Chapters_1-2

Chapters_3-6

Chapter_7

Chapter_8- Appendix B

Appendix_C – Figure F-2

Chapter 3 -- Clinical Issues Related to Integrating Vocational Services

There are many compelling reasons for vocational components to be part of the substance abuse treatment plan for clients in recovery. For example,

• Achievements such as completing education or training, finding a job, and maintaining employment counter a sense of personal incapacity and provide a basis for increasing self-esteem. Many substance-using clients used drugs initially to avoid feelings of worthlessness and powerlessness.
• The work environment offers an opportunity for the client to apply recovery skills, such as building supportive relationships, learning to work within an authority structure, accepting responsibility, managing anger, and recognizing boundaries.
• As clients consider the possibility of entering or reentering the workforce, highly charged clinical issues may emerge. For example, some clients have painful memories of school and consider themselves failures, especially if they have specific learning difficulties. Other clients may have had limited social interactions during their periods of substance abuse and may find the complex relationship patterns of a new work environment mystifying or frightening. Clients' family histories will also affect their view of workplace authority figures.
• Meaningful progress toward employment can reduce the potential for relapse.
• To help clients attain work-related goals that will also support their recovery, the alcohol and drug counselor should consider the cultural, sociopolitical, physical, economic, psychological, and spiritual circumstances of each client. This is known as the "biopsychosocial-spiritual" model of treatment. For example, clients who enter a workplace culture that contradicts their cultural values will face a particularly difficult challenge, and clinicians will need to help these clients mediate between the two opposing cultural realms.

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.

Incorporating Vocational Services

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

1. Use screening and assessment tools, specifically for vocational needs, when appropriate.
2. Develop and integrate a vocational component into the treatment plan.
3. Counsel clients to address their vocational goals and employment needs.

These recommendations are discussed in more detail below, except for screening and assessment, which are discussed in Chapter 2.

Developing and Integrating a Vocational Component Into the Treatment Plan

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:

• The client is asking questions about employment or vocational goals that the clinician has difficulty answering.
• The counselor and client cannot develop a clear and concise set of goals concerning vocational issues because of a lack of information or guidance.
• The client needs special vocational testing or training beyond the expertise of the counselor or has a disability that requires special accommodations to obtain employment.
• The client's vocational history is either nonexistent or has been so seriously affected that another person with expertise in this area should be introduced to assist the client with vocational issues.
• The client clearly wants to accomplish something meaningful through work but needs help, for whatever reason, to make such a major life change.

Counseling Clients To Address Vocational Goals and Employment Needs

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:

• Help the client establish a positive life vision. What were the client's childhood dreams?
• What kind of person does she want to be now?
• Establish life goals with the client that are consistent with this life vision and realistic in terms of the client's knowledge, skills, and abilities
• Identify the objectives, resources, and specific steps needed to enable the client to meet those goals within an appropriate timeframe.

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.

Competency Areas for Employment

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

• Identifying vocational goals
• Seeking appropriate education or training
• Coping with medical and psychological challenges
• Coping with environmental challenges
• Coping with legal challenges
• Developing social and life skills
• Finding and maintaining employment
• Planning for a career and resilience
• Preventing relapse

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.

Identifying Vocational and Employment Goals

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:

1. Use the relevant job history, training, experience, skills learned, and responsibilities handled and identify the client's relevant characteristics (e.g., physical capabilities, working conditions, education).
2. Translate these characteristics into measurable traits and skills and assign a value or level to skill development.
3. Conserve the value of specific residual skills unaffected by disability (i.e., what the client has not lost because of disability).
4. Apply the residual traits and skill levels to the universe of potential jobs.

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.

Assessing the Need for Education or Training

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:

• What are the client's functional limitations that influence the type of work that would be appropriate?
• What strengths and attributes does the client bring to the world of work?
• Is the client literate in any language?
• Does the client use more than one language?
• What is the client's language preference?
• Is improving language skills important to the client?
• What is the client's level of education?
• What level of education does the client want to have?
• What is the client's past experience with schooling or learning?
• What is the client's present attitude toward schooling or learning?
• What level of literacy or educational attainment is necessary to meet the client's current vocational goals?

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.

Finding and Maintaining Employment

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:

• Overcoming the fear of change or the unknown. Counseling can be a valuable resource in overcoming this fear, which can lead to relapse in a newly recovering substance user. This fear is also addressed by pointing the client toward a job club formed by others in a similar position or by helping the client find a peer or mentor who has traveled a similar path. Judicious self-disclosure by the clinician may also be appropriate. Moving toward desired goals may still be anxiety producing, and small steps will maximize success.
• Developing job-seeking skills. These skills include allocating an appropriate amount of time to job hunting, finding ways to compensate for the lack of a network of well-placed contacts, using the job search methods most likely to be successful, being available for employer contact, and mastering the "walk, talk, and dress" of an employable person.
• Being patient. Overcoming the desire for immediate gratification, learning to accept incremental progress, handling disappointments appropriately, and keeping things in perspective are all parts of a healthy approach to work.
• Communicating effectively with the employer. Clients must learn how to present facts about the past and any disabilities to employers in a positive framework as well as how to gauge a prospective employer's willingness to work with a person in recovery. Addressing gaps in employment that have resulted from being fired from previous jobs or from being incarcerated is also important. This provides an opportunity to frame the treatment experience as a transition, focusing on the client's views for the future--but without dishonesty or denial. It can be beneficial for clients to talk with their employer about treatment and the choices they are currently making, placing their past choices firmly in the past. For some, being employed will provide incontrovertible evidence of the changes they have made. Counselors should caution clients to be selective in self-disclosure. Some employers can be very judgmental. Figure 3-2 depicts a model for an appropriate dialog that the client could practice through role-playing exercises with the clinician or therapy group members (recognizing that interviews in the real world are not likely to be so straightforward).

