into the curriculum of the short-term residential program. Typically, these programs are education-oriented and based on a revolving curriculum of modules about clients' substance abuse and the consequences of not arresting the addiction process. With a minimal level of consultation from a VR counselor, it should be simple for programs to build in a module about vocational issues and what vocational rehabilitation involves. This module could be targeted to the needs of the majority of clients in a given program. It should motivate clients to seek VR services upon referral to ongoing outpatient treatment and other community-based services.
Detoxification facilities, which typically provide stabilization, will not be able to provide VR services. Because most programs will gather some information about the client's work history through a psychosocial interview and the administration of the ASI or similar assessment, it is recommended that detoxification facilities address vocational needs as part of the discharge plan. In this way, the recovery program to which the client is referred will have information that gives a snapshot of the client's potential vocational issues.
Some methadone maintenance programs have introduced vocational services. In a demonstration project sponsored by the National Institute on Drug Abuse, a vocational readiness screening instrument was developed for methadone maintenance clients that measured five dimensions: the client's vocational status, level of motivation, level of social support, ancillary needs, and barriers for vocational activity (Dennis et al., 1994; Karuntzos and Dennis, 1994). In this demonstration project, the screening instrument was administered by a VR counselor, but an alcohol and drug counselor with some vocational expertise could be trained to use it. An alcohol and drug counselor was trained to provide vocational counseling and build positive work attitudes and behaviors. The project hired a case manager to deal with barriers to employment such as transportation and child care. The project funded some clients' return to school and purchased tools for other clients pursuing vocational goals. One key program component--creating relationships with employers--was identified as a critical aspect of success.
The Opioid Maintenance Program of the University of New Mexico's Center on Alcoholism, Substance Abuse, and Addictions is developing the position of a transitional agent. The case manager is part of a multidisciplinary team whose approach is designed to be harmoniously inclusive of basic living needs. A networking system within the community provides referrals for vocational training, educational opportunities, employment resources, and housing needs. Welfare to Work is also coordinated through this resource.
A key component of these kinds of programs is teaching clients job readiness skills. For example, the frequent visits required (especially in the early stages of treatment) can be scheduled on an appointment basis, as opposed to a drop-in basis, to address punctuality, time management, and personal responsibility issues. For more information about methadone maintenance programs, see TIP 20, Matching Treatment to Patient Needs in Opioid Substitution Therapy (CSAT, 1995c).
Utilizing a vocational case manager can help greatly when the primary counselor is very involved in the vocational counseling aspects of the client. A specific person who is responsible for trying to reduce barriers that could prohibit clients from job training, continuing education, job placement, aftercare, and so forth is essential. The primary counselor may not have enough time to deal with those issues.
Halfway houses or other reentry facilities are an important element in the continuum of care. To be eligible to live in most halfway houses, clients must be in a training program or a job during the day. Most halfway house residents are trying to stabilize themselves in many aspects of their lives, including work, before they move out to live on their own. Thus, a support group for maintaining both sobriety and employment is appropriate in this setting. Such a group, meeting in the evening, could address issues related to helping residents keep their jobs and become more effective employees. The staff can help group members recognize triggers in the work environment that alert them to a risk of relapse. It is most helpful when staff members in halfway houses see a client's job not as a "given," but as a set of newly acquired skills that need strengthening.
A halfway house or group of halfway houses can hire a VR counselor as a consultant to conduct group sessions or hold educational seminars for staff. Community volunteers, including individuals who have completed the halfway house program, can be important resources for helping residents maintain employment and stabilize their recovery.
The measurement of treatment outcomes is no longer just a research issue. In the current health care environment and with recent reforms in the welfare system, all treatment programs must demonstrate to payors and other funders that clients are achieving the goals to which the program is dedicated--the goals by which the program defines "success." Demonstrating the program's success is also important for recruiting new staff members and for maintaining or improving the morale of the existing staff.
For many years, abstinence was the only successful outcome recognized by most substance abuse treatment programs. However, treatment programs have begun to recognize the many different criteria that can be used to define success. Examples of criteria include (but are not limited to)
A similarly flexible approach should be considered in defining a successful vocational rehabilitation outcome. Outcomes must be defined and measured within a realistic framework. For clients with significant disabilities and who have strong family support, doing part-time or volunteer work may be a realistic goal. In the case of a single woman with young children who has minimal social supports and will soon lose welfare benefits, achieving gainful employment is an important goal, but perhaps harder to achieve.
What, then, should be called a successful outcome in terms of vocational rehabilitation? Some vocational measures include
As described in TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (CSAT, 1995a), all programs must have mechanisms in place to ensure the ongoing collection of reliable data. For example, one State has enhanced a version of the ASI so that it assesses 10 domains and is more relevant to Native American populations and other groups. This and other assessment instruments that are administered at intake should be periodically readministered and linked to outcomes.
It is best to conceive of a continuum of outcomes, from part-time to full-time work, from volunteer work to full-time homemaker, all of which may be considered successful depending on what was realistic at baseline for the client. The personalized vocational goals that clients articulate in their rehabilitation plans may not fit the program's measurement categories. However, helping clients attain these goals may represent a significant investment of staff energy, and programs will find ways to measure and report these outcomes.
More data are needed on employment outcomes across the array of substance abuse treatment modalities. Until recently, research has tended to focus on clients in methadone maintenance programs and has used mostly simple outcome measures (e.g., job versus no job). Building databases on employment outcomes from treatment programs is critical to future understanding of the dynamic connection between these two areas. In general, the field has focused on whether substance abuse treatment results in improved employment. However, it is also important to determine whether implementing vocational services and focusing on clients' vocational needs result in better substance abuse treatment outcomes. Important work also remains to be done in identifying treatment-level and client-level variables (such as clients' satisfaction with services) that are related to good employment outcomes. Accurate outcome data can also support future funding requests to legislative and other decisionmaking bodies and help ensure the fiscal viability of integrated treatment and vocational services.
To understand long-term employment outcomes, it is important for programs to obtain followup data after clients leave treatment. Vocational outcomes can be better during the posttreatment period, when clients are farther along in the recovery process and can focus more energy and attention on job performance. Outside of formal research studies, followup data are often difficult to obtain because many clients are lost to the program when they complete treatment. One program that has a high rate of success in contacting clients for followup interviews makes sure that at discharge it obtains the names, addresses, and telephone numbers of two significant others in the client's life who are not in the same household. The program should have the client update his address and telephone number before leaving.
The program should also have the client sign an authorization for followup that allows the program to contact the significant others whose names the client provided. Each substance abuse treatment program must define successful outcomes appropriate to the population it serves and ensure that funders understand the importance of these outcomes and the services necessary to achieve them. There are many variations of employment success, including obtaining and maintaining a full-time job, one or more part-time jobs, seasonal jobs (in which clients are unemployed for part of the year), or sheltered employment making or selling hand-crafted goods.
Figure 4-3 provides information about a client outcomes initiative developed by CSAT.
It is not uncommon for different funding agencies to require substance abuse treatment programs to report different types of data or to report the same data but in different forms. Program administrators are beginning to call on agencies to standardize reporting categories, not just to ease the programs' reporting burden but to facilitate comparisons among data sets. Another significant problem is that funders generally ask for aggregate data that are not broken down by the severity of clients' substance abuse disorders or VR needs.
Interpretation of such data is difficult, and reported results can be misleading, especially when the outcomes of two programs with different case mixes are compared. However, Federal minimum data sets do require pre- and posttreatment status reports concerning client employment, and such data can currently be analyzed concerning client characteristics, type and intensity of substance abuse treatment, and the like that lead to success in the employment domain. Substance abuse treatment agencies involved in providing vocational services must lobby strongly to have outcome indices related to employment inserted in such uniform data packages.
Adopting a holistic view of clients in substance abuse treatment is especially important for any service provider making referrals to other providers or agencies. At the point of referral, there is both an opportunity to address a client's unmet needs and a potential danger of losing the client. Collaboration is crucial for preventing clients from "falling through the cracks" among independent and autonomous agencies. Effective collaboration is also the key to serving the client in the broadest possible context, beyond the boundaries of the substance abuse treatment agency and provider.
