Implementing an Adapted Version of the Job Seekers’ Workshop in a Residential Program for Patients with Substance Use Disorders

Abstract

Objectives

To evaluate the feasibility and effectiveness of adapting the Job Seekers’ Workshop (JSW) to a residential setting within a Massachusetts-based substance use disorder treatment agency.

Methods

Implementation of the adapted JSW consisted of a continual sequence of three weekly sessions that focused on job interview rehearsals, practice completing job applications, and identification of job leads. Data were compiled on the employment rates of the 188 patients discharged from the residential treatment program during July – December 2006 (baseline participants, n = 95) and January – June 2007 (JSW intervention participants, n = 93). The effectiveness of the adapted JSW was evaluated through a comparison of baseline and intervention participants’ employment rates at discharge from residential treatment.

Results

Analyses indicated a trend towards a significant increase in employment at discharge for the intervention period (40.9%) compared to baseline (29.5%), χ²(1, N = 188) = 2.675, p = .051.

Conclusions

Further evaluation of the JSW in residential settings is necessary, but this preliminary research suggests that the intervention could begin to address the need for vocational services in residential treatment for substance use disorders.

The Job Seekers’ Workshop (JSW) was developed to help people with substance use disorders (SUDs) acquire the requisite skills to successfully obtain employment (Hall et al., 1977, 1985). Initial research on this intervention with patients receiving methadone maintenance treatment as well as with heroin addicts on probation or parole indicated that participants had significantly greater job and training placement rates at follow-up compared to controls (Hall et al., 1977; Hall et al., 1981). More recently, the JSW was evaluated in outpatient SUD treatment programs under the auspices of the National Institute on Drug Abuse Clinical Trials Network (CTN). The objectives of the CTN study were to test the effectiveness of the JSW in augmenting employment and to assess acceptance of the intervention among patients with SUDs (Svikis, 2005). The results of this study have not yet been published.

Although the CTN study was conducted in an outpatient setting, the JSW appears well-suited to implementation in residential SUD treatment settings, for several reasons. First, patients in residential treatment frequently have more difficulty obtaining and maintaining employment compared to outpatients, because they tend to experience more severe SUDs and related problems (Harrison et al., 1988; Budde et al., 1992; Harrison et al., 1996; Harrison & Asche, 1999). This means that they could potentially benefit more from attending the JSW than could people in outpatient treatment. Second, in the “working halfway house” treatment paradigm (common in residential treatment), patients are expected to be employed. For example, in the Ryan House Residential Recovery Home, a Massachusetts-based working halfway house, patients must agree to search for a job when initiating treatment; after a 2–4 week period of orientation, they are expected to obtain work within 30 days. Third, too few residential programs offer adequate vocational training (Hall et al., 2001; Magura & Staines, 2004), despite patient interest in such services (Hser et al., 1999; Friedmann et al., 2004). Fourth, the JSW’s focus on increasing patient confidence makes it an appropriate intervention for residential SUD programs, given research suggesting that such programs would benefit from fostering patients’ self-efficacy (Martin et al., 2006; Dolan et al., 2008). Fifth, implementation of the JSW in a residential setting would appear to be very feasible. The intervention is manualized, easily comprehensible, and neither time-consuming nor expensive to administer, as staff training and required equipment are minimal. Finally, research on the JSW has revealed low participant attrition from the workshop (Hall et al., 1977), suggesting that the intervention can sustain patient interest.

To test the feasibility of adapting the JSW to a residential setting, we implemented this intervention in the Ryan House Residential Recovery Home, a working halfway house within CAB Health & Recovery Services (CAB) in Lynn, Massachusetts. CAB was one of 11 sites nationally that participated in the CTN study. We assessed the adapted JSW’s effectiveness in increasing employment by comparing rates of employment for patients discharged during the baseline period (i.e., July 1 – December 31, 2006) to rates of employment for patients discharged during the intervention period (i.e., January 1 – June 30, 2007).

Methods

Residential Program

The Ryan House Residential Recovery Home is a 38-bed residential SUD treatment facility, with one house dedicated to men (20 beds) and a separate house for women (18 beds). During their stay, patients received single-gender individual and group counseling, case management services, and vocational assistance. Counseling sessions addressed substance abuse, general health, mental health, housing, legal, social, and employment issues, focusing especially on relapse prevention. The therapeutic program combined motivational enhancement and cognitive-behavioral strategies. Prior to the implementation of the adapted JSW, vocational assistance was limited to helping patients devise a job search plan, giving them information on services offered by off-site career centers, and discussing appropriate attire for job interviews.