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.

Coping With Medical and Psychological Challenges

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]).

Coping With Environmental Challenges

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.

Housing and other basic needs

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).

Transportation

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.

Child care

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.

Coping With Legal Challenges

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).

Developing Social and Life Skills

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

• Communication skills, including appropriate and inappropriate responses to supervisors and coworkers
• Cleanliness, personal hygiene, and appropriate dress
• Management of personal finances
• Healthy eating habits
• Management of time, including getting enough sleep and being at work on time, managing competing obligations to family, work, and treatment (especially regular attendance at AA or NA meetings)
• Coping with crises that can trigger relapse
• Responding to invitations to "happy hour" or office parties
• Recognizing and respecting unwritten "rules" of the work culture, such as not bringing friends or children to work

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.

Planning for a Career and Resilience

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.

Preventing Relapse

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,

• Losing a job may trigger relapse.
• Jobs that do not provide sufficient structure can lead to boredom--a common trigger for use. Time away from work, formerly structured by alcohol or drug-related activities, will also need to be structured.
• Some workplaces offer frequent invitations to socialize where alcohol or even, in some environments, drugs are consumed. The client may need help maintaining a substance-free lifestyle without becoming an outcast.
• Job finding will have a systemic impact on the family, especially when the "screw up" suddenly becomes the breadwinner and wants a major or leading role in family decisions. To help other family members cope with such changes, family therapy should be considered at an early stage of vocational counseling (if it is not already a component of substance abuse treatment). Family members are more likely to support the client's vocational goals if they understand the issues and feel included in the process.

Developing the Treatment Plan

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

• Why work is done ("Why do I work?")
• The degree of importance placed on work ("How much does work really matter to me?")
• The client's life goals ("Where will it get me?")

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:

• Multidisciplinary participation
• Timing of vocational training, rehabilitation, and employment services delivery in relation to substance abuse treatment service delivery
• Tailoring treatment plans for the different stages of the substance abuse disorder and recovery, as well as plans related to recovery from use of, or dependence on, different substances
• Consideration of external factors in treatment planning
• Maintenance of employment gains and relapse prevention

Multidisciplinary Participation

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:

• VR counselor
• State or local employment service representative
• Education specialist or special education person for school or transition programming
• Nurse, physician, mental health clinician, or psychiatrist (for coexisting disorders)
• Adult education consultant
• Vocational trainer or work adjustment trainer
• Social worker
• Disability specialist
• Job placement specialist

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.

Timing of Vocational Training, Rehabilitation, and Employment Services

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

• The client's stage of recovery
• The client's stability
• Any external legal mandates
• Impending termination of public assistance benefits (for either the client or dependent children)
• Limits on duration of treatment
• The client's goals
• The identification of therapeutic goals that may be addressed through the vocational domain (such as the need to learn to structure time or respond appropriately to authority)
• Client recovery needs that can only be met through gainful employment (such as earning funds necessary to move from a house where people are using substances)

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.

Tailoring Treatment Plans

Stages of substance abuse and recovery

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).

Substance abuse

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.

Substance dependency

Short-term dependency

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.

Chronic dependency

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 in early recovery

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.

Mid-range abstinence (3 months to 2 years)

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.

Recovery from different substances

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.

Alcohol

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).

Amphetamines

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.

Cocaine

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).

Heroin

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.

Prescription drugs and narcotics

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.

Polysubstance abuse

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.

Consideration of External Factors in Treatment Planning

Welfare-to-work issues

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.

Child custody issues

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.

Lack of finances

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.

Discrimination in the labor market

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.

Maintenance of Vocational/Employment Gains and Relapse Prevention

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

• Active drinking or substance use by other employees
• Pay day (i.e., money management)
• Working a rotating, "graveyard," or night shift
• Seasonal work
• Lack of supervision
• Working excessive overtime
• Dealers near the job
• Access to marketable goods or petty cash
• Receiving cash tips
• Transportation issues
• Too much free time on the job
• Working two jobs
• Too much pressure on the job
• Job dissatisfaction or boredom
• Required business meetings, dinners, and parties where drinking alcohol is expected
• The other issues and crises that cannot be addressed because of time limits now that the person is employed

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.

Case Studies

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.

Case Study 1: "Kay"

Background

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.

Counseling strategy

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.

Case Study 2: "Young-Hwa"

Background

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.

Counseling strategy

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.

Case Study 3: "Julia"

Background

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.

Counseling strategy

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.

Chapter 4 -- Integrating Onsite Vocational Services

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

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

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

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

Planning an Integrated Program

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

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

Choosing a Program Model

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

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

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

The vocational needs of the majority of the program's clients, as well as other client-related factors such as their values and the realities they face in finding employment, are other key factors to consider in deciding the parameters of the onsite services offered. The important issue of cultural competence is discussed more fully in Chapter 5. Suffice it to say here that programs must ensure that staff members have a thorough knowledge of the diverse populations represented in their treatment program and the particular challenges that different groups face in securing and maintaining work. It is also important to understand various cultural attitudes toward work.

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