This chapter explores the elements of integrated services using a community-collaborative model. This model is based on an agency's ability to make effective referrals within a network of numerous agencies, including vocational services, serving common clients. Only when these service providers are truly interconnected can they work together toward the common goal of successful client outcomes. The phrase authentically connected has been coined to describe an integrated network in which agencies function as equal players with each other and with the client to identify and address the complex interplay of needs that is typical of clients with substance abuse disorders.
When the many agencies that work with clients who have substance abuse disorders work independently of each other, the result is that the client is subject to fragmented services, none of which might address the client as a whole person. One of the biggest challenges to any collaborative or network-based model occurs when each of numerous agencies wants to use a different assessment tool to gather the same information. At best, this produces a fragmented portrait of the client; at worst, it creates frustration and confusion for the client, who may drop out of treatment as a result.
A shared vision among potential collaborators facilitates strategies to achieve common goals (Nelson et al., 1999). The biggest benefit of collaboration among health agencies is the improved health of clients and therefore of the community. One study found that health is dependent on how people perceive the quality of their community. Leadership and vision among collaborative agencies can make a difference in the quality of a community health care system and in the cost-effectiveness of the care provided (Molinari et al., 1998).
Collaboration among agencies is the key to preventing fragmentation. In addition to reducing the likelihood of clients falling through the cracks between disparate and unconnected agencies, collaboration can foster a more holistic view of the client. Sometimes just a simple change of perspective can make the difference between circumstances being viewed as "needs" and being viewed as assets. For example, a single parent who cannot find a babysitter on a particular evening misses a treatment session. This client is then labeled "noncompliant" by one treatment provider, but another provider who focuses on child care and parenting skills recognizes the client's adherence to her parental responsibility as a positive asset. With effective collaboration, service providers will learn to recognize these differing viewpoints through their contact with professionals with expertise in different areas.
Another approach to prevent fragmentation is to designate one agency as the primary contact both for the client and for the other agencies. The primary agency provides a holistic assessment that accompanies the client throughout the referral process. The assessment must be comprehensive enough to satisfy all the agencies and organizations participating in the client's care and might include medical/psychiatric history and conditions, substance use patterns, work history, housing situation, physical/sexual abuse history, involvement in family violence and the criminal justice system, and other data about the client. In addition to decreasing paperwork and minimizing fragmentation, this process could help to strengthen linkages and communication among various agencies providing different services.
The traditional referral system from substance abuse treatment programs to outside agencies can create obstacles to effective collaboration. Examples of obstacles are designation of which agency has major responsibility for a client, structural barriers driven by funding sources (e.g., payment to only one treatment agency), difficult-to-treat clients, and differing staff credentials.
The issue of which agency "takes credit" for a client is a difficult question arising from competition among different agencies, each of which has an interest in maintaining a certain "head count" to ensure continued funding. This barrier highlights the need to change the way that agencies are credited for their participation in a client's recovery. In many treatment systems, only one agency can receive credit for clients who are served by several service providers. It would be preferable to allow all participating agencies to take credit for these clients. For example, this happens in communities that have collaborative relationships based on shared outcomes negotiated across agencies. These cross-agency outcomes can occur across service systems (e.g., substance abuse treatment and social services) or across provider networks (e.g., residential and outpatient providers). Outcomes are negotiated both across agencies and with funders of services. Funders play a critical role because they must "change the rules" that allow only one agency to receive credit for a client. This change from a rules-driven system to a results-based system encourages all participating agencies to be recognized for their contribution to client outcomes. Also, it is important that each provider understand the role of the other providers so that it does not seem as if they are competing. Each provider must create an appropriate working relationship with the other providers so the client can benefit from all.
Structural barriers may also be posed by program policies that are determined by the program's primary funding source. Such policies may dictate, for example, that clients cannot engage in concurrent activities, such as vocational training and treatment of substance abuse disorders. If the State or a managed care system does not allow clients to participate in concurrent services, then collaboration efforts will be difficult, or even impossible. However, in some cases, this is simply a program philosophy and not a formal policy, and efforts should be made to change this mode of operation. Another major barrier in the past has been confidentiality requirements. One answer to addressing this problem is joint training.
In the present system, there are no rewards for serving difficult-to-treat clients, and sometimes agencies set criteria under which only the clients with the greatest potential for success are accepted. Incentives are needed for programs to accept those clients who have the greatest problem severity or multiple needs. This is known as "case mix adjustment." The incentives should be based on three factors: (1) identification of difficult-to-treat clients based on analysis of differential outcomes and clients' characteristics, (2) analysis of the additional average costs of serving these clients, and (3) provision of either explicit incentives for serving these clients or a more equitable approach. A key element in a more equitable approach is for funders to recognize that serving difficult-to-treat clients is as valuable as serving clients with fewer risk factors, even though success rates will be lower as a result. Referring difficult-to-treat clients should be viewed not as a matter of "handing off" problematic clients, but rather as securing additional services to meet these clients' needs.
Staff licensing can sometimes be a barrier to collaboration because it is defined categorically. For example, sometimes the referring agency has a policy requiring that the staff members of the receiving agency have the same licenses and credentials as the referring agency's staff. In addition to requiring specific types of expertise, a referring agency sometimes requires the staff members of the other agency to be "professionals" with advanced degrees. The unfortunate consequence is that credentialing standards, rather than transdisciplinary collaboration, often dictate the services clients receive.
Programs must look at their clients with the assumption that it is not feasible or effective to provide everything that clients need "under one roof." A more fruitful approach is to collaborate with other agencies on the basis of client needs and overlapping client caseloads. This procedure is called data matching. Figure 5-1 provides an example of this process.
Agencies and organizations that provide vocational training in collaboration with substance abuse treatment programs can be divided into two levels--agencies providing specific training for employment (Level 1), and agencies with resources and services needed by clients at the same time they are receiving substance abuse treatment and employment rehabilitation services (Level 2). Examples of Level 1 resources include
Examples of Level 2 resources include
Often, collaborating agencies must be educated about the nature of substance abuse disorders, including the cycles of relapse and recovery. Alcohol and drug counselors may also benefit from applying the relapsing and remitting model in areas other than substance abuse disorders. For example, clients may also "relapse" into and out of employment, medication management, or violent situations. The failure of any one of these supports can then be a trigger for failure of any of the others. All collaborators, including those providing treatment for substance abuse disorders, should be aware that their efforts are likely to be ineffective unless all the client's life areas are addressed. To that end, agencies must recognize the existence, roles, and importance of each other in achieving their goals. It is preferable to have formal written agreements that outline the responsibilities of each agency.
Although the prison population has grown substantially in the last several years, vocational training programs for inmates are limited. The vocational training programs that are available to incarcerated individuals will vary according to the setting of the incarceration, and treatment programs will need to be in contact with penal institutions in order to find out what particular types of substance abuse treatment and vocational training are available (see Chapter 8 for more information about working with ex-offenders). Providers interested in more information concerning the particular procedures and problems involved in establishing service agreements with criminal justice agencies (including prisons, detention centers, and community supervision agencies for ex-offenders) should consult Chapters 1 to 4 in TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community (CSAT, 1998d).
Figure 5-2 summarizes the steps that substance abuse treatment providers can take to establish an authentically connected network with other agencies or to screen potential collaborators. The next section provides more detailed information about this process.
In its conventional sense, a multidisciplinary team is composed of members from different service areas (e.g., substance abuse treatment, vocational rehabilitation, mental health). This method of service, which is more common in programs that provide multiple services in-house, is just one way of functioning in a multidisciplinary manner. In an authentically connected referral network, however, members of the multidisciplinary team provide their services in different locations. Still, in an authentically connected network, a multidisciplinary team approach can be fostered by regularly scheduled case conferences.
In the authentically connected model, the agencies are interdependent. They cross-train their staffs in concepts and methodologies from different disciplines and promote awareness of resources that each agency might provide. Instead of being dependent on certification, learning about other disciplines, and becoming recertified every few years, service providers are taught how to learn on their own.
