Personal and environmental factors related to employment: implications for substance abuse intervention.

Rehabilitation professionals frequently emphasize that legitimate employment is a significant factor associated with rehabilitation and adjustment of individuals who abuse substances (e.g., Peele, 1985). In research on substance abuse, employment is commonly used as an important measure of rehabilitation outcome or of how well the individual functions within his/her community environment (e.g., Hubbard & Harwood, 1981; Maisto & McCollam, 1980; Snyderman, 1974). There is also some evidence that employment is not simply an indicator of rehabilitation outcome or function, but rather, a critical factor in the adjustment process (Billings & Moos, 1983). Although the precise nature of the relationships among work, rehabilitation outcome, and adjustment in individuals who abuse substances warrants further investigation, it is clear that strong, definite linkages do exist among these variables.

It is a recurrent and well-documented theme in the addiction literature that unemployment and vocational instability are serious problems among persons who abuse substances (Gardiner, 1978; Peachey, & Franklin, 1985; Waldo, & Gardiner, 1984). Annual intake records between 1985 and 1989 for the Addiction Research Foundation (Clinical Institute) in Toronto, Ontario indicate that unemployment for this population is much higher than the current average rates for North America (Addiction Research Foundation [ARF], 1986, 1987, 1988, 1989). For the 14,659 substance abuse clients reporting their employment status during this period, the mean annual rate of unemployment was 36.9% (ARF, 1986, 1987, 1988, 1989).

Based on the foregoing, it is clear that rehabilitation professionals who work in addictions are facing a formidable challenge. As Peele (1985) argues, intervention with substance abuse clients will be successful only to the extent that it focuses on developing their personal and environmental resources, including those related to work. In essence, professionals must conceptualize and implement effective vocational interventions that will address the specific, serious problems related to employment. Such interventions will ultimately contribute to successful adjustment of these clients within the community.

To date, some global difficulties have been identified in the literature, namely, securing and retaining employment (Hubbard et al., 1978; Waldo & Gardiner, 1984). However, there have been only a few attempts to investigate these work-related problems in any detail. There has also been scant attention to the integration of existing, more generic research findings concerning substance abuse which may contribute to our understanding of these problems (e.g., Newton, Elliott, & Meyer, 1988; Renwick & Krywonis, 1988; Whitehead & Simpkins, 1983).

Given the growing emphasis on a number of commonalities across the various addictive behaviors (Donovan, 1988), references in this paper to "substance abuse", "addiction", and "substance-dependence" are intended to denote the use of alcohol or drugs or a combination of both. In fact, the use of two or more substances, that is, polydrug use, now appears to be a commonly observed pattern (ARF, 1988, 1989; Yates, Petty, & Brown, 1988). In keeping with the foregoing, this paper draws upon literature on both alcohol and drug dependence in order to examine theoretical and practical implications for vocational intervention with clients who abuse substances.

Employment Difficulties

Employment difficulties for individuals who abuse substances are related to both obtaining and maintaining work (Renwick & Krywonis, 1988; Yates et al., 1988). A retrospective interview study of clients admitted to a treatment facility for substance abuse intervention demonstrates drastic declines in vocational productivity over the year prior to their treatment (Gardiner, 1978). This research also indicates that vocational stability, measured in terms of the number of jobs held, is generally poor during this period. Another study focused on maintaining employment following residential treatment for addiction suggests that employment stability deteriorates markedly from one month post-discharge and onwards (Waldo & Gardiner, 1984). This research underscores the need for particular attention to "job survival" (Gardiner, 1978, p. 502) skills. This is critical in light of the connections between work and adjustment (including relapse) in this population (Hubbard & Harwood, 1981; Billings & Moos, 1983).

Some of the major factors likely to interfere with obtaining and retaining a job reside primarily with the individual, that is, personal characteristics, cognitions, and behavior patterns. Others originate in the individual's environment. These two clusters of factors are examined in the sections which follow.

