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PubMed2005

Beyond the chalkboard: the interacting domains in undergraduate psychiatric teaching.

OBJECTIVE: To identify and describe interacting domains that are present during undergraduate psychiatric teaching and impress on educators the roles of these domains. CONCLUSIONS: Undergraduate psychiatric teaching is an essential part of general family physicians' training and practice. Undergraduate students' exposure to psychiatry might be inadequate. Curricular goals, teaching and evaluation of students need to be aligned. Research and information technology can play a bigger role in teaching. Validation of patients, students and teachers during the teaching process is important, but not always emphasized. Educators should be aware of society's unwritten expectations, judgements and opinions of mental illness sufferers. Identifying and facilitating the various interacting domains during psychiatric teaching may contribute to better education in psychiatry, better retention of knowledge for students and an improved recruitment of students to a psychiatric career.

Attitude of Health Personnel↗
PubMed2004

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.

Humans↗
PubMed2004

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.

Employment↗
PubMed2004

Combining stepped-care approaches with behavioral reinforcement to motivate employment in opioid-dependent outpatients.

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, 1995). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients--a "stepped care" service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care--MSC; Brooner and Kidorf (2002) was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. 1999), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August--September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.

Adult↗
PubMed2004

Special section: the most critical unresolved issues associated with contemporary vocational rehabilitation for substance users. The critical relationship between employment services and patient motivation.

Several interventions and service delivery models now exist to help unemployed people in treatment for substance use disorder seek gainful employment (Platt, 1995). Some of these interventions can be conveniently offered within substance user treatment settings. One of the best known examples of these interventions is job seeking skills training and support services that help patients develop resumes, complete employment applications, learn effective networking strategies, and develop and practice effective responses to common issues and questions raised during employment interviews. A wide range of more comprehensive off-site employment programs that provide intensive vocational training and rehabilitation also exist in many communities. The growing availability of on-site services in substance user treatment programs also creates the

Employment↗
PubMed2004

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.

Employment↗
PubMed2004

Better definition of vocational services is critical within substance user treatment programs.

Vocational rehabilitation in substance user treatment programs is often poorly defined; programs rarely provide adequate descriptions of the vocational services they offer. There is no standardization in the content of vocational counseling, in the format of its delivery, or in the qualifications of staff that deliver it. Thus, the type, intensity, and quality of vocational services can vary widely among programs, as well as over time within a given program due to vocational staff turnover. However, current demands for greater accountability in social services pose a challenge to this state of affairs. There is no evidence that vocational services as currently delivered in treatment programs are either effective or even reasonably efficient. Note that "programs are increasingly called on to justify their existence, their expenditure of funds and their achievement of objectives. Behind the call for accountability is an awareness of the gap between almost unlimited social need and limited resources" (Weiss, 2004). It is difficult to achieve accountability for ill-defined and variable vocational services.

Counseling↗
PubMed2004

Efficacy of the customized employment supports (CES) model of vocational rehabilitation for unemployed methadone patients: preliminary results.

This article presents initial efficacy data for an innovative vocational rehabilitation model designed for methadone-maintained patients--the Customized Employment Supports (CES) model. In this model, a CES counselor works intensively with a small caseload of patients in order to overcome the vocational as well as nonvocational barriers that hinder their employment, with the goal of attaining rapid placement in competitive employment. The CES model was implemented at two Manhattan methadone treatment programs as part of a randomized clinical trial comparing the model's employment outcomes with those of standard vocational counseling. The study tested the hypothesis that patients in the experimental group will have better employment outcomes than those in the comparison group. The data were collected from May 2001 through September 2003. The sample consisted of the first 121 patients who had completed their 6-month follow-up interviews. The preliminary results supported the hypothesis for two indices of paid employment, i.e., the CES group was more likely to obtain both competitive employment and informal paid employment. The clinical trial is continuing.

Adult↗
PubMed2004

Computer-based typing and keypad skills raining 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 1.73h 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.

Adult↗
PubMed2004

Effectiveness of vocational problem-solving skills on motivation and job-seeking action steps.

Most research on employment interventions focuses on job acquisition as the sole outcome measure, despite the fact that there are many intermediate steps to obtaining work. This article examines the impact of a vocational problem solving skills (VPSS) intervention to increase motivation and action step activities that lead to employment. Over a 1-year period between 1995 and 1996, a sample of 109 methadone maintained treatment clients were randomly assigned to either a 10-session vocational problem solving intervention (N= 62) or a time and attention control condition (N=47). The Addiction Severity Index (ASI) and a Vocational Motivational Assessment Checklist (VMAC) were administered upon enrollment in the study and at 6 months postbaseline. The VMAC was completed on a biweekly basis over the 12-week intervention period. The VMAC measures both the behavioral actions to obtain employment (e.g., reading want ads, completing job applications) and client perceived motivation to obtain a job. There were no differences by condition in the level of motivation to secure employment and the number of job seeking activities during the intervention period. However, motivation to work and number of action steps did predict obtaining employment for the sample as a whole at the 6-month follow-up. Although the intervention did not increase motivation and job seeking activities, information regarding reasonable outcomes for this population of chronically unemployed persons was identified. Also, practical and methodological implications are discussed.

Adult↗
PubMed2004

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.

Adult↗
PubMed2004

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.

Adult↗
PubMed2004

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment.

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Adult↗