Careful consideration must be given to the formation of a multifocal treatment team. One approach is to view the team as a pie divided into sections, with the team members proportionally reflecting the needs of clients in areas such as coexisting mental disorders, job skills and employment, and child custody and care. The community must be considered as a whole throughout the treatment and referral process, and all available resources in the local geographic area should be considered to meet client needs. Multidisciplinary teams can be composed of credentialed specialists as well as self-help and grassroots organizations. The more diverse the team, the more likely that the client will be viewed holistically.
True collaboration is a higher order of referral than either cooperation or coordination. Referral is a term that is used to mean many different things. Whereas a traditional referral is unidirectional (e.g., the client is sent for services to an outside agency), an authentically connected referral network is multidirectional and incorporates the ideals of collaborative relationships, accountability, cultural competence, client-centered services, and holistic assessment.
People live in different environments, and service providers have a responsibility to understand the contexts in which their clients operate. Client-focused treatment and referral must be based on an understanding of the family relationships, cultures, and communities of the clients. Culture can be broadly defined as incorporating demographic variables (e.g., age, sex, family), status variables (e.g., socioeconomic, educational, vocational, disability), affiliations (formal and informal), and ethnographic variables (e.g., nationality, religion, language, ethnicity). In many cases the client's belief system is intricately woven with culture, and providers must start where the client is and acknowledge the spiritual part of the work. Substance abuse treatment programs should be open to faith-based organizations in their communities, which can be valuable collaborative partners.
Throughout this chapter, the expression cultural competence refers to the capacity to view and understand individual clients within these contexts (Center for Substance Abuse Treatment [CSAT], 1999a). It is a core philosophy that must be integrated into and must guide the entire treatment and referral process. Too often, cultural competence is equated with the completion of a workshop, a multicultural staff, or proficiency in the language(s) spoken among the client population served. However, diversity of staffing does not ensure the cultural competence of the treatment program. Cultural competence is not achieved solely by attending workshops or by having a diverse, multilingual staff. When taken seriously, cultural competency is a continual learning process that is dynamic and is constantly expanded, refined, and defined by the community being served.
Building an integrated service model based on community partners must begin from the clients' base, taking into account their values and building on the strengths of their culture to create referrals that are appropriate and effective for their particular needs. Issues of culture can begin during the intake and assessment process, when clients are asked about their ethnic identification, their religion, and their participation in culturally based activities. Providers should feel comfortable discussing these issues with their clients and not make assumptions based on outward appearances, whether they are related to attire, complexion, or language. In programs working with highly diverse, multicultural populations, it may not be possible to be intimately familiar with all the details of each group's customs and culture. In any case, it is probably more important for providers to be aware of what they do not know and to have access to resources that can help, such as local community centers working in collaboration with their program.
Moreover, a delicate balance is needed between a client's current circumstances and the historical and cultural issues that come into play. Some cultures may be relatively "closed" to nonparticipants. One must sometimes maintain a presence for years until he is accepted as a participant or observer. Although outwardly some groups may seem more approachable, gaining the trust of any client takes time.
Substance abuse treatment that is both client-centered and client-focused is more likely to improve the lives of clients. Collaboration among agencies providing requisite services is an initial step toward client-centered care. Referral can be a way for agencies to hold each other accountable for getting results for clients. Referrals are necessary and appropriate when the substance abuse treatment program cannot provide special services needed by their clients. Some of the areas for which referrals may be needed include job readiness, job training, medical care, and ethnic/cultural expertise.
If the rationale for integrated treatment is a successful outcome for the client, there must be some way of measuring whether the referral is successful. From the referring provider's perspective, referral represents an act of faith, hope, and trust that the agency to which the client is referred will be accountable and will share the goal of client success along with the referring agency. Referrals also represent an opportunity for change, growth, and development. Far too often, however, a referral consists merely of handing a client a list of names and telephone numbers and assuming or hoping that the client will take the initiative to make the necessary contacts.
Distinct from this traditional model is one in which collaborations are fostered and maintained among agencies providing services to clients with overlapping needs, such as substance abuse treatment, employment, housing, education, and child care. In this context, the multidisciplinary team approach comes into play, but rather than coexisting under one roof, team members work within the various agencies engaged in collaboration. Referrals are negotiated among interlinked and interdependent agencies that share mutual goals and outcomes. These authentic connections and shared outcomes can then serve as an agreed-upon basis for the involved agencies to measure their results instead of merely going through the motions of collaboration. Figure 5-3 lists the characteristics of authentically connected referral networks.
In general, an authentically connected referral network is composed of a set of defined relationships formed as clients' needs dictate, using sound principles of case management and building in flexibility and adaptability to meet the needs of individual clients (see also TIP 27, Comprehensive Case Management for Substance Abuse Treatment [CSAT, 1998a]).
Although authentically connected referral networks share several features such as those listed in Figure 5-3, this similarity does not constitute a mandate for all treatment programs to form identical referral networks. Rather, in order for such an authentically connected network to be effective, each program must understand its own mission as well as those of the other agencies.
The authentically connected model calls for a communication mechanism that allows the timely dissemination of information to all agencies and stakeholders. An authentically connected network also includes continually updated information about available resources. For example, a network might use a Web site to post referral information, which can readily be updated (see the "Inventory" section later in this chapter for more information about electronic communication).
Focusing on communitywide outcomes allows community leaders and agencies, as well as clients, to set priorities based on client populations in individual communities. Authentically connected referral networks also educate the larger community about substance abuse in general. In so doing, they encourage responsiveness on the part of the community and the network as a whole, rather than from the agency only. The use of a community scorecard is one method to rate a community's responsiveness to treatment issues.
Authentically connected referral networks are vision driven and have client needs as the primary focus of the agencies' existence. The emphasis is on shared purpose while acknowledging the organizational "cultures" among collaborating agencies. In contrast, "rule-driven" systems are agency centered and tend to be focused on agency policies.
Mutual provider credibility and trust are at the core of the referral relationship. In the absence of trust, even the most sophisticated system will fail. Clients' trust must be built on the reliability of the provider and the provider's ability to be a consistent, accessible presence for the client. To be otherwise is to risk reinforcing a history of repeated abandonment and disappointment. The need for trust speaks to the credibility of providers and whether they are truly client oriented or are merely protecting the status quo of the program.
A sense of uniformity and cooperation is fostered by effective referrals. In a well-coordinated referral system, providers have some sense of being part of a systematic network rather than one of many disparate and independent agencies. Clients and providers alike find it easier to work through a collaborative, uniform system.
Fostering collaborative interagency relationships in the community is only one step in the development of an authentically connected network. Once the participants in the network are identified and information about them gathered, the collaborating agencies can then begin to develop an interconnected service system that reflects the needs of the local community. The next step is to form a focus group involving all the agencies. This group will develop a shared vision of the services the community needs in regard to substance abuse treatment. Lastly, the collaborators can then determine which provider is best equipped to offer which services; this step takes the form of resource mapping, which is discussed below.
Resource mapping consists of gathering information about agencies and programs in the community with which linkages can be made to provide collaborative services to clients. This mapping of available resources should include the funding sources of these programs. In a collaborative effort, money can be pooled from the various funding streams and then "decategorized" so that it no longer drives the roles of service providers. A proposal can be sent to Federal, State, and local funding sources for approval of small demonstration projects or experimental initiatives. If these efforts are successful, this model might be accepted on a more global level.
Many agencies that are willing to make referrals find that they may not know of all the resources and services available to meet their clients' needs. To fill in knowledge gaps, some communities maintain a database or inventory of available resources and geographically map them with computer software to facilitate the logistics of referrals. Such an inventory needs to include not only programs and agencies but also collaboratives. One way to make this information useful is to create a directory that is updated periodically. This directory could be posted on the Internet and also include information on eligibility criteria and available slots. For substance abuse treatment providers, an inventory of the full range of vocational opportunities available in the surrounding area can be a useful resource. Another important source of information is the State Occupational Information Coordinating Committees (SOICCs), which can provide labor market information. Computer technology can be a valuable resource for managing and updating information and matching data across systems and agencies, within the limits of confidentiality (see Chapter 7 for discussion of confidentiality issues).