The residential program was structured by a progressive level system, which afforded patients additional privileges as they progressed to higher levels. Achievement of higher levels was based on the amount of time spent in the program as well as the attainment of specific goals (e.g., securing employment). Upon entering the program, patients participated in a 2–4 week orientation phase, during which they were confined to the program grounds and attended individual and group sessions. In this period, patients were also asked to create a job search plan and present it to their counselor. Following approval of the plan, patients (in almost all cases) progressed to Level 1, in which they were allowed to accept visits on weekends and leave the program grounds daily to search for employment and attend self-help meetings in the community. Typically, patients not able to find a job within 30 days of being in Level 1 were given additional time, provided that they were meeting other treatment goals. Only in rare instances were patients discharged or referred to another level of care solely because they were unable to obtain employment. Patients had to obtain employment (30 hours or more) to progress to Level 2, which afforded greater privileges lo leave the treatment premises. Additional privileges were added when patients reached Levels 3 and 4. All privileges were applied equally across all patients. There were also no differences in the use of these motivational techniques (including the discharge of patients unable to obtain employment) between the baseline and JSW intervention periods.

Patients completed treatment once they had secured stable employment, found safe and sober housing, achieved adequate supports in the community, and met individual treatment goals such as developing drug refusal skills and becoming stabilized on medication. Typically, a full treatment program lasted from 3 to 6 months.

Intervention

The JSW as implemented in the CTN trial consisted of three weekly sessions, with each session lasting four hours. The first session involved participant discussion of successes in and barriers to finding employment (with Criminal Offender Record Information and gaps in employment being the barriers cited most frequently) and introduced patients to initial videotaped interviews about their vocational backgrounds and interests. The second session focused on completing sample job applications and conducting a first mock job interview with video feedback. The third session involved identifying job leads, calling potential employers during the session, and conducting a second videotaped job interview. Following every videotaped interview, each patient received positive feedback and coaching from both the facilitator and other participants. Patients were then asked to role-play another, refined job interview; thus, all patients completed two interviews in the third session.

In the present study, accommodating the residential program schedule as well as patient and staff preferences required several modifications to the JSW as implemented in the CTN trial. These changes included shortening the weekly time commitment of the intervention to 1.5 hours and creating single-gender groups to eliminate the distraction observed in early testing with mixed-gender groups. The latter change reduced the size of groups to 8–12 persons per group. In addition, videotaping of mock interviews was made optional in response to patients’ strong resistance to role-playing in front of a camera. Patients were not initially offered the possibility of opting out of videotaped interviews. When the workshop was first introduced, the JSW facilitators sought to minimize patients’ discomfort with videotaped rehearsals by encouraging them to begin with brief interviews, to view the interview as a fun exercise, and to not worry about their appearance. Videotaping was made optional only after increasing numbers of patients indicated a preference to interview without a camera. In the last two months of the intervention (May–June 2007), approximately half of the participants refused videotaped interviews. Instead of denying them the opportunity to rehearse job interviews, the JSW facilitators made videotaping optional for these people. Once this happened, rehearsing without a camera became the norm quickly.

Another change to the JSW involved continuing the intervention beyond three sessions. As a result, implementation of the JSW in Ryan House consisted of a continual sequence of three weekly sessions. After the third session, the sequence was repeated, beginning with session 1. Most patients attended 3–7 JSW sessions. Patients began to attend the JSW as soon as they were admitted into the treatment program, and they continued to attend until they found employment or were discharged from treatment. The JSW was mandatory for all unemployed residential patients. Employed patients were exempted from attending the workshop.

Finally, not all patients initiated the JSW at the same session, since rolling admission to the residential program made rolling admission to the JSW most feasible.

Clinicians

Clinician training was delivered by the Clinical Manager (S.M.C.), who had served as a JSW Intervention Supervisor for the CTN study. Clinicians were trained in two 1.5-hour sessions. During training, clinicians conducted videotaped role-play of job interviews that paralleled the procedures to be used by patients. Trainees also observed two JSW sessions before leading groups themselves. To ensure adherence to the training protocol, the Clinical Manager monitored clinicians’ performance in person during the first two weeks of their group sessions. Monitoring included ensuring that clinicians (n = 2) were providing adequate levels of positive feedback, operating the video camera properly, and using job applications, local newspapers, and Yellow Pages. The on-site Senior Counselor also observed a portion of each JSW group during the first month of the workshop to make certain that clinicians were following the protocol. Thereafter, the Clinical Manager and Senior Counselor met on alternate weeks to discuss challenges encountered by the clinicians, consider JSW modifications, and review job search data.

