The utilization of vocational rehabilitation services in ... - IOS Press

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Journal of Vocational Rehabilitation 29 (2008) 71–75 IOS Press

The utilization of vocational rehabilitation services in substance abuse treatment facilities in the U.S. Steven L. West Department of Rehabilitation Counseling, Virginia Commonwealth University, P. O. Box 980330, Richmond, VA 23298-0330, USA Tel.: +1 804 827 0921; Fax: +1 804 828 1321; E-mail: [email protected]

Abstract. Unemployment and underemployment are major issues for persons with substance abuse and addiction concerns. The failure to address these issues can have substantial negative effects on the ability of such individuals to attain and maintain sobriety. Preliminary research indicates that the provision of vocational rehabilitation (VR) services can aid substance abusers not only in attaining competitive employment, but also in maintaining a substance free lifestyle. Despite this fact, early indications suggest that few substance abuse treatment facilities provide VR to clients. The present study assessed the use of VR services and the training and VR related credentials of clinical staff members in a nationally representative sample of 159 substance abuse treatment facilities. Results indicate that few of these substance abuse treatment facilities provide VR to their clients, have staff members equipped to provide such services, or actively refer clients to outside VR agencies. Given the extreme need for VR by persons with substance abuse concerns, these are issues that must be addressed by both substance abuse treatment and VR service providers. Keywords: Vocational rehabilitation substance abuse substance abuse treatment employment

1. Introduction One of the strongest and most consistent predictors of substance abuse treatment success and sobriety maintenance post-treatment is gainful employment [3,7,14, 17,19,28]. Research over the last several decades has shown that when individuals are gainfully employed they are more likely to engage in treatment, to complete a treatment regimen, and to remain substance free after treatment completion [3,7,14,17,19,28]. Employment has also been found to correlate with less severe rates of substance use before treatment, shorter lifetime rates of use and addiction, and lower rates of co-occurring conditions and outcomes typically associated with use [15, 17]. Conversely, unemployment and underemployment have been found to correlate with more frequent and heavy use, longer histories of use, and a variety of other concerns. Such associations are evident among non-clinical community samples as well, where gainful

employment is linked with increased abstinence rates, lower rates of consumption among users, and lower levels of use related negative outcomes [17,31]. These associations tend to hold true in most instances except in cases of jobs with high stress and/or volumes and for those individuals who experience economic stress despite employment [7,17]. Competitive employment is also thought to aid in the recovery process by facilitating increases in self-worth and by aiding in the building of drug-free peer relations [1,4,20]. Not surprisingly, unemployment is common for individuals with alcohol and other substance use problems. National studies have long noted the rate of unemployment among persons with alcoholism and other drug addiction in community settings to range from 40% to 80% with little variation [2,18]. Such rates are many times greater than the national unemployment rates. Unemployment for persons in substance abuse treatment is likewise extreme. For example, un-

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employment among persons in treatment, regardless of drug of choice and across all forms of treatment, has recently been reported at 77% for females and 64% for males, rates substantially greater than the national average [26]. Even when illegal activities resulting in income are included in the equation, the unemployment rate among persons with substance use concerns is still notable [17]. Substance abuse is also an independent and significant predictor of unemployment and underemployment when controlling for such factors as level of education, age, gender, and ethnicity [17]. Substance abuse treatment is itself linked with greater rates of employment even when treatment protocols do not actively include vocational rehabilitation (VR) elements. Although gains in employment are greater for those employed or having work histories pretreatment, successfully completing a substance abuse treatment program increases the likelihood of gainful employment for a variety of client populations [10,13, 21,22,24]. Such gains tend to be modest, but have none-the-less been noted by a number of researchers over the last thirty years. Several small scale programs and clinical trials of vocational service programs for persons in substance abuse treatment have also been detailed in the literature and have had limited yet positive findings [11,12]. Professionals engaged in substance abuse treatment also report that employment counseling strategies are one of the most pressing needs of their clients [8]. Such associations would seem to suggest a strong need for vocational rehabilitation services for clients in substance abuse treatment. Recent research, however, indicates the provision of vocational services by substance abuse treatment providers is an infrequent and limited activity [6,16,29,30]. For example, Olmstead and Sinclair [16] studied the prevalence of employment counseling in substance abuse treatment facilities nationwide. Using data from the 2000 National Survey of Substance Abuse Treatment Services (NSSATS), a dataset collected annually by the federal government regarding typical treatment practices, they found that only about 31% of treatment facilities in the U.S. offer employment counseling as a standard component of treatment. A study by West [29,30] examining the services provided by substance abuse counselors in Texas (n = 61) found similarly low rates of vocational service provision. Responding counselors in this study were asked about their use of a host of vocational services as well as their training and professional credentials related to vocational rehabilitation. As was the case in the Olm-

