The Effectiveness of Vocational Services for Substance Users in Treatment

Employment appears frequently in the literature as an outcome criterion for substance users in treatment, and most clinicians subscribe to the belief that work plays an important role in recovery from addiction. Despite the importance attached to employment, the major standard treatment modalities have not been shown as effective in increasing client employment after treatment. The article presents a critical review and synthesis of three decades of research on the effectiveness of specialized vocational intervention for addiction treatment clients.     

Introduction: Program Quality in Substance Dependency Treatment

The purpose of this volume of articles is to present the current “state of the art” in conceptualization and research concerning program quality in substance dependency treatment, which includes the following topics: How should treatment program outcomes be defined? How can research-based quality treatment be disseminated to the field? What is the role of innovative accreditation models in promoting treatment quality? How can the conceptualization and measurement of the treatment process be improved? What more can we learn about elements of program/treatment quality from the research base? These issues are explored theoretically and empirically in 20 original articles.     

The Value of Vocational Rehabilitation in Substance User Treatment: A Cost-Effectiveness Framework

Vocational rehabilitation (VR) programs within addiction treatment traditionally consider employment as the desired outcome. This singular focus ignores other benefits, such as reduced substance use. A framework for evaluating the cost-effectiveness of VR within addiction treatment is presented and illustrated with data from the Alcohol and Drug Services Study (ADSS, 1996–1999). VR was associated with a 2.5% increase in probability of abstinence at an $883 increase in cost per admission. Thus, the estimated cost-effectiveness of VR in promoting abstinence is $35,000 per additional abstinent client ($883/0.025), indicating that VR is a cost-effective contributor to other goals of addiction treatment.     

The Impact of Employment Counseling on Substance User Treatment Participation and Outcomes

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.     

Learning from Disappointing Outcomes: An Evaluation of Prevocational Interventions for Methadone Maintenance Patients

To increase rates of employment and improve overall rehabilitation in methadone maintenance treatment, three prevocational trainings, Vocational Problem Solving, Job Seekers Workshop, and the two combined, were evaluated as adjunctive services. Between March 1995 and April 1998, subjects in treatment were interviewed at baseline, randomly assigned to one of the trainings, and followed up at 6 and 12 months postbaseline. None of the three models produced significantly greater employment or better overall rehabilitation. Experience from the study suggests that closer integration of prevocational training with treatment, individualizing efforts to meet training needs, and providing support during job-finding and early job-holding might improve program effectiveness.     

Working It Out: Development and Testing of a Multimedia,Vocational Education Program

A self-administered, CD-ROM-based, interactive multimedia psychoeducational intervention, called Working It Out, was developed to improve employment functioning for clients in substance dependency treatment. The computer-based program's effectiveness was tested in comparison with printed material. During 2000–2001 194 clients with employment concerns in six treatment programs were randomly assigned to a CD-ROM or print material condition and evaluated at baseline and 6 months later. A main effect for improvement was observed on employment indices, but there was no condition-by-time interaction. Results suggest that clients are willing and able to use vocational rehabilitation information presented in any format, although the CD-ROM-based program received significantly better satisfaction ratings than did the print material.     

Homelessness and Substance Misuse: A Tale of Two Cities

In this article we examine the relationship between alcohol and drug misuse among the literally homeless (those living out of doors and in emergency shelters) in Hartford, Connecticut and Providence, Rhode Island, two northeastern U.S. cities of comparable size. We worked with homeless advocacy organizations in both cities, using a point-in-time census (N = 1058) and random sample (N = 66) in Hartford, and a sampling of clients (N = 82) of six shelters serving residents of Providence (N = 82). We found substance misuse relevant in 47.2% of the homeless in Hartford and in 45.1% of the homeless in Providence. We conclude that there is a great need for substance treatment services inside shelters, soup kitchens, and day centers so that homeless individuals have an opportunity to engage in treatment within their own milieu.     

Introduction: New Directions for Vocational Rehabilitation in Substance User Treatment: Rebuilding Damaged Lives

If an important objective of addiction treatment is to increase patient employment, then it makes sense to locate vocational assistance within treatment programs. The purpose of this special issue is to present new research on the improvement of vocational services in addiction treatment. The volume begins with a critical review and synthesis of three decades of research on the effectiveness of specialized vocational services for addiction treatment patients. The new evaluation studies in this volume break down into those conducted in methadone treatment vs. other types of treatment settings. The volume concludes with a framework for evaluating the cost-effectiveness of vocational rehabilitation within addiction treatment. Critical issues that need resolution in this field are identified.     

