...rather than only within the clinic, was assessed through a quasi-experimental study of the first 55 patients receiving the model in 2 clinics. Employment outcomes after 6 months were compared between patients who received vocational fieldwork (n = 18) and those who did not (n = 37). Logistic regression analysis demonstrated that patients receiving vocational fieldwork had significantly better outcomes for competitive work, informal work, and any paid work.

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Historically, individuals in substance-abuse treatment programs have had lower participation rates in the workforce than the general population (Friedman, Graniek, Bransfield, Kreisher, & Schwartz, 1996; Gardiner, 1978; Harley & Hanley-Maxwell, 1994; Lamb, Kirby, Kimberly, & Platt, 1996; Schottenfeld, Pascale, & Sokolowski, 1992). Methadone-treatment patients, in particular, have had poorer employment