Equipment

Equipment included a video recorder, a television, sample applications, local newspapers, Yellow Pages, pencils and a cell phone for employment-related calls.

Measures

This study was a post-hoc analysis of existing data. Data were taken from the Massachusetts Bureau of Substance Abuse Services discharge logs. These logs provide data on employment and other treatment outcomes for patients discharged from Massachusetts-based SUD treatment programs, aggregated over 6-month periods. Our outcome measure was the percentage of patients employed—either full-time or part-time—at discharge. Employment data were collected at Ryan House by the counselor assigned to the individual patient and were verified through review of weekly pay stubs.

In the present study, we compared employment rates for patients discharged in July – December 2006 (baseline period) with employment rates for patients discharged in January – June 2007 (intervention period).

Procedures

During the baseline period, clinician training and initial implementation in mixed-gender groups occurred, with the first session beginning in October 2006. At the start of the intervention period, clinician training had been completed and the adapted JSW intervention was implemented in single-gender groups.

Participants

Our sample consisted of 188 patients in the residential treatment program. The baseline group consisted of 95 patients discharged from July 1 to December 31, 2006, and the intervention group consisted of 93 patients discharged from January 1 to June 30, 2007.

The discharge logs from which outcome data were compiled do not contain demographic data. However, admission logs compiled on 210 patients admitted during the same time period (i.e., July 1, 2006 – June 30, 2007) indicate that 99.5% of those patients were unemployed at admission. Patients’ average age was 32 years, and 51.9% were female. In terms of race, 86.7% of patients were Caucasian, 8.6% were African, 0.5% were Asian, and 4.8% identified as “other.” Ethnically, 3.8% were Hispanic. Heroin was the primary substance of abuse for clients (63.3%), followed by alcohol (17.6%), cocaine (11.9%), and marijuana (1.4%).

Results

The Clinical Manager and on-site Senior Counselor ensured adherence to the training protocol by monitoring newly-trained JSW facilitators’ group sessions in person. All JSW facilitators performed adequately. We did not formally track patient attendance at the JSW. Since the workshop was mandatory for all unemployed patients, they attended sessions unless they were excused due to illness, job searches, or other approved reasons.

The average length of stay for patients discharged between July 1, 2006 and June 30, 2007 was 56.9 days. Of the patients discharged from treatment during this time, 15.4% completed treatment, 31.9% dropped out, 20.7% were asked to leave due to rule infractions such as stealing, repeated tardiness, or inappropriate sexual contact with other residents, 29.3% relapsed and were referred to a higher level of care or discharged, and 2.7% left for other reasons (including being discharged due to an inability to obtain employment). There was no significant difference between the percentages of baseline and intervention participants who completed treatment (12% and 17%, respectively) versus those who dropped out, were asked to leave, relapsed, or left for other reasons, χ²(1, N = 188) = 1.149, p > .10.

A chi-square analysis was performed to determine whether employment rates at discharge differed significantly between baseline and intervention groups. An alpha level of .05 was used for all statistical tests. One-tailed values were computed, since our a-priori prediction was that participation in the adapted JSW would be associated with a greater employment rate at discharge than would participation in the baseline condition.

We found that 28 of 95 (29.5%) patients in the baseline group were employed at discharge, versus 38 of 93 (40.9%) patients in the intervention group. These rates indicate a trend towards a statistically significant difference in employment between the baseline and intervention groups (χ²[1, N = 188] = 2.675, p = .051). This difference in employment at discharge cannot be attributed to a pre-existing disparity at admission. There was no difference in employment between the baseline and intervention groups at admission (Fisher’s exact test [two-tailed], p = 1.0). Only 1 of 95 patients in the baseline group was employed at admission, compared to none of the 93 patients in the adapted JSW group.

Discussion

The Job Seekers’ Workshop (JSW) was initially developed to teach the skills required for obtaining employment to patients receiving methadone maintenance treatment as well as probationers and parolees with substance use disorders (SUDs; Hall et al., 1977; Hall et al., 1985). This intervention demonstrated effectiveness in early research and was the focus of a national multi-site trial implemented within the National Institute on Drug Abuse Clinical Trials Network (CTN) in 2004. After participating in this trial, CAB Health & Recovery Services (CAB) adapted the JSW for use in one of its residential programs.