Substance Use Among Women Veterans: Epidemiology to Evidence-Based Treatment

An increasing percentage of women are U.S. Military Veterans. We review the substance misuse rates and comorbidities and the risk factors for and consequences of substance use among women Veterans. Women Veterans may have higher rates of substance misuse and comorbid psychiatric and medical disorders than male Veterans and women who are not Veterans. Studies support the AUDIT-C as a scaled marker of alcohol-related risk among female Veterans, but validated drug screening instruments are needed. We discuss evidence-based approaches in terms of treating women Veterans’ substance misuse in primary and specialty care settings, along with knowledge gaps and potential research priorities to improve care in this special population.     

Paths to Recovery from Substance Misuse: Change of Lifestyle and the Role of Treatment

Controlled outcome studies have, on the whole, failed to demonstrate more than rather weak and short-lived effects of substance misuser treatment. There is, at the same time, growing evidence that people often recover from substance misuse problems without the help of formal treatment. This state of affairs has, not least in times of economic recession, been taken as an argument for cutting fundings of treatment facilities and other forms of formal help. This article questions that present knowledge necessarily justifies such conclusions. We do know that even severe misusers are sometimes capable of changing their way of life. We do not, however, know very much about the circumstances and situations—planned or not and designated as “treatment” or something else—that contribute to such change processes. A closer integration of two research areas—outcome research and research on “spontaneous recovery”—is proposed as a way of learning more about the possible interplay between “real life” events, various formal interventions, and change of life style.     

Improving the Quality of Substance Dependency Treatment with Pharmacotherapy

This article provides an overview of current pharmacological treatments for alcohol, opioid, cocaine, and nicotine use disorders. Guidelines for a “patient-treatment” matching framework to physicians working with various “substance-abusing” patients are presented, as well as recommendations regarding when to initiate and discontinue pharmacotherapy. Standard and newer pharmacological treatments for substance dependence are reviewed, as well as therapies that may be especially useful when treating the patient with comorbid substance dependency and psychiatric disorders. To maximize the therapeutic benefits of substance dependency treatment, patients should be individually assessed and provided adjunctive medications as clinically indicated. Specific areas for future laboratory and/or clinical research are recommended.     

Computer-Based Typing and Keypad Skills Training Outcomes of Unemployed Injection Drug Users in a Therapeutic Workplace

The Therapeutic Workplace is an employment-based treatment for chronic drug misuse and unemployment. As a part of this intervention, participants are taught skills to perform data entry jobs and are paid based on attendance and productivity. In this study, computerized typing and keypad training programs were evaluated in recently detoxified HIV-positive injection drug users (n = 32) enrolled in the Therapeutic Workplace treatment program between October 2000 and September 2001. Results show that trainees can be taught fundamental typing and keypad skills in an average of 51.48 and 1.73 h of training, respectively, administered over 17.91 and 12.59 weeks, respectively. Overall, the results demonstrate that adults with long histories of chronic unemployment and drug addiction can reliably acquire typing and keypad skills and do so over relatively short periods of time.     

Pathological Gambling and Substance Misuse: A Review of the Literature

This paper reviews research conducted on the link between pathological gambling and substance misuse. We first examine the phenomenon of “pathological gambling,” including similarities between pathological gambling and substance misuse, instruments used to measure pathological gambling, and the prevalence of pathological gambling in the United States and internationally. We then examine research on substance misuse among pathological gamblers, pathological gambling among substance misusers, and the treatment of the pathological gambler-substance misuser. We conclude with a discussion of future research needs.     

Chapter 10. Perspectives on Treatment,Alliance and Narratives Concerning Substance Use-Related Dependency

This article considers different perspectives on the treatment of substance use-related dependency, focusing on the importance of a therapeutic relationship, working alliance, counseling, and the use of narrative methods. The article also discusses some unresolved critical issues concerning the possibilities and limitations of acquiring necessary knowledge about substance use-related dependency when using narrative research methods. The main conclusion is that the therapeutic relationship between the therapist and the client is of crucial importance for a positive outcome of treatment and that narrative methods provide a detailed empirical database for analyses of substance use-related dependency.     

