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Brian Morales

Vocational Training: During or After Treatment?

Brian Morales - 10 July 2020

I created this forum because of several questions that I have encountered over the years visiting treatment programs and seeing various models of job skills training.  

 

One question which is important to address relates to the best time to introduce job skills training, also referred to as vocational rehabilitation.  

1) Should vocational rehabilitation occur during the drug treatment phase (e.g. as part of an inpatient/residential program) or should it be offered only after successful completion of a treatment program as part of the reintegration and recovery phases?

 

2) If you agree that job skills training can take place in a treatment program, then a second important question relates to income generated through the training.  Should clients or the treatment organization be allowed to earn any revenue from the products or services rendered by the clients as part of their training?  I have visited centers where clients make pottery, cultivate crops, bake bread, among other things.  I have wondered where the research comes down on this question and whether it is a good practice.

 

I am curious to know the thoughts of ISSUP members around the world. 

 

Brian

ADITI GHANEKAR

We offer vocational services after the completion of the treatment program. It's a choice the client makes when they approach the end of the treatment. The counselor motivates them to take this option.

Who takes these options: Clients who have no employment , or those who haven't worked for many years.

Objective: 1. They learn a new skill, eventually to start on their own.

2. They get into a routine of work culture and learn ethics of work culture.eg: coming on time, eating at lunch break, getting along with coworkers, following orders from the boss, keeping targets,making quality products,marketing skills etc.

3. They earn an income which raises their self esteem, and learn to manage money.eg: save money, paying back debts,sharing the expenses with their family etc.

4. This is a secured environment where the chances of getting a craving of using substances is less. 

5. They come for work which means the access to their counselor is easy. Their follow ups are regular. If craving happens, they can discuss with their co-workers and take help.And in case of lapse or relapse, they get immediate help. 

So this becomes their stepping stone to a better job outside.

Regards,

Aditi

 

 

Raj Boyjoonauth

I am glad to see that this topic which has been around for the last four decades is back again on the drug treatment agenda again. Yes, of course I am totally in support of vocational training to be an integral part of care and treatment, which should be individually tailor based to their needs and capacity. In fact. training and work based therapy have been around in mental health for quite a number of years in many countries. And if we take the view that SUDs is no different to other lapse and relapse lifestyle disease related problems such as Diabetes, high BP conditions, mood swing disorders, etc, then there should be no exception as to why people with SUDs cannot have the same vocational recovery pathway too as the rest of the client groups as mentioned. 
As for payments to their respective treatment centres, again there are many existing such models in mental health services varying across countries with different economic status. 
I personally used to work in a mental health service where inpatient used to go to skill based training centres and commercial shopping centres like Marks and Spencer,etc whilst they were still in treatment, though not in their acute phase. They were allocated their own individual rooms and made a contribution to a common pot of funds. 
Going back to the old days, work therapy whilst in treatment were seen as an essential part of the recovery process for patients which included problem drinkers and drug takers with mental health problems.
In brief, treatment model should be considered. It may not work for everyone, but there have certainly been evidence of its effectiveness with other client groups, which are transferable to our users in treatment.                          
 

 

Keith Errol Na…

Thank you for these great questions, Brian. My thoughts are solely based on what I've seen and observed in my country. 

 

1) Should vocational rehabilitation occur during the drug treatment phase (e.g. as part of an inpatient/residential program) or should it be offered only after successful completion of a treatment program as part of the reintegration and recovery phases?

For me, it would really depend on a couple of things. The client's situation (recovery capital), his readiness (in connection with the stages of change model), and the extensiveness of the treatment program that the client is in. I've seen a couple of clients enter vocational courses during inpatient/residential rehabilitation programs and it helped them a lot. It motivated them, gave them a sense of purpose, and most of all it kept them busy from different kinds of negative emotions that usually happen during the first few months of being clean & sober or just being in treatment. This is why I believe that his/her recovery capital & stage of change would also be important because in some cases when choosing a vocational in primary inpatient would be a "requirement" instead of a "goal to accomplish" and there would be times that the client will just do it for compliance in the program. I've seen clients just complying and it becomes a stressor rather than a motivator thus making the vocational a hindrance to their progress (because it becomes a stressor) unless of course they really don't have a choice (as per their agreement with the facility). It would however be better if the addiction professionals handling the client would be able to systematically work on how he/she would benefit from vocational rehabilitation (usually happens in a more private treatment facility). Good teamwork with the recovery coach, counselor & client would have a great impact on whether the client would need to push through with the vocational and to when he/she would be ready to do so if ever. 