Our experience indicated that it is feasible to adapt and implement the JSW in residential treatment. This intervention required minimal staff training time and little equipment. All materials were affordable and available. Additionally, the JSW was adaptable to the residential program schedule as well as to patient and staff preferences. As a result of its overall ease of implementation and acceptance by patients and staff, the adapted JSW has been adopted as a permanent part of the residential treatment program.

Our comparison of baseline and intervention participants’ employment rates suggests that the JSW may be effective in increasing employment. The percentage of patients employed at discharge was 40.9% post-intervention, compared with 29.5% at baseline. Although these results indicated only a trend towards statistical significance, several characteristics of this study may have limited its ability to detect differences between groups.

First, this study consisted of an analysis of data from an existing database that permitted only a comparison of aggregated employment rates at different six-month intervals. A related limitation was the lack of a true control group that could account for cohort effects due to the timing of the intervention. It is possible that factors in the job market differed between the baseline/training and intervention periods. Data limitations also did not permit an examination of the potential effects of demographic and psychosocial characteristics on response to the adapted JSW.

Our decision to make the videotaping of job interviews optional represented a substantial modification of the JSW, which may have limited its effectiveness. This decision was made as a result of strong patient resistance to videotaped interviews, and we do not necessarily endorse rendering videotaping optional in future adaptations of the workshop. Future studies could develop strategies for handling potential patient resistance to videotaping, including methods for achieving clinician enthusiasm for videotaping. One reason that might explain why our residential patients resisted videotaping more than prior JSW participants did is that the original JSW studies and the CTN study were conducted with patients who elected to participate in the JSW. Those patients may have been more intrinsically motivated to obtain employment than were our residential patients, who were required to attend the JSW.

A potential limitation that could have resulted in an artificial difference between the baseline and JSW intervention groups concerns the use of motivational techniques to encourage employment-seeking. Although, theoretically, the use of these techniques did not change between the baseline and intervention periods, it is possible that the staff at Ryan House were more stringent with the enforcement of certain contingencies (e.g., discharging patients who were unable to secure employment) when a JSW group was offered; this would have resulted in greater motivation to find employment after JSW implementation. The study would have been strengthened by a systematic tracking of the enforcement of motivational techniques.

It is also worth noting that, because patients who obtained employment were exempted from attending subsequent JSW sessions, those who found jobs soon after admission to treatment attended fewer JSW sessions than those who found jobs later or those who had not found jobs at discharge. Participants’ ability to obtain employment is, of course, not only a function of attending JSW sessions, but also of their responsiveness to the JSW as well as their education, skills, and credentials. This study did not seek to establish a dose-dependent relationship between the JSW and employment.

Despite the fact that employment has often been found to be correlated with treatment completion, our data showed that the baseline and JSW intervention groups differed with respect to their employment outcomes but not their rates of treatment completion. This finding is not altogether surprising. The JSW was a small component of a much larger residential SUD treatment program, and its effectiveness may well be limited to employment outcomes. In fact, previous studies (e.g., McLellan et al., 1994) have found that psychosocial services, including vocational training, are predictive of subsequent social adjustment but not substance use outcomes. Additionally, patients in our residential program discontinued treatment for a variety of reasons, including because they had found appropriate housing, re-established social supports, or gained employment. Thus, treatment discontinuation was not necessarily a sign of treatment failure.

Despite the noted limitations, this study has potential important implications. Our experience with the JSW indicated that it is a promising intervention for residential patients with substance use problems. Too few residential programs offer adequate vocational training (Hall et al., 2001; Magura & Staines, 2004), even though patients express interest in such services (Hser et al., 1999; Friedmann et al., 2004). Further testing of the JSW in residential settings is necessary before it can be endorsed as clearly effective, but preliminary research suggests that this intervention could begin to successfully address the need for vocational services in residential treatment for substance use disorders.

Conclusions

Initial testing of an adapted version of the Job Seekers’ Workshop (JSW) in the Ryan House Residential Recovery Home, a working halfway house within CAB Health & Recovery Services (CAB) in Lynn, Massachusetts, revealed a trend towards a statistically significant increase in employment at discharge for the intervention period compared to baseline.

Although additional research testing the feasibility and effectiveness of the JSW in residential settings is necessary, this study indicates that the intervention is easily adaptable to a residential setting and may be effective in increasing employment.