Organizational alignment means that a service provider's vision, structure, mission, and policies are all based on the same underlying philosophy. All the activities and services the organization provides must be evaluated to determine the degree to which they contribute to client success. Having a mechanism for measuring client outcomes is important; information systems that track referrals and fiscal responsibility play key roles in identifying successful referrals as well as troubleshooting for cases in which needs were not adequately met.
Capacity building is the process by which organizational alignment is achieved; it involves elements such as program assessment and staff development.
For substance abuse treatment programs, capacity building includes changing the way in which assessment is viewed. At the client level, assessment involves determining a client's needs and assets and viewing the individual within the concentric contexts of family, culture, and community. At the agency level, assessment means evaluating the collaborative network of service providers and determining how well they are serving clients. This allows the collaborating agencies to better understand their missions and how they overlap and support each other. There is a potential pitfall, however, that must be monitored. As an organization begins to engage in capacity building, it will find that its initial costs may be higher than under the old method. Programs and funders will need to be educated that in the short run, the new authentically connected referral model will be more expensive, and capacity building initially will incur more overhead costs. However, once the network is in place, it will maximize the use of funds by avoiding duplication of services and, most important, it will result in higher client rehabilitation success rates.
Cross-training initiatives are key to building the capacity to serve clients more directly and efficiently. Communication mechanisms must be established among collaborative agencies to provide and receive feedback that can be used to improve services. For example, in the Substance Abuse Treatment Initiative in Sacramento County, California, the entire staff of the County Health and Human Services Department (about 1,500 people) completed training in addiction and recovery. In addition, it should be noted that alcohol and drug counselors should be cross-trained in VR issues. The initiative was intended to ensure that staff members conducting intake interviews in county health and human services agencies understood concepts related to substance abuse and were able to identify individuals and intervene when appropriate. The Child Welfare League of America has published a book (Young et al., 1998) reviewing the lessons learned from this and other projects across the fields of substance abuse treatment and child welfare services. Several other California counties and the State of Oklahoma have implemented cross-training based on the curriculum developed by Sacramento County.
Capacity building also affects staff hiring, promotion, and compensation practices, which must be geared toward enhancing client outcomes rather than based solely on an individual's credentials. Newly hired staff members should be informed that their responsibilities include becoming proficient in a sophisticated network of referral to and from other agencies with which collaborations have been formed.
Public substance abuse treatment programs have traditionally relied on three funding streams: Federal substance abuse block grants, Medicaid reimbursement, and State general funds. These traditional funding sources have now been joined by new potential funding sources at both the Federal and State levels. Most of these provide funding for substance abuse treatment within the context of other services such as job training, child protective services, or criminal justice.
This chapter offers guidance for administrators and providers as they attempt to navigate through this changed funding environment. Because of the extreme complexity of this new environment, it is crucial that providers develop a strategic approach to obtain sustainable funding that supports the provision of client-centered services. The first question to ask before seeking funds from any funding source is, how would these funds help our agency to achieve our mission and meet our clients' needs?
The hidden costs involved in relying upon short-term grant funding are often not well understood. Not only is a cost incurred for every grant sought, but every grant obtained incurs costs to maintain, administer, and meet funders' reporting requirements. A strategic approach is to consider ways to reduce the burden of grant administration on a program's budget.
A client-centered funding strategy focuses on connecting clients with the services they need to achieve both recovery from substance abuse and self-sufficiency through sustainable employment--not necessarily with providing all these services within the substance abuse treatment program (as described in Chapter 5).
In addition to substance abuse treatment and vocational services, clients often need housing, child care, transportation, primary medical care, or protection from domestic violence before they can reasonably be expected to find and succeed in a job. As this section will show, public funds are available for all of these services through a variety of Federal, State, and local channels. Having first identified the services that their clients need, providers then should identify the funding streams for those services in their State and community.
The best way to obtain any of these services for clients may be to contract with an outside agency that specializes in the provision of that service. Such an agency may already have funding to provide services to individuals with substance abuse disorders or may be in a stronger position to obtain such funding than the substance abuse treatment program (see Chapter 5 concerning referral networking).
The growth of managed care offers alcohol and drug counselors opportunities to contract to provide substance abuse treatment to the enrollees of managed care health plans. Such contracts can be a sustainable, flexible funding source without the restrictions that often apply to grant funding.
For example, nonprofit providers that receive publicly funded grants may not carry funds over from year to year and are restricted in the extent to which they can switch funds among budget categories. However, no such restrictions apply to payments received through managed care contracts. Any savings that a provider can make on a contract, while providing the agreed-upon level of service, represent funds that can be spent on other program services or set aside for future use. In addition, managed care contracts usually do not carry the sometimes onerous reporting requirements that may apply to grants.
Alcohol and drug counselors who are interested in obtaining managed care contracts must have an understanding of how managed care works. Managed care evolved as a system of controlling health care costs. Costs are controlled by limiting the length of care that is reimbursed and by negotiating costs on a capitated (i.e., per-patient) or fee-for-service basis. Contracts are awarded through a competitive bidding process. To achieve economies of scale, managed care companies generally prefer to contract with a single service provider. Small providers can improve their competitive position by collaborating with other providers to submit a single bid. It is also in providers' interests to form a coalition to establish reasonable contractual rates, thus minimizing managed care companies' ability to shop for the lowest cost provider.
Thus far, this chapter has offered a snapshot (which is, of necessity, partial and incomplete) of the highly complex new funding environment that has been created as a result of these policy shifts and in which alcohol and drug counselors must now learn to operate. This new environment necessitates a radical rethinking of traditional approaches to the provision of substance abuse treatment. The field has traditionally been independent and focused on the goal of helping clients achieve abstinence from substance use. However, the imperatives of welfare and health care reform mean that this traditional narrow focus can no longer be sustained.
To maintain financial solvency in this new era of policy and funding shifts, alcohol and drug treatment agencies must forgo their traditional independence and focus on building collaborative partnerships to meet their clients' needs. Substance abuse treatment must become an integral component of a community-based, collaborative network of services, including welfare, primary health care, mental health, vocational, and family support services. Some of the public funding sources that treatment providers and their community partners can use to support the range of services that clients with substance abuse disorders need were described above. The potential of managed care contracts as a funding source was also discussed.
The transformation of substance abuse treatment from an independent service to an integrated element in a community-based collaborative service network cannot be expected to occur overnight; rather, it is a process of transition. This section describes how providers can begin to make the changes and develop the relationships necessary to enable them to serve their clients effectively in an environment that operates under assumptions fundamentally different from those under which they operated in the past.
It must be noted that existing categorical funding mechanisms do not provide incentives for collaboration. Both State and Federal governments need to make policy changes to provide such incentives in order to foster the development of community-based collaborative service networks (see the subsection "Creation of Flexible Funding Mechanisms").
Like the process of recovery from substance abuse disorders, the process of change by providers in response to the imperatives of a new policy and funding climate can be broken down into a series of steps:
The defining feature of the new funding environment is change. Although the recent shifts in policy and funding are significant, there is no doubt that further change will occur in the future as new policies undergo further refinement and as States and localities embrace their devolved authority. For example, new Federal legislation affecting job-training reform was enacted shortly after the Consensus Panel convened for this TIP. The potential impact of this new legislation--the Workforce Investment Act of 1998--has not yet been assessed. Flexibility is a key attribute associated with success in an environment characterized by change.
Providers must accept not only the need to change in response to an altered environment, they must also accept the need to continually adapt. They must develop and implement flexible strategies that will continue to serve them as further change occurs. In addition, providers must learn to regard substance abuse treatment as a service that can be delivered in a variety of ways in a variety of settings rather than as a program characterized by a defined setting and defined, sequential components.
A second defining feature of the new environment is local variability. Although certain features of new policies on welfare are, for example, federally mandated, in general States and localities have considerably more authority than they previously did to make decisions about policy implementation and funding that can significantly affect the provision of substance abuse treatment. One result of increased State and local discretion is that decisions implemented in one State or community may differ greatly from the choices made elsewhere.