However, it can also be beneficial for the client to have this after completion of the program and as part of the reintegration process because this gives more time for the addiction professionals to know what works and what doesn't work for the client. Given that all or most of the issues have already been addressed in the primary treatment, the client along with the addiction professionals can have a better perspective on what the client might want to do as a vocational as part of his/her continuing care if needed. Having this in the continuing care can be very beneficial especially for clients that would have a hard time connecting to support groups after treatment.

Bottom line is, should a vocational rehabilitation happen during inpatient or after successful completion of a treatment program, the primary treatment must be complete, solid, and must not be compromised regardless. Good primary treatment with trained addiction professionals will be able to gauge the client's need and readiness for vocational. With that in place, I can see a client's success in having a vocational rehabilitation in inpatient/reintegration. 

 

2) If you agree that job skills training can take place in a treatment program, then a second important question relates to income generated through the training.  Should clients or the treatment organization be allowed to earn any revenue from the products or services rendered by the clients as part of their training?  

I've seen a handful of treatment centers do this practice as well. For me, it would really depend on the treatment center's and/or the client's situation. If the treatment center's sustainability and operational cost are being sustained by the income generated by livelihood through vocational rehabilitation (given that the center is taking from 0 to a minimal fee from the clients) then why not. There can also be benefits when clients are given their share of the revenue from the products or services whether it's given in cash or in kind. Nevertheless, it would always be better for treatment centers/organizations to be transparent when it comes to these things especially on where the revenue will be allocated. The clients who will be working are usually the frontlines in generating this income and they will usually ask questions like "Where does this income go?" and "How would doing this benefit me?" It usually is a good question up until the time that they don't see how it's benefiting them.

As long as the addiction professionals in the center are able to "honestly" let the client see how the particular job skills training will benefit him/her in the future especially in sustaining a recovery-oriented life, then I don't see anything wrong with it. In a treatment center/organization that has this set-up, the client must feel that it's a win-win situation for them and the center/organization. In the first place, these programs were put in place to help the client. And that should remain to be its utmost priority before anything else.

 

 

Evans Oloo

Very thought-provoking questions

1) To your  first question, the answer is both yes and no: depending on the reasons/objectives  for  job skills training.

Yes , the training should be offered during the treatment phase   if the objective  is to help persons in recovery  begin to  develop a sense of structure, a sense of responsibility and sense personal value in their own  lives and that of others. Depending on the type of program, a 90-day program is too short for anyone in recovery   to fully come to terms and reflect on the reasons they are in treatment, to understand the concepts of addiction, to learn skills of relapse prevention and  at the same time   discover hidden talents or  consolidate learnt  skills for future use. The objective of training at this phase should therefore not be for future use but  for confidence building as a valuable member of the community.NO, if the intended objective is for future utilization of skills learnt,as much as that may be the unintended outcome. 

 

2) To your second question the answer is yes they should benefit from any income generated from their  works.As part of the objective mentioned above,i.e to help them develop a sense of responsibility,. then the income generated should be directed back to them and probably to contribute to the cost of treatment and to their upkeep while in treatment.That way clients will  develop confidence and  pride in their achievements and contributions.Of course the un- intended outcome  is that some may take up the learned  skills  beyond treatment phase.The reality  however is that recovery is a long-term journey, and consequently skills development for future use should  be properly considered   after the basics are addressed.

 

Naina Kala Gurung

First Question: My take on this is that vocational rehabilitation should be a component of the treatment phase. Clients should, however, be prepared and motivated to taking up some kind of hobbies or vocational, recreational, leisure activities during the treatment phase. It is necessary that the care providers need to jointly, work on client readiness to take up vocational trades or hobbies.

If the clients are already employed or have some kind of employability skills, they could be motivated to take up relevant occasional vacations or some hobbies of interest.  

Second Question: Yes, the clients or the treatment organization be allowed to earn any revenue from the products or services rendered by the clients as part of their training. However, there should be some kind of protocol on when and how the payment is to be made for the clients. One stance is that payment be made after the treatment phase is over.

So that the clients are purposefully led towards finding their own valuable qualities and their self worth. This process requires creative, constant, compassionate confrontation and gentle pursuit on the part of the care givers. 