Personal Factors

Individuals who abuse substances typically have a poor conception of self and a weak sense of self-esteem (Carmichael, Linn, Pratt, & Webb, 1977; Craig, 1982; Ericson, 1977; Manganiello, 1978). As Cox (1985) notes, although addiction contributes to poor self-esteem, abstinence does not typically lead to rapid improvement in this respect. Further, they perceive that they have less internal control over their own lives and outcomes, compared to individuals who are not substance-dependent (Manganiello, 1978). Negative thinking patterns are also a problem for these clients. This has been observed and noted by rehabilitation professionals, especially with respect to the process of searching for and obtaining employment (Snyderman, 1974). In addition, compared to control subjects, individuals who use drugs tend to perceive the causes of negative life events as more stable or, in other words, as less possible to change (Reich & Gutierres, 1987). A review by Craig (1982) concludes that these individuals also "tend to demand immediate gratification, have low frustration tolerance, and to be impatient" (p. 202). Similarly, Maisto and Caddy (1981) describe the characteristic preference of substance-dependent persons for engaging in behaviors which provide short-term rather than delayed reinforcement.

Clearly, this pattern of characteristics could seriously interfere with the processes involved in obtaining and holding a job. In fact, these characteristics are highly similar to the personal factors identified as major obstacles to a successful vocational rehabilitation outcome (Farley, 1984). They could also have consequences for the type of position sought. For instance, based on Craig's (1982) conclusions, a particular job could be inappropriate for the individual's abilities or skill levels (or both) but might be appealing in the short-term because it is the easiest one to secure. However, a job that does not match an individual's skills and abilities will probably not be successfully maintained. In addition, the findings regarding self-esteem (Cox, 1985) and stable perceptions of negative events (Reich &

Gutierres, 1987) suggest that persistence in searching for legitimate work following rejections by several potential employers would be unlikely. Similarly, perceived performance failures in the early stages of a new job could significantly interfere with successful retention. Further, a weak self-concept (Carmichael et al., 1977) can result in poor self-presentation in the context of employment interviews. If the individual is hired, a poor self-concept can generate behaviors which make job survival difficult.

Environmental Factors

Employment-related difficulties fostered by personal factors are compounded and complicated by their interaction with a number of environmental variables. While some of these environmental factors are structural (i.e., inherent in the rehabilitation system or the workplace), others are interpersonal in nature.

Circumstances intrinsic to the rehabilitation services system can easily frustrate the individual's desire to secure and retain legitimate work. Many vocational rehabilitation agencies and programs explicitly exclude or do not provide services to individuals who abuse substances while others will accept these clients only after they have demonstrated a specified minimum period of abstinence (Allison & Hubbard, 1985). Thus, vocational intervention is often not available to these individuals in conjunction with or immediately following other treatment (Peachey & Franklin, 1985). This can present a significant barrier to rehabilitation given that relapse typically occurs approximately one month after completion of alcohol and drug treatment programs (Marlatt, 1985a). Lack of access to vocational intervention programs during this vulnerable period (when positive motivation toward employment should be reinforced, mobilized, and supported) can have serious consequences for the individual's ability to find, and, in particular, to retain employment.

In the workplace, negative stereotypes and attitudes on the part of employers, supervisors, and fellow employees (Tootle, 1987) can make job survival more difficult. An analysis of working environments by Newton et al. (1988) also clearly delineates some of the structural dimensions of work which may interfere with abstinence and, thus, with job maintenance. They emphasize that the features of a particular job or work setting may undermine self-control with respect to substance use and, hence, successful retention of employment. For example, they discuss such factors as opportunity for substance use, unclear job expectations and production goals, irregularity of hours and seasonal nature of a job, and the degree of stress it generates.

Provision and mobilization of appropriate social support can contribute to successful adjustment which includes securing and maintaining a job (Billings & Moos, 1983; Caplan, & Killilea, 1976; Dumont, 1974; Hawkins, Catalano, & Wells, 1986; Steer & Miller, 1978; Valliant, Milovsky, Richards, & Valliant, 1987). Given that individuals with substance abuse problems typically have difficulty forming and maintaining long-term relationships (Craig, 1982; Yates et al., 1988), this social support is critical. As Fagan (1986) notes, over time, behavior related to substance abuse can eventually disrupt the individual's interpersonal relationships to the extent that little or nothing of the social support network remains. Further, the persons with whom these individuals most frequently interact may themselves be involved in the substance abuse subculture. Therefore, they are unlikely to actively provide support and, in fact, may counteract support from other sources as these individuals search for legitimate work and attempt to sustain employment.