As previously noted, in some States the Single State Agency (SSA) has been subsumed within a larger State agency, such as the department of community or behavioral health. Federal funds that are administered by the department of education in one State are the responsibility of the department of community health in another State and of the executive office of the governor in a third. In some States substance abuse treatment has become the responsibility of local communities, and it has become an optional service.
Given the extent of local variability, providers have no choice but to find out which agencies in their State and locality are making important policy and funding decisions that affect the delivery of substance abuse treatment. Contacts in the SSA may be a useful source of such information. Active involvement in a State or community providers association is another effective strategy for learning who the key "budget holders" are and where the key decisions are made. Subscriptions to journals in the substance abuse treatment field can also be important sources of information. Examples of journals include Alcohol and Drug Abuse Weekly, Substance Abuse Funding News, Substance Abuse Report, and Drug Abuse Monitor. In addition, a great deal of information about policy changes and funding sources can now be obtained via the Internet; for example, The Welfare Information Network (www.welfareinfo.org), The Finance Project (www.financeproject.org), and the National Performance Review (www.npr.gov).
Providers should ask their SSA for a copy of the agency's annual plan for the allocation of substance abuse prevention and treatment block grant funds. This plan can provide crucial information about the State's funding priorities for substance abuse treatment. Some States, for example, have made a policy decision not to allocate block grant funds to methadone maintenance programs or to give such programs low funding priority.
Providers can also ask their SSA to publish an annual inventory of all funding sources for substance abuse treatment services. The annual inventory published by the State of Arizona is a model that other States could emulate (see the section titled "The Role of the SSA" later in this chapter).
Other important pieces of information for providers to know are the amount that their State allocates from its general funds to support substance abuse treatment and the level at which their State provides matching funds when required to obtain Federal funds. Some States contribute the minimum required in matching funds, whereas others have set higher levels. A local providers association or sources in the SSA may be the best places for providers to begin their search for this information.
To succeed in the new environment, providers must have a clear understanding of the demographic characteristics and service needs of their client population. They must know, for example, how many of their clients are on welfare, how many have children, and how many are involved with the criminal justice system. Armed with this information, they are able to clarify their mission--what they need to do to meet their clients' needs, who they need as partners, and what resources are needed from partner agencies.
Having thoroughly assessed their client population and aligned their mission to focus on their clients' needs, providers next need to assess their existing capability and resources to meet those needs. A realistic appraisal of the program's strengths and limitations is a crucial part of this process. It is not necessary--indeed, it is not possible--for any program to meet all its clients' needs with in-house resources. Rather, a program should begin to identify potential collaborators in its community that are already providing services needed by its clients (see Chapter 5).
Figure 6-1 outlines a process by which programs can assess their clients, their mission, their strengths and limitations, and their community resources and relationships.
It must be acknowledged at the outset that collaboration presents many challenges. Collaboration is difficult for many reasons, not the least of which is that at some level it requires relinquishing control over certain processes.
Once a program has adopted an approach that is centered on meeting clients' needs and has realistically assessed its own strengths and limitations, collaboration becomes a strategy that enables it to meet its clients' needs more effectively than it otherwise could.
Collaborative relationships with providers of services whose clientele may overlap with that of the substance abuse treatment program (such as welfare, vocational rehabilitation, law enforcement, and public housing agencies) are also a strategy for ensuring that all individuals with substance abuse disorder problems--no matter what their point of entry into the human services system may be--have access to treatment. Providers may also find it mutually beneficial to collaborate with other substance abuse treatment programs. For example, a coalition of several providers may be in a better competitive position when seeking a contract to provide substance abuse treatment services to a managed care organization. One partner whose strength is screening and assessment can undertake that function for the entire coalition, whereas a partner who already has a highly developed information system can perform the coalition's data collection and analysis. Similarly, a provider that has specialized culturally sensitive services for one ethnic population may be able to help another agency that does not have such services.
Collaboration can also be a strategy for obtaining services such as cost-effective staff training. For example, two or more providers could share the cost of holding a staff training workshop on vocational and substance abuse issues.
Once a program's mission becomes client-centered, the next step is to adopt a client-centered funding strategy. This means that rather than pursuing all possible sources of funding, a program focuses on seeking sustainable funds that will enable it to achieve its mission and meet its clients' needs.
Such an approach may initially seem counterintuitive. The experience of many substance abuse treatment programs is that competing for the largest and broadest range of funding is the key to success. However, this approach fails to take into account the hidden costs of reliance on short-term grant funding.
The U.S. Department of Housing and Urban Development (HUD) provides an example of collaboration encouraged by funding. To apply for funds to provide services for homeless individuals (many people in substance abuse treatment are homeless under HUD's definition), communities must form coalitions and work collaboratively toward implementing strategies aimed at eliminating homelessness. These collaborations must define how money will flow to ensure that clients receive the needed services, from substance abuse treatment and medical services to food, etc. HUD requires that these coalitions seek more involvement from the private sector, especially the business community. This holds tremendous potential for matching clients with jobs and pooling resources to ensure that clients are successful.
Adopting a sustainable funding strategy means identifying and pursuing institutional funding sources such as Title XIX of the Social Security Act (which covers Medicaid reimbursement), Title IV of the Social Security Act (which covers treatment for parents who are clients of child protective services agencies), private health insurance reimbursement, and contracts to provide substance abuse disorder services to managed care companies, welfare and public housing agencies, and so on.
Also part of a sustainable funding strategy is forging agreements with other agencies to provide services required by a substance abuse treatment program's clients. For example, clients on welfare who have substance abuse problems might be referred to a vocational services agency or a community-based organization (CBO) that has funding through the Department of Labor's Welfare-to-Work program. Such a strategy leverages nontreatment funds to meet clients' needs for services that will help them along the path to self-sufficiency through sustainable employment.
Before being ready to pursue sustainable funding mechanisms, an alcohol and drug administrator must understand how funding streams flow in its State and community (Step 2), must have identified potential collaborators that are providing services needed by the alcohol and drug agency's clients (Step 4), and must have accepted collaboration as a strategy for more effectively meeting its clients' needs (Step 5).
There has been a trend in recent years toward demanding greater accountability by all kinds of publicly funded programs, including substance abuse treatment programs. Evidence of effectiveness is frequently a prerequisite for continued funding. Federal agencies such as the Department of Health and Human Services (DHHS) are known to be interested in offering more grants that are linked to performance.
Providers who recognize the need to form collaborative partnerships to meet clients' needs must be prepared to be accountable for treatment outcomes. The collection of outcomes data at the community level serves two purposes:
Outcomes data serve to document the value substance abuse treatment adds to the services of other agencies; that is, how substance abuse treatment helps reduce costs and enhance client success for other agencies. For example, substance abuse treatment can enable former welfare recipients to sustain employment, which in turn might decrease drug-related violence and criminal activity in a public housing complex.
Providers have a responsibility to make resources available for the collection of outcomes data, whether or not such resources are earmarked by funders. It is not sufficient to collect data about the numbers of clients treated. Although many States collect outcomes data, it is in programs' interests to collect and analyze their own data. Computer technology now makes it easier for programs to do this.
In addition, programs can use their clients' experiences to provide powerful anecdotal evidence of the benefits of treatment to individuals and communities. Examples include a woman who regained custody of her children or a man with a history of incarceration for drug-related offenses who now works to prevent substance abuse among at-risk youth in a public housing complex.
In the postwelfare-reform environment, it is essential that the practical effects of work-first policies are documented. A great deal of evidence demonstrates that mandatory work programs are unlikely to succeed when they fail to take into account individuals' needs for substance abuse treatment, vocational rehabilitation, and family and workplace support services.
As noted earlier under Step 2, States and communities now have much greater discretion over policy implementation in welfare, substance abuse treatment, and other related services. Increased State and local discretion means that providers must put a great deal of effort into understanding how the new policies are being implemented in their community. It also presents the substance abuse treatment field with much greater opportunities for influencing the direction of State and local policies on substance abuse treatment. Decisions made at the State and community levels can be changed by advocacy. It is more important than ever, therefore, for providers to become actively involved in the policymaking process, providing concrete data to document the effectiveness of substance abuse treatment services.