Igor Koutsenok, MD

1. Both options are possible, depending on the assessed needs and the type of treatment modality. For instance, in TCs vocational training is a major therapeutic tool.

2. Earning money during vocational training in treatment is possible if it serves therapeutic purposes. A huge body of literature on contingency management as both stand alone intervention and in conjunction with CBT actually provides a lot of evidence. In that case generating income for the client  could be a good idea, but not the primary goal. There is a number of treatment programs that operate as businesses and clients earn money for their work. That doesn't mean that these programs are bad, but I have not seen any reliable data to support (or not) this model.

Maria Nativida…

1.  Vocational rehabilitation can be made part of an inpatient/residential program based on the identified needs , preferences and interest, readiness and the over all impact of drug use on the individual.  I have observed that some clients struggle at doing things simultaneously, that of completing the recovery program and learning new tasks. Setting priorities in drug treatment is an important factor that can help the client make decisions or choices for himself. 

Research has shown that prolong drug use may impair the cognitive processes and other areas of functionality which is found also to improve  with long abstinence periods. Hence, the need for regular monitoring and assessment to address such issues.

In a TC, we offer it as part of the Re-Entry Phase where continuing care is in place. 

2.  This question touches  on an ethical issue  that concerns the Center and the implementors of the program. If there are provisions in the policies and guidelines of a particular country or city that supports such practice and protects the interest of the client, first and foremost, and the Center and its staff as well, then well and good. Otherwise, even if the center management means well, if anything happens that puts at risk the recovery, the welfare and safety of the client, it may not be a good practice ( for example, what if an accident happens like burns or cuts,etc.). 

Best regards, 

Claire

Dato’ Zainuddi…

1. Vocational rehabilitation serves several purposes whether it is provided during treatment or after: it instills discipline, provides a functional structure to life and develops a new set of skills. These would tremendously assist the recovering person in post-treatment. It stands to reason that primary treatment needs to be completed before vocational rehabilitation can be effected.

The following factors need to be taken into consideration before one ventures into vocational rehabilitation program: the duration of the treatment program, the resources available and the client’s own disposition towards vocational rehabilitation.
For so long as the vocational rehabilitation does not compromise the overall treatment program, it should be encouraged regardless of the modality of treatment. There are indeed considerable benefits to the client that participates in such vocational rehabilitation.

2. Clients who are engaged in vocational rehabilitation brings income to the facility. Clients should be allowed to keep at least part of their earnings as this serves as an incentive. For obvious reasons the facility needs to ensure that such earnings do not encourage relapse. 
Depending upon the financial status of the facility, it may opt to keep part of the clients earnings to pay for its upkeep. This is quite a common practice in many countries. Again it must be stressed that such practice should not amount to the exploitation of the clients. Transparency must be the norm.

 

Rogers Mutaawe

Should job skills training/ vocational rehabilitation occur during the drug treatment phase or should it be offered only after successful completion of a treatment programme as part of the reintegration and recovery phases?

There has been a surge in the recent past on the increase and expansion of vocational skills training (VST) globally and Uganda in particular since early 2010s. Vocational skills training (VST), also referred to as technical training, has been broadly defined, to include formal classroom training with an extensive curriculum, a specific trade, an apprenticeship model, or can be delivered in an informal setting. The theories that support that vocational skills can make people move out of drug abuse reduce their vulnerability and consolidate resilience are still limited. Vocational training is largely upheld as a panacea in dealing with vulnerability and improving livelihood amongst the recovering substance users and improves their confidence and self-esteem.

We think that the job skills training can be done either way depending on the severity of the case at hand. The decision should be done on case by case basis. Our experience shows that there are clients who are still in control of their mental capacities and can therefore participate in job skills training during treatment phase whereas those who have been dependent can only do vocational rehabilitation after successful completion of the treatment program.

Should clients or treatment organisations be allowed to earn any revenue from the products or services rendered by the clients as part of their training?

We think that clients can earn revenue from the products because they should be compensated for their time but also its one way of rehabilitation which encourages clients to work hard in order to survive positively without using drugs. However, care should be taken not to give the money to some clients because they can easily use it to for illicit activities. This should be done on case by case basis taking into consideration the environment where rehabilitation is taking place. Organisations may open up an account/ledger where revenue records of each client are documented and this can be given to the individual clients upon successful reintegration.