stead and Sinclair [16] study, the use of vocational rehabilitation was limited and such counselors were not generally equipped to provide VR services. Additionally, these substance abuse counselors were not likely refer clients to VR despite self-reporting a great need for vocational rehabilitation by their clients. The majority (n = 35, 57%) of the counselors did not conduct vocational assessments, nearly 70% did not provide job seeking skills training or vocational counseling, and over 83% did not provide job placement services for clients. Further, less than 5% (n = 3) reported that they referred clients to VR services despite the fact that most (75%) indicated the need for such services by their clients was great. Only nine (15%) reported having any training in vocational service provision, and none of the respondents reported having credentials typically associated with VR. Together, these two studies paint a discouraging picture of the utilization of vocational rehabilitation services in substance abuse treatment. However, the state of the field with regard to VR services cannot be fully understood from these studies. Although the information provided by Olmstead and Sinclair [16] from the NSSATS dataset provides a generic estimate of employment counseling, it does not provide information on the type or nature of the employment counseling provided and does not address VR services beyond general counseling. The NSSATS data is also limited by its reliance on the assessment of services that are offered as a standard component of treatment; that is, services that are routinely provided to all clients. VR services offered by counselors on an as-needed basis, or services other than basic employment counseling may exist below the radar of the NSSATS data. The actual rate of use of VR services in substance abuse treatment centers cannot be fully discerned from this data. The information provided by West [29,30] is more comprehensive in terms of its assessment of a wider array of VR services, but is limited by a reliance on a small sample taken from only one state. The field is thus lacking a comprehensive assessment of the provision of vocational rehabilitation services by substance abuse treatment providers in the U.S. The present research was undertaken to fill this deficit by assessing the use of VR and the training and certification of substance abuse counselors with regard to the provision of VR services in a nationally representative sample. To meet this objective, a mail survey was sent to a stratified random sample of substance abuse treatment facilities across the U.S. Respondents were asked about the use of a wide variety of VR services includ-


ing vocational assessment, counseling, and placement, the training, licensure, and certification of their staff in vocational service areas, and the tendency to refer clients to VR services. 2. Methods Data for this study were collected via a mail survey sent to a nationally representative stratified random sample of substance abuse treatment facilities in each of the 50 states and the District of Columbia. Stratification was based on the 2000 U.S. Census and was generated on the region (i.e., midwest, northeast, south, and west) and states of those regions to ensure representation within the sampling frame of facilities from all states regardless of total population or number of treatment providers. Using this technique, 525 substance abuse treatment facilities were selected from the 2003 National Directory of Drug and Alcohol Abuse Treatment Programs [25] which lists the address and contact information for over 11,000 treatment facilities from across the nation. Each facility was sent an independently developed survey regarding services offered, qualifications and profiles of those staff members providing direct clinical care to clients, and the number of clients seen during the twelve months prior to the survey. The survey procedure followed the Dillman [5] method for data collection wherein each respondent received an advance notice letter, followed at seven days by a survey packet. This was followed at ten days by a follow-up reminder thanking respondents and encouraging nonresponders to complete the survey. A total of 159 surveys were received for response rate of slightly more than 30%. The resulting sample included treatment facilities from each of the four major regions of the nation (midwest = 37, northeast = 42, south = 44, west = 36) and included treatment centers in 40 states. Outpatient services were the most common form of treatment offered (54%), and services were overwhelmingly provided in privately held facilities (79%). Together, these substance abuse treatment providers employed 3,190 clinicians who served over 55,000 clients (all new admits) during the twelve months before data collection. Due to the relatively low response rate, comparisons between responding and nonresponding facilities on known variables were made. Responding facilities did not differ from nonresponding centers on census region location (X 2 = 1.47, ns), facility type (i.e., outpatient or inpatient; X 2 = 2.10, ns), or agency type (i.e., public or private entity; X 2 = 2.31, ns).

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3. Results 3.1. The provision of VR services The vast majority of the responding facilities reported that they did not conduct vocational evaluations or assessments of their clients (n = 116, 73%). Similarly, the majority of respondents (n = 116, 73%) indicated that their facilities did not provide vocational counseling as a standard component of treatment services. Job seeking skills training was offered by only 32% of the respondents (n = 51), and job placement services were offered by even fewer facilities (n = 23; 15%). When asked if they refer clients to VR services, only nine (6%) of the facilities indicated that they made such referrals. 3.2. Staff training in VR services As noted above, direct client care was provided by a total of 3,190 counselors in these 159 facilities. Respondents were asked to detail the number of counselors on staff who had any training on vocational rehabilitation topics, and the number holding licenses or certifications associated with VR services. A total of 324 (10%) counselors were reported to have had some training in VR service provision, although no information was available on the nature of this training. When considering those certifications and licenses associated with vocational rehabilitation services, few of the facilities reported having staff with relevant credentials. Only 4% (n = 6) of responding facilities reported having a clinician on staff who held the certified rehabilitation counselor (CRC) designation. Of those facilities having a CRC credentialed counselor, five had one CRC on staff and one facility employed two CRC’s. Three (2%) facilities reported having a certified vocational evaluator (CVE) on staff; each of these employed one individual with this credential. None of the respondents reported having a certified work adjustment specialist (CWA) or a certified insurance rehabilitation specialist (CIRS) on staff. When considering the certified case manager (CCM) credential, a total of 9 facilities (6%) had staff members with this credential; six of the responding facilities had one CCM, two facilities had three CCM’s, and one had six CCM’s on staff. The most common of all of the vocational related credentials was the licensed vocational nurse (LVN). Fourteen of the responding facilities (9%) employed LVN’s on their staff; six facilities had one LVN each, three employed two each, two had four each, and three facilities had five LVN’s on staff.