State and community provider associations, in addition to being useful arenas for providers to share information about policy developments and funding sources, can also be effective advocacy organizations for substance abuse treatment. In several States and communities, provider associations have sponsored town hall meetings and other forums to educate community leaders and legislators about the benefits of substance abuse treatment. In communities where no providers' association exists, providers are strongly advised to form one. For example, Rhode Island's provider trade association offers multiple services for alcohol and drug treatment staff, including a forum for meeting and discussion, education/training, and a political power base for client and provider advocacy. In California, statewide advocacy groups represent the county substance abuse treatment agencies, providers, and other related organizations. These groups meet regularly with the SSA in a policy forum that serves as an arena for exchanging information and providing the opportunity to influence policy decisions.
Providers have a responsibility to make their voices heard when States and communities set priorities that exclude or adversely affect substance abuse treatment. By presenting data on the extent of untreated substance abuse disorders among women on welfare, for example, they can draw attention to the shortage of publicly funded treatment slots for women and the need for support services such as child care that make it possible for women with children to obtain treatment.
The substance abuse treatment field in general has not advocated effectively for the benefits of treatment. Policymakers and many members of the public support reforms such as work-first initiatives because such policies are consistent with deeply held beliefs in mainstream American culture about personal responsibility for life choices, but also because they are often genuinely unaware of the substantial body of evidence that substance abuse treatment works.
Providers must become more actively involved in educating the public and community leaders about the effectiveness of substance abuse treatment. The ability to present compelling data that demonstrate the benefits of treatment not only to individuals but also to communities as well as to society in general is a prerequisite for effective advocacy. Thus, advocacy is strongly linked to accountability.
Providers must clarify their mission, understand their clients' needs, develop a client-centered focus, and become full partners in a collaborative service network that endeavors to meet the multiple needs of clients recovering from substance abuse disorder. This represents nothing less than a transformation of the substance abuse treatment field.
State and Federal agencies have a responsibility to facilitate this transformation not only by adopting policies and procedures that encourage and reward collaboration, accountability, and client-centered approaches to care but also by embracing these principles in their own behavior. This final section examines the changes necessary at State and Federal levels to model the transformation of substance abuse treatment services at the provider level.
The overarching message of this chapter is that substance abuse treatment services must cease to be a self-sufficient entity not engaged with the wider health and human services community and must become an integral part of a community-based service network. It follows, therefore, that the future role of the SSA must extend further outside the traditional boundaries of the substance abuse treatment field than has previously been the case for SSAs.
Welfare reform enacted by Congress in 1996 both created new Federal mandates for States to carry out and devolved to States many decisions about implementation of the new policy. Most of these mandates and decisions are not carried out by SSAs, yet their impact on both clients and providers of substance abuse treatment services is substantial. In addition, new funding streams controlled by other State agencies may be used to support the provision of substance abuse prevention and treatment services as well as vocational and other services needed by individuals with substance abuse disorders who are subject to the work requirements and benefit from time limits imposed by welfare reform.
As a result of State government restructuring, in many States the SSA is no longer a free-standing agency but a division within a larger department such as community or behavioral health. Such restructuring should not, however, be an excuse for lack of outreach efforts. It could, indeed, facilitate outreach because at least other divisions within the same agency may provide some of the other services that deal with clients with a substance abuse disorder.
These changes make it necessary for SSAs to adopt a much broader view of substance abuse policy and their role in its implementation. Although Federal substance abuse block grant funds still represent an important funding source for substance abuse treatment services, substance abuse policy at the State level must transcend decisionmaking about the distribution of the SSA's "own" block grant funds and take into account the reality that clients with substance abuse disorders are also likely to be clients of the State's welfare, criminal justice, public housing, child protection, and community health services.
SSAs, like providers, must adopt a client-centered approach that focuses on ensuring that the multiple needs of clients with substance abuse disorders are met across a spectrum of fragmented agencies and services. Outreach to other government agencies that provide services to individuals with substance abuse disorders must become a key objective for SSAs.
SSAs also have a responsibility, in addition to collecting and analyzing data on the outcomes of substance abuse treatment, to ensure that lessons learned through data analysis are applied in ways that improve outcomes for clients. Data collection is only useful if it results in policy and program changes that benefit clients. For example, the fact that nationally only 27 percent of all publicly funded treatment slots are allocated to women has great consequences for links between employment programs for welfare recipients and treatment programs needed to make these clients self-sufficient while addressing the critical needs of their children at the same time. The data point of 27 percent is the beginning of such a policy discussion, but when a community does not focus on gender in its discussion of who receives treatment benefits or amalgamates both genders and their needs into a single group, it becomes more difficult to use existing data to support requisite system reforms.
Most funding mechanisms remain narrowly focused and fail to provide incentives for the interagency collaboration that is required to make the envisioned client-centered care network a reality. At the Federal level, it is likely that a multiplicity of categorical funding sources will remain for the foreseeable future, although there is a trend in some Federal agencies toward awarding more performance-driven grants. It is extremely cumbersome for providers to have to deal with such a vast number of funding sources, all of which operate under different procedures and rules.
One approach that may represent a way out of this dilemma is to promote mechanisms that permit flexible or "wraparound" funding that involves a shared fiscal responsibility at the local level. Simply put, shared fiscal responsibility involves empowering local multidisciplinary coalitions to tie together funds from a variety of categorical sources to support an integrated network of services. This approach also might be termed "bottom-up block grants."
Several States--including Georgia, California, Minnesota, and Oregon--have passed legislative incentives for funding that allow wraparound or shared fiscal responsibility at the local level. In some States, the executive branch may be able to use existing authority to create such incentives. Nonlegislative approaches are also possible. The Federal government's National Performance Review is sponsoring several models of how shared fiscal responsibility might work (see their Web site, www.npr.gov), and the Washington, DC -based Finance Project has published a series of reports on shared fiscal responsibility outside the substance abuse treatment field (see www.financeproject.org).
At present, States that wish to provide incentives for some kinds of shared fiscal responsibility must obtain a waiver from the Federal government.
The criminal justice orientation of the public substance abuse treatment system devalues the treatment of women and ignores the intergenerational effects of substance abuse on children. For example, as mentioned earlier, 27 percent of publicly funded admissions are women. Some treatment agencies and funders do not collect data on the children of their clients.
In addition to a reconsideration of the allocation of public treatment slots to women, there is a need to integrate prevention and treatment activities focused on families to recognize that substance abuse treatment for a mother represents substance abuse prevention for her children. Substance abuse treatment for the mother leads to better parenting skills, which in turn decreases the number of neglect and child abuse cases. Such prevention also may mean the difference between a child's continuing dependency on the social service and criminal justice systems or his becoming a contributing member of society.
Current categorical funding mechanisms and a traditional focus on clients over families serve as major disincentives to such integration.
While the major source of public funding for substance abuse treatment comes through the SSAs, a variety of funds useful to substance abuse treatment providers are also available from other sources. This chapter describes 12 major sources of public funding that may be of use to treatment programs. Different sources will pay for different types of services and many stipulate the specific population for which the funds can be used.
The agencies responsible for administering Federal funds at the State level vary enormously. For example, the department of economic development in one State, the department of education in another, and the department of health in a third may handle vocational rehabilitation (VR) funds. Also, in some States the SSA has been subsumed within another State agency.
Many States also offer their own funding sources that may be used to support substance abuse treatment and related services. However, State funding sources are too numerous, and the State-level administrative structures responsible for such funding too diverse, for a list to be useful. Providers need to become familiar with the organization of their State government and find out which divisions are responsible for which funds.
Federal sources of discretionary, time-limited project grants that may also be available are summarized in Appendix F.
The bulk of these funds, which support a full range of substance abuse prevention and treatment services, are awarded to States by formula (42 U.S.C. §300). Thirty-five percent of the SAPT block grant funds are earmarked for prevention and treatment activities relating to alcohol abuse and 35 percent for prevention and treatment activities relating to drugs. Twenty percent of the grant is to be used for primary prevention activities and 5 percent for the administration and support of the SSAs. Other SAPT block grant "set asides" were established for programs that target special populations, such as services for women, especially for pregnant and postpartum women and their substance-exposed infants, and, in certain States, for HIV screening.