Discussion

The literature examined clearly identifies personal (i.e., cognitive and behavioral) and environmental (i.e., social and structural) factors which can be serious obstacles to securing and retaining employment. Although these factors have been explored separately, in practice, their interaction can result in a complex and problematic set of constraining forces for individuals who abuse substances. Therefore, rehabilitation professionals are faced with a considerable challenge.

However, the previous analysis of the literature also suggests several main constituents of an effective approach to vocational intervention. Specifically, coping strategies for dealing with the problematic personal and environmental factors described earlier as well as the development and mobilization of appropriate social support are clearly critical elements to include. The necessary skills for both finding and obtaining work should also be emphasized. However, since sustaining employment is so fraught with difficulty, strategies that directly address job maintenance must be a very strong focus. Finally, and most fundamentally, such an approach must be grounded in a theoretical framework that will integrate these components and provide a powerful basis for effecting enduring change in these clients' employment-related cognitions, behaviors, and coping strategies.

Previous Approaches to Vocational Intervention

It is noteworthy that most vocational programs which have been developed for or include clients with substance abuse problems focus exclusively or primarily on finding and securing work (e.g., Azrin & Philip, 1979; Friesen & Young, 1978; Hall, Loeb, Norton, & Yang, 1977; Hall, Sorensen, & Loeb, 1988; Hubbard & Harwood, 1981). They have not emphasized employment maintenance (Herbert, 1988). But, as discussed previously, obtaining a job is likely to precipitate a whole constellation of vocationally related problems and crises.

Those few programs which have included attention to work maintenance training have tended to be protracted, complex, and relatively expensive to implement (e.g., Dickinson & Maynard, 1981; National Institute on Drug Abuse [NIDA], 1978). They have also focused, to a great extent, on skills related to specific jobs or occupations (Dickinson & Maynard, 1981; NIDA, 1978). This is surprising since skill deficits of these kinds have been identified as much less probable causes of job loss than personal and environmental factors (Neff, 1977; Newton et al., 1988). Evaluations of these programs indicate either mixed outcomes or much weaker favorable effects on employment than anticipated, or both (Dickinson & Maynard, 1981; NIDA, 1978).

There is some evidence that vocational intervention programs grounded in behavioral theory (Azrin & Philip, 1979; Hall, Sorensen et al., 1988) have assisted substance-dependent clients to find work more readily than control subjects. Nevertheless, behavioral techniques alone may not be sufficient to maintain these individuals in the same job over an extended period of time. Behavioral techniques used with unemployed persons (including those with addiction problems) have resulted in longer periods of full- time work than for control subjects (Azrin, Flores, & Kaplan, 1975; Azrin & Philip, 1979). However, it does not appear that job stability, that is, the actual number of jobs held within the time frames studied was of any concern to these investigators. Yet, there is a profound difference in being skilled at readily finding a series of short-term jobs and being able to maintain one job for an extended period of time. For instance, there would be a marked difference in the relative contribution of each employment pattern to the individual's level of adjustment overall.

In conclusion, earlier approaches to vocational intervention with substance abuse clients have fallen short of adequately addressing their employment-related difficulties. They have either not been specifically tailored to this client group or have not adequately incorporated the major elements of effective intervention (identified previously), or both.

Recommendations for Vocational Intervention

The recommendations presented here are an elaboration on the main constituents of an effective approach to vocational intervention delineated earlier. The most important consideration in this respect is the theoretical basis of the intervention. A cognitive-behavioral approach would be most appropriate because it emphasizes that cognitive processes mediate or influence the individual's behavioral and emotional responses (Stone, 1980). A significant advantage of this approach is that "what the client says to himself and imagines about ...his own behavior change influences the stability and generalization of treatment" (Meichenbaum, 1977, p. 225). As Meichenbaum (1977) asserts, "if the change process is to be lasting then one must not only teach new behavioral skills, alter internal dialogue, but also influence cognitive structures" (p. 226). Vocational intervention based on cognitive-behavioral principles could be targeted to changing both the behaviors and cognitions that interfere with securing work, and more important, with sustaining it in the long-term. Techniques derived from this theoretical framework (e.g., behavioral rehearsal, cognitive restructuring) emphasize both personal and environmental factors and have already been successful in the context of other types of intervention with substance abuse clients (Shiffman, 1987). These techniques could readily be focused on altering maladaptive cognitions and behaviors and on developing strategies for dealing with the problematic personal and environmental factors discussed earlier. Such cognitive-behavioral coping strategies could include ways of dealing with self-presentation in job interviews as well as resolving conflicts, resisting substance use, and dealing with boredom on the job. Finally, a cognitive-behavioral approach to vocational intervention would be congruent with some of the most current models being applied in other areas of substance abuse treatment (Marlatt, 1985b).