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4. Discussion A decade ago, Platt [17] concluded his comprehensive review of vocational rehabilitation services for substance abusers by emphasizing the need for such efforts and by chastising the field for failing to provide VR services on a regular basis. Both of these views were actually repeats of similar calls for action going back at least two decades before [9,23,27]. More recent efforts have also called on the field to more actively link substance abuse treatment to vocational rehabilitation services [14]. The current research would suggest that such calls have gone unheard or at least unheeded by substance abuse treatment providers. Given the extreme need for vocational rehabilitation services and the negative implications for clients in substance abuse treatment if such services are not received, this is an issue that needs immediate attention. This work is thus a repeat of these earlier calls to action. It is unfortunate that little to no real progress has been made in the intervening years since these earlier studies. As awareness is generally considered an important first step in addressing a problem, perhaps the current study will aid in raising an appreciation and facilitating further discussion and eventual action in the area. Substance abuse treatment could be an optimal and perhaps crucial time to address vocational rehabilitation issues. An individual’s entry in to treatment services signals a willingness to attempt change, an openness to the assistance of others, and a desire to better oneself. As gainful employment is a crucial element known to facilitate reductions in use and to aid in sobriety maintenance, it seems evident that assisting individuals with vocational exploration, training, and placement should be an integral component of the process. Vocational rehabilitation as a component of substance abuse treatment or as a referral to be completed on an adjunct or follow-up basis could substantially aid the recovery process. Unfortunately, the current study indicates that such services are not the norm. In this respect, a prime opportunity to intervene appears to be lost. Given prior research on the topic, it is not wholly surprising that the substance abuse treatment providers in this sample do not engage in or are particularly equipped to provide vocational rehabilitation services. The fact that these findings are not unexpected, however, does not diminish the negative implications of and the need to address these shortcomings. More discouraging than the failure of these substance abuse treatment facilities to provide vocational rehabilitation services is their failure to actively and routinely refer

clients to appropriate vocational service providers. One may not realistically expect substance abuse treatment counselors to provide a specialized service such as VR that is outside their primary domain of practice. Vocational rehabilitation services are likely to be outside the general domain of substance abuse treatment providers, and may also be a practice that exceeds available time and monetary constraints. Providing in-service training for staff or utilizing time for what may be viewed as a tertiary component to core services could be viewed as impractical activities by such providers. As is the case in many other social services, substance abuse treatment providers are frequently overburdened by large client loads, low operating budgets, and a variety of other demands. Indeed, research has shown that substance abuse treatment providers are sometimes hesitant to provide adjunct services such as VR due to budgetary and time constraints [19]. However, it is realistic to expect such counselors and the facilities in which they work to provide referrals to appropriate resources. The failure of these substance abuse treatment facilities to make such referrals despite the need for vocational rehabilitation services among substance abusing caseloads is both perplexing and troubling. Establishing a contact for referral to the existing state/federal VR system should not be time consuming; giving a client a referral to such resources would likewise take little time and would be cost-free to the referring providers. Unfortunately, these data do not provide insight in to why this failure to refer exists. The failure to provide or refer clients to VR could be a reflection of a lack of awareness of treatment providers as to the need and benefits of such services. It would behoove the VR field in general and those involved in the state/federal VR system to educate substance abuse treatment providers in the importance and availability of VR services for their clients. Additional research is needed to both clarify why VR services are not being utilized in substance abuse settings and to facilitate methods to incorporate such activities into the substance abuse arena. Regardless of the precise reasons for these issues, the field needs to begin to remediate these concerns. Both vocational rehabilitation and substance abuse treatment providers need to become more familiar with the vocational service needs of persons with substance abuse concerns, and action needs to be taken to ensure that such individuals receive the services they so clearly need. The disconnect between these two service domains needs to be remedied so that effective and appropriate referral networks are established. Advocating for vocational rehabilitation services for this population could be an important first step in this process.


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