Regards

Mr. Rogers Kasirye

Rogers Mutaawe

Uganda Youth Development Link

 

 

mohammad Aqa …

Q1- Should job skill training /vocational rehabilitation occur during the treatment phase (e.g. as part of an inpatients/residential program) or should it be offered only after successful completion of treatment program as part of reintegration and recovery phases.

A1- Skill training or vocational rehabilitation occurring during the inpatient / residential program will be much effective and must be accommodated as a part of the residential phase in the package , I think the followings are the benefit for ,

  1. The clients may be encouraged to stay longer until the end of the treatment and rehab program and mostly they will stay to complete the 45 days or more in the program.
  2. During the  residential  period if we do not have vocational training or we get this out of the residential program  the efficacy of the program and interest of the clients in inpatient/residential will be lost and we will face within incomplete treatment and will have the chance of more relapse cases .
  3. The clients will lose its attachment within the center, as most clients are mentally receptive to the residential attachment and are preferring the inpatients services.
  4. The number of the clients will be dropped and the modality of center may be assimilated to out -patients service and will affect the referral system between the out and inpatients centers.
  5. For our setting in Afghanistan it is better to be part of the residential program, as most clients when they are discharged from the residential program they are going to find job or to be engaged to their former business to earn money and run their family as the evidence show that that most clients are in young ages 18-45 which is a productive tenure of their life.
  6. Am not totally rejecting the vocational program after residential program or reintegration and recovery phases , but mostly running rehab centers which are not supported by the government or donor agency they are not providing vocational  services after the residential program  due to
  1. The costliness of the program and unaffordability by the clients.
  2. Few clients can afford the charges after their residential program to provide their vocational skill and allocate their time to stay and learn the new skills in.
  3. Mostly having no time to go under vocational training after the residential program (we are witness of this issue even in the residential programs funded by donors ) when there is time of their agriculture yield / products they have not been  available to get entered to the residential program in contradiction to their waiting as long as in the winter season , so in this connection sometimes we have the low rate of beds occupancy in some DTCs too.  

 

Q2- Should client of treatment organization be allowed to earn revenue from the product or services rendered by the clients as a part of their training.

A2- If the skill training is a part of residential program my thought are:

  1. The clients should not be allowed to earn the revenue from the products because the raw materials, equipment used have been procured/provided by the center and the center can sale or get their money deposited to their income generation program to get sustained in the future.
  2. The center can hire professional trainers specifically for each profession and use this money for their wages etc .
  3. If the product is better in quality the center can find suitable market for their product and attract more clients demand to run the center as professional and finally expand the program to cover more clients in the future.
  4.  The product money/revenue can be used for their occupational health and emergency service during or after their skill training to keep the clients attached to the vocational skills  or job placement services.
  5. Am not pro to the revenue of the product used by the clients, because they may temporarily be attached to this program due to this revenue, if we cut them off from this product revenue they may dramatically be detached from the program. It’s better to be used by the center and revitalize their system to avoid any expected shortfall and budgetary constraints.

 

 

Regards and thanks for having a chance to participate and express my thought in this connection.

 

Dr Mohammad Aqa Stanikzai,

Kabul Afghanistan.

Cameron Kieffer

1) Vocational and educational training can be a component of a comprehensive treatment strategy.  Such vocational programs should supplement, and not replace, evidence-based treatment that may include psychosocial and pharmacological treatment.  These programs should provide individuals with training and job skills beyond repetitive menial labor and appropriate to the skills, needs, and interests of the individual.

2) This is a difficult question and the answer is likely specific to each treatment program and maybe even to each individual patient. One thing to keep in mind is to ensure vocational skills training does not have, or appear to have, characteristics consistent with forced labor. Forced labor can take many forms, but often requires participants to work the equivalent of a full-time job or more, frequently performing menial tasks.  Individuals subjected to forced labor generally do not receive adequate, evidence-based psychosocial and pharmacological treatment and any care that may be provided is not overseen by appropriately credential healthcare professionals.  Individuals subjected to forced labor requirements may receive no compensation, compensation below the minimum wage, or have their wages reduced to pay for food, accommodation, and program administration costs.  Additionally, participants may be isolated from the outside world and prevented from leaving the forced labor program by physical force or threats of incarceration.

In general the best interests of the patients and therapeutic goals of the program should guide when to employ vocational programs and what forms they should take.