Work adjustment training

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

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

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

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

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

Activities of daily living

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

Formal vocational services

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

Setting goals and developing a personal plan

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

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

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

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

Education about work and job seeking

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

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

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

Vocational assessment

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

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

Incorporating vocational issues into group counseling

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

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

Detoxification

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

Methadone maintenance programs

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

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

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

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

Halfway houses

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

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