Reading Ability in Patients in Substance Misuse Treatment Centers

Adult inpatients in state-supported (public) and private substance misuse treatment settings were tested for reading ability. Patient education materials and consent forms were assessed for readability levels. Public patients' mean reading levels were significantly lower than those of private patients, and were 4 to 5 years below the level needed to read and understand standard treatment materials. More than half of the public and almost one-third of the private patients tested were reading below a 9th grade level. Standard treatment materials were written on 11th to 12th grade reading levels; admission and consent forms were written on 12th to 18th grade levels. Patients in substance misuse settings should be tested for literacy levels upon admission and provided with materials commensurate with their reading ability     

A New Work Placement Model for Unemployed Methadone Maintenance Patients

Traditionally, methadone-maintained patients have made only limited progress in vocational rehabilitation programs, largely because they encounter multiple individual-level barriers to their employment. The Customized Employment Supports (CES) model is designed to help patients overcome these employment barriers and attain paid work as soon as possible. To facilitate this transition, the model assigns CES counselors small caseloads so that, using intensive interventions, they can engage patients in a working alliance and enhance patients’ self-efficacy. Methods used to help patients increase their self-efficacy are derived from social psychological literature and include role modeling, persuasion, and minimizing emotional arousal. Because the transition to competitive work is a major change, many patients initially take smaller steps such as entering training programs and accepting informal employment. The CES model is being evaluated in a randomized clinical trial.     

Contrasting the Views of Substance Misuse and Mental Health Treatment Providers on Treating the Dually Diagnosed

Service delivery to dually diagnosed individuals is often impeded by the divergent treatment approaches used by mental health and substance misuse treatment providers. This paper describes findings from a survey of mental health and substance misuse treatment program administrators and staff in Los Angeles County (n=275) on their views about treating the dually diagnosed. All groups agreed about the challenges of treating dually diagnosed patients; however, there were differences both between and within providers in the two treatment systems on other aspects of treatment. The findings are discussed within the context of clinical and programmatic efforts to improve service delivery to the dually diagnosed.     

Substance Dependency Treatment for Adolescents: Practice and Research

This paper reviews the more common treatment approaches that address adolescent substance abuse and the spectrum of problems which often attend involvement with drugs. The most common outpatient treatment approaches for adolescents are 12-step based programs and family-based therapies which may be used separately or in conjunction with each other. The therapeutic community is a residential approach, characterized by the use of the peer community itself to facilitate social and psychological change in individuals. Both outpatient and residential modalities have demonstrated effectiveness in working with adolescents. Ideally, the type of intervention will depend upon the young person's needs, in particular the extent and effects of his/her drug use, as well as the level of other problems. Overall, treatment must address a range of concerns of special relevance to adolescents because of their age and dependency status; for example, developmental stage, cultural issues, and gender issues.     

SUBSTANCE USER TREATMENT PROGRAM QUALITY: SELECTED TOPICS

This panel explores the “state of the art” in conceptualization and research pertinent to program quality in substance user treatment. First, seven critical questions for program quality are identified and discussed. Second, a recent national evaluation of treatment examines the implications of long-term patient outcomes for treatment quality. Third, a large number of clinical trials of behavioral and pharmacological treatments for cocaine dependence were conducted during the 1990s; this research is synthesized and interpreted. Fourth, progress is reported in improving the quality of treatment through standardized criteria for patient placement matching.

Truth seems to come with its final word; and the final word gives birth to its next.

Rabindranath Tagore, Stray Birds     

Vocational Rehabilitation of Participants with Severe Substance Use Disorders in a VA Veterans Industries Program

There are approximately 100 Veterans Industries work therapy programs in the Veterans Health Administration (VHA) throughout the U.S. The majority of participants are veterans with severe substance use disorders and their length of stay ranges from 3 to 12 months. This study examines the Veterans Industries work therapy model at one site where veterans are referred from an addictions partial hospitalization treatment program. The study period was from 1996–97 and includes 80 patients. The characteristics of the participants are described. Barriers to employment are identified including unemployment rates, homelessness, drug of choice, age, and disability status. Outcome rates are reported including employment, abstinence, and housing support.