Each State's SSA is responsible for delivering these Federal funds to counties and individual providers. Treatment programs should contact the appropriate SSA for more information.
Title XIX of the Social Security Act (42 U.S.C. §§1396-1396v) provides funding for substance abuse treatment of Medicaid-eligible individuals as an optional benefit at the States' discretion. The availability of Federal Medicaid funds is conditional upon the provision of State matching funds; the level of matching funds required is variable based on a number of factors. Medicaid eligibility varies by State and is based on income, age, participation in other Federal programs (such as Supplemental Security Income [SSI] and adoption assistance/foster care), and pregnancy status. States have discretion over whether to provide a substance abuse treatment benefit to their Medicaid populations, and different States have different levels of coverage (e.g., residential, outpatient, day or night treatment). Many States have opted not to provide such services.
In most States, Medicaid funds do not flow to the SSA, and the agency administering the Medicaid program varies by State. Many States now require Medicaid-eligible individuals to enroll in a managed care program. Interested parties should contact their State's Department of Health and Human Services for further information.
The Temporary Assistance for Needy Families (TANF) program has several purposes: (1) to provide assistance to needy families so that children may be cared for in their own homes or in the homes of relatives; (2) to end needy parents' dependence on government benefits by promoting job preparation, work, and marriage; (3) to prevent and reduce the number of out-of-wedlock pregnancies; and (4) to encourage the formation and maintenance of two-parent families. As discussed earlier (in Chapter 2), benefits are time-limited and work is mandatory; more information on TANF can also be found in Chapter 7.
Each State receives a block grant based on its previous level of spending on Aid to Families With Dependent Children (AFDC), the Federal welfare program that TANF replaces in accordance with the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. For many States, this block grant represents a financial windfall. Although TANF funds cannot be used to provide medical services, some substance abuse treatment (e.g., outpatient counseling, residential services) can be paid for by TANF funds. Providers need to know the amount of the grant in their State and whether any of those funds were set aside for substance abuse treatment services.
The U.S. Department of Labor's welfare-to-work program also awards grants to support employment services for TANF recipients and the noncustodial parents of children receiving TANF. Three-quarters of the funds go to States in the form of formula grants and one-quarter go to local communities in competitive grants. Any services that overcome barriers to employment, such as job training, transportation, child care, and substance abuse treatment, are eligible for funding. Formula funds are directed to Private Industry Councils (PICs) or Workforce Investment Boards (WIBs), Workforce Development Boards, and similar bodies at the State and community levels; the precise funding channels vary by State. This program's specific recognition of a substance abuse disorder as a barrier to employment is an innovation. As previously noted, some States consider participation in substance abuse treatment to be a valid work activity, whereas others do not.
The Department of Labor also offers job training funding for economically disadvantaged individuals through the Job Training Partnership Act (JTPA) (29 U.S.C. §§201-206). Eligible services include basic and remedial education, job skills assessment, on-the-job training, job-search assistance, work experience programs, internships, school-to-work transition programs, and transportation and relocation assistance. Specific groups eligible for services include unemployed adults, youth, the disabled, dislocated workers, Native Americans, migrant and seasonal farm workers, and veterans. Funds are channeled to States, which oversee the planning and operation of local programs; programs can contact their State department of labor for further information. Alcohol and drug counselors should consider partnering with agencies receiving JTPA funds in their locality to offer vocational services to the substance abuse treatment agency's clients. However, the JTPA act is superseded by the Workforce Investment Act of 1998 (P.L. 105-220) and was repealed July 1, 2000.
The Workforce Investment Act consolidates more than 60 Federal programs into 3 block grants to States for employment, training, and literacy. This job training reform measure replaces programs currently under JTPA, the Stewart McKinney Act, and the Carl Perkins Act. Under this new law, States will receive block grants for adult employment, training for disadvantaged youths and families, and literacy. The legislation establishes a system of "one-stop" centers that are intended to provide job seekers with the information and advice they need to obtain training and employment. Individuals who seek services at the one-stops will be given vouchers with which to fund training. The current local decisionmaking entities--PICs or WIBs--will continue to exist under a new name but will have less stringent membership requirements with respect to union- and community-based representation.
The bill establishes State WIBs and requires States to submit a plan that outlines a 5-year strategy for their statewide workforce investment systems. States are required to designate local workforce areas, and local WIBs are to be appointed by the chief elected local officials. Functions of the local WIBs include, among other things, development of the local plan; designation, certification, and oversight of one-stop operators; identification of eligible providers of intensive and training services; and development and entry into memoranda of understanding with one-stop partners.
The one-stop delivery system in each local workforce investment area is to provide core services and access to intensive services, training, and related services. Included in those program elements for youth activities are comprehensive guidance and counseling, which may include drug and alcohol use counseling and referral. For adult training, the bill requires use of Individual Training Accounts but allows for use of contracts for training services for CAOs or other private organizations that serve "special participant populations," defined as those who face multiple barriers to employment.
Furthermore, with regard to vocational rehabilitation, the bill calls for evaluation activities on identifying what works well rather than continuing to seek to define the chronic problems connected to the employment of individuals with disabilities.
HUD offers funding for substance abuse treatment of public housing residents under the Public Housing Drug Elimination Program (42 U.S.C. §11901). HUD awards grants to Public Housing Authorities (PHAs), Tribes, or Tribally Designated Housing Entities (TDHEs) in order to create programs to eliminate substance abuse and substance-abuse-related crime in their developments.
Services eligible for funding include substance abuse prevention, intervention, referral, and treatment as well as job training (aimed at assisting prevention efforts), and security improvements in public housing complexes. Funds are channeled to local public housing authorities, which contract with service providers.
These funds, administered by the U.S. Department of Education, support services to enable people with disabilities to participate in the workforce. Funds are provided according to the Workforce Investment Act of 1998 (P.L. 105-220 §106) and the Carl D. Perkins Vocational and Technical Education Act of 1998 (P.L. 105-220). Chapter 7 of this TIP provides further information on both of these Acts.
Services eligible for funding include substance abuse disorder assessment and treatment, prescription medications, equipment that enables disabled individuals to have access to and function in the workplace (such as wheelchairs, hearing aids, and adapted computers), and transportation. Vocational rehabilitation will also fund training and secondary education, as well as vocational testing and evaluation. Funds are channeled to State agencies with responsibility for vocational rehabilitation. The location of this agency within the State government varies by State.
Title IV of the Social Security Act (42 U.S.C. §1862) provides funding for foster care and services to prevent child abuse and neglect. Eligible services include substance abuse treatment for parents who are ordered by a court to obtain treatment and are at risk of losing custody of their children, and child care while a parent is in residential treatment. The estimated overlap between clients of child protective services agencies and parents with a substance abuse disorder is 60 to 80 percent (National Center on Addiction and Substance Abuse at Columbia University [CASA], 1999; Young et al., 1998). Title IV funds are usually administered by State social services departments.
Title IV funds represent a large, open-ended potential funding source for substance abuse treatment for women who are involved in the child welfare system, an underserved population. Women with children may be unlikely to enter residential treatment if the facility cannot accommodate their children, if adequate child care is not available, or if doing so means giving up their children to foster care (Strawn, 1997). For more information on child abuse and neglect issues and substance abuse treatment, see the TIP, Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues (CSAT, 2000a).
Title XXI of the Social Security Act (P.L. 105-33 §4901a) provides Federal funding for the Children's Health Insurance Plan (CHIP), a public-private initiative to provide health insurance coverage for children who are ineligible for Medicaid and not covered by private insurance. Funds are awarded to States by formula, and States have considerable discretion in deciding what services to cover. In some States, substance abuse treatment for adolescents is a covered service. The agency administering CHIP funds varies by State; it may be a State agency or a private entity. Interested providers should contact their State's Department of Health and Human Services to find out what services are covered and who is the funding intermediary in their State.