Social support should also be an integral component of intervention and could be incorporated within the cognitive-behavioral framework proposed. Simple social reinforcement and support by family and friends of the type described by Azrin et al. (1975) can be included. However, more intensely focused, conscious attention to social support is also necessary for individuals who have substance abuse problems. Some clients will have alienated or lost the support of those significant others who do not use drugs themselves. Therefore, vocational intervention should focus on the active development of other sources of social support and new strategies for cultivating these. Further, clients' cognitions and behaviors with respect to drawing upon appropriate existing social support networks (e.g., family and friends who do not abuse substances) and the instrumental and emotional benefits they provide (Billings & Moos, 1983) will need to be re-oriented. In essence, they will need to learn to recognize the value of and to appropriately utilize this supportive safety net during the process of seeking and obtaining work and, in particular, when attempting to maintain a job. The support component of vocational intervention will be of greatest benefit if it is continued after employment is secured and is available to all employed clients who have participated in the intervention program (e.g., an ongoing support group).

It has been a recurrent theme in the addiction literature that obtaining employment is a significant problem (e.g., Gardiner, 1978; Hubbard et al., 1978; Maisto & McCollam, 1980; NIDA, 1978). Therefore, as discussed earlier, vocational intervention should include attention to the job-seeking process. However, the employment-related personal and environmental factors delineated previously underscore for formidable difficulties associated with job retention. Thus, even clients who are already employed are likely to require attention to this area. Accordingly, vocational intervention should be more strongly focused on employment maintenance. Further, early attention needs to be given to maintenance issues, that is, even clients in the stages of seeking work should be learning and practising relevant cognitive and behavioral strategies. This would serve to foster a sense of competence and confidence which will also exert a positive influence on them as they seek work. For those clients who have already found work or who have had ongoing problems with keeping a job in the past, mobilization of appropriate social support and attention to job maintenance strategies should also begin in the early stages of intervention.

The timing of vocational intervention is critical because of the rapid increase in relapse rates (Marlatt, 1985a) and decline in employment stability (Waldo and Gardiner, 1978) following completion of other treatment programs. Further, motivation towards work tends to be high while individuals are participating in such programs (Marlatt, 1985a). Thus, vocational intervention should attempt to foster and mobilize this motivation (using some of the methods mentioned above), desirably in conjunction with other kinds of treatment. At the very least, it should begin within one month of completion of other substance abuse intervention programs.

These recommendations are consistent with contemporary theoretical approaches to other aspects of substance abuse intervention (Billings & Moos, 1983; Donovan, 1988; Marlatt 1985a, 1985b; Shiffman, 1987). They are also likely to be no more complex or expensive to implement (and, conceivably, less so) than earlier approaches to vocational intervention for these clients (e.g., Azrin & Philip, 1978; Hall et al., 1988; Hubbard & Harwood, 1981; NIDA, 1978). This is the case because some out-patient group sessions can be integral to the intervention process and a relatively brief time span is required for training in cognitive-behavioral strategies. Once these strategies have been learned, the individual can engage in practice and self-monitoring on a relatively independent basis (Marlatt, 1985b; Stone, 1980).

In conclusion, rehabilitation professionals are faced with a considerable challenge in their efforts to re-integrate substance abusers into the workforce. Incorporating the recommendations proposed here could increase the probability of accomplishing this goal.

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Renwick, Ph.D., Associate, Centre for Health Promotion and Assistaant Professor, Department of Rehabilitation Medicine, University of Toronto, 256 McCaul Street, Toronto, Ontario, Canada, M5T 1W5.