Employment enhances the outcomes of substance dependency treatment. Although unemployed methadone treatment patients frequently state they are interested in a job, many fail to participate in vocational services when available. Unless patients become engaged, vocational services do not have an opportunity to be effective.
The purpose of this study is to examine a broad array of variables that may be associated with differential engagement in vocational services among methadone patients, including the availability of a special vocational program that emphasized outreach to ambivalent patients. The ?ndings are intended to inform recommendations to improve engagement of methadone patients in vocational services.
The setting was two methadone maintenance clinics in Manhattan in New York City.
The study sample consisted of 211 patients of the two clinics. The criteria for inclusion were unemployed or underemployed at study entry, stabilized on methadone dose, negative urine toxicology for both opiates and cocaine for the patient‚ last four weekly urine tests, and no physical or mental condition or caretaker responsibilities that would absolutely preclude employment Nearly three of the study participants were male, and a majority (75%) was non-white, with an average age of 45 years.
Participants were interviewed at study entry using a computer-assisted personal interview constructed with the Questionnaire Development System. In addition to the interview data, a vocational activities log that included information on vocational services provided and patients vocational outcomes during the period of service was recorded by the vocational counselors. Chi-square tests, t-tests, and logistic regression analyses were used for bivariate analyses. Multiple logistic regression was used for multivariate analysis.
The experimental vocational program, Customized Employment Supports (CES), offered more individualized counseling than traditional services. Patients were expected to participate in up to three sessions per week at the start, which was made possible by limiting CES counselors caseloads to 15 active cases. The emphasis was on establishing a therapeutic alliance, overcoming both vocational and non-vocational barriers to employment, and enhancing patients' self-efficacy and motivation to work.
The control group received the clinics standard vocational programs. In both clinics this consisted of individual and group vocational counseling depending on the needs and desires of the patients. These activities included initial assessment, helping with resume preparation, and workshops on topics such as job readiness and interviewing skills.
Thirty percent of the sample was de?ned as engaged, that is, had 5 or more in-person sessions with their counselors during the ?rst 6 months after study induction. Those who became engaged with vocational services were more likely to be non-Hispanic, with high school education or beyond, had ever injected drugs, had ever used crack, experienced a drug overdose, had reported emotional chronic problems and scored relatively high on depression and psychological distress, had ever attended Anonymous groups, had previously enrolled in
methadone two or more times, had been exposed to hepatitis B or C, and had positive attitudes toward employment. Relative to the intervention more engagement was found among CES than standard vocational program participants. The CES intervention was also the strongest predictor of engagement in the multivariate analysis.
Methadone treatment is a challenging environment for vocational counseling. The CES model suggests a new approach to increasing active participation of unemployed patients in vocational services, without which no service can be effective. In addition, the acceptance rate of the model was high among patients.