Title XX of the Social Security Act (42 U.S.C. §§1397-1397f) provides flexible funding that States can use for child care, transportation, detoxification, and substance abuse treatment services, and social services for clients with substance abuse problems. This block grant is administered by DHHS, and eligibility is State-determined. Providers should contact State Departments of Health and Human Services for further information.
The U.S. Department of Justice (DOJ) Weed and Seed program administered under P.L. 105-277 is intended to reduce drug activity in target communities. Substance abuse treatment for residents of the target communities is an eligible service. Funds are channeled through the offices of State attorneys general. Most grantees are law enforcement agencies that are working as part of a community coalition. Treatment providers should contact the Executive Office for Weed and Seed (EOWS) at the DOJ for further information on this program.
The DOJ Office of Justice Program's (OJP) Drug Courts Program Office (DCPO) administers the Drug Court Grant Program, which originated under Title I, Subchapter XII-J of the Omnibus Crime Control and Safe Streets Act, as amended by Title V of the Violent Crime Control and Law Enforcement Act of 1994 ("the 1994 Act").1 This legislation authorized the Attorney General to make grants to States, State courts, local courts, units of local government, and Indian tribal governments to establish drug courts in response to the needs of increased numbers of nonviolent, substance-abusing adult and juvenile offenders. Congress has appropriated substantial sums of money for the Drug Court Grant Program each year since the program's inception. Most recently, in the Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999, of October 1998, Congress appropriated $40 million specifically for the Drug Court Grant Program, "as authorized by Title V of the 1994 Act."2
In January 1997, the DOJ released Defining Drug Courts: The Key Components, a report developed through a cooperative agreement between the OJP, DCPO, and the National Association of Drug Court Professionals, that describes the 10 key components of a drug court and specifies performance benchmarks for each component. This report was endorsed by the Conference of Chief Justices, Conference of State Court Administrators, and National Association of Pretrial Services Agencies. The 10 key components and their performance benchmarks provide the foundation for the guidelines available on the DCPO Web site for those completing grant applications. The report is available through the National Criminal Justice Reference Service Clearinghouse at (800) 421-6770, and on the DCPO Web site (http:// www.ojp.usdoj.gov/dcpo/Define).
At its Web site, the DCPO specifies that drug courts funded under the grant program must be defined as "a specially designed court calendar or docket, the purposes of which are: to achieve a reduction in recidivism and substance abuse among nonviolent adult and juvenile substance abusing offenders; and to increase their likelihood for successful rehabilitation through early, continuous, and intensive judicially supervised treatment, mandatory periodic drug testing, and the use of graduated sanctions and other rehabilitation services. A separate or special jurisdiction court is neither necessary nor encouraged."3 In addition, drug courts must include two specific critical elements:
Funds available for the treatment of clients making the transition from incarceration to the community vary from State to State. Chapter 4 of TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community (CSAT, 1998d) describes the ways in which funding practices differ between States. Providers seeking additional information concerning Federal funding opportunities (such as vocational training pilot programs for criminal offenders) should contact the Office of Correctional Education (OCE) in the Department of Education. The OCE coordinates all correctional educational programs in the department, and provides technical support relating to correctional education (see their Web site at www.ed.gov/offices/OVAE/OCE/).
The Rehabilitation Services Administration (RSA), which is housed under the U.S. Department of Education's Office of Special Education and Rehabilitative Services, oversees programs that help individuals with physical or mental disabilities obtain employment (Rehabilitation Act of 1973, 29 U.S.C. §701ff). Employment is obtained through the provision of such supports as counseling, medical and psychological services, job training, and other individualized services. RSA's major formula grant program provides funds to State VR agencies to provide employment-related services for individuals with disabilities, giving priority to individuals who are severely disabled.
In addition, general equivalency diploma (GED) programs are offered free of charge by many public school systems. High school equivalency or remedial programs for students with special needs may also be offered by some State education departments. Academic tutoring is offered at many libraries by literacy volunteers. Other private, nonprofit social services agencies such as Travelers Aid and vocationally oriented mental health programs (e.g., Fountain House in New York City), also offer educational remediation and GED preparation.
Finding adequate transportation is a major challenge facing people who are making the transition from welfare to work. Two-thirds of new jobs are in the suburbs, but three of four welfare recipients live in rural areas or central cities. There are several programs that help to provide transportation for people transitioning to work (Federal Transit Administration, 1998). Under TANF, funds may be used for a range of transportation services as long as these expenditures reasonably accomplish a purpose of the TANF program, such as promoting job preparation and work.
The U.S. Department of Labor provides Welfare-to-Work (WtW) funds to States and local communities to help create additional job opportunities for the hardest-to-employ TANF recipients. WtW funds also can be used for transportation assistance to help these recipients move into unsubsidized employment.
The Federal Transit Administration, which is housed within the U.S. Department of Transportation, oversees the Job Access and Reverse Commute grant program. This program, funded under the Transportation Equity Act of 1998 (49 U.S.C. §5309), helps States and local communities develop flexible transportation services that connect welfare recipients and other low-income persons to jobs and other employment-related services. These projects are aimed at developing new or expanded transportation services, such as shuttles, vanpools, new bus routes, connector services to mass transit, employer-provided transportation, and guaranteed ride home programs. The Job Access and Reverse Commute grant program also is intended to establish a collaborative regional approach to job access challenges and involves organizations such as transportation providers, agencies that administer TANF WtW funds, human services agencies, employers, metropolitan planning organizations, States, and affected communities and individuals.
The Empowerment Zone and Enterprise Community Initiative (26 U.S.C. §1391) provides tax incentives and performance grants and loans to create jobs and expand business opportunities in the 87 urban areas and 38 rural areas that have been designated as Empowerment Zones (EZs) or Enterprise Communities (ECs). The initiative also focuses on activities to support people looking for work, including job training, child care, and transportation. Within each EZ or EC, residents decide what projects and activities should occur in their own neighborhoods. Grants can be used for a wide range of activities that assist residents, including job creation efforts linked to welfare reform, job training, and substance abuse prevention. Although the authorizing legislation made clear that the provision of substance abuse treatment services should be a priority, grantees have considerable discretion over the kind of activities they wish to support and in many cases have not chosen to fund substance abuse treatment services.
HUD and the U.S. Department of Agriculture (USDA) designated the original EZs and ECs; originally there were 72 urban areas and 38 rural areas, and 1997 legislation authorized HUD to designate 15 more urban areas and USDA to designate 5 more rural areas. HUD reviews the strategic plan and annual performance reports from each EZ or EC. Providers can contact HUD for a list of designated EZs and ECs as well as more information about activities funded under this program.
Alcohol and drug counselors may apply for community development block grant funds to support capital improvements such as roof repairs and building renovations. These grants were authorized by the Housing and Community Development Act of 1974 (42 U.S.C. §5301). They are administered by HUD, are distributed by formula to qualifying cities and urban counties and, through the States, to small communities that do not qualify for direct entitlement grants. The program's objectives are to benefit low- and moderate-income persons, aid the elimination of slums or blight, and meet other urgent community development needs.
Funds may be used to carry out a wide range of community development activities directed toward neighborhood revitalization, economic development, and the provision of improved community facilities and public services.
1 Title I, Subchapter XII-J of the Omnibus Crime Control and Safe Streets Act, as amended by Title V of the Violent Crime Control and Law Enforcement Act of 1994 ("the 1994 Act"), 42 U.S.C. §§3796ii et seq. (1994 & Supp III 1998) (repealed 1996). U.S. DOJ regulations for the Drug Court Program can be found at 28 C.F.R. 2 Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999, P.L. No. 105-277, 112 Stat. 2681-63 (1998). 3 U.S. DOJ, Office of Justice Programs, Drug Court Program Office. FY 1998 Program Plan [Online]. Available: http:// www.ojp.usdoj.gov./Plan/text/dcpo.txt [Accessed August 8, 1999]. 4 U.S. DOJ, Office of Justice Programs, Drug Court Program Office. FY 1998 Program Plan [Online]. Available: http:// www. ojp.usdoj.gov./Plan/text/dcpo.txt [Accessed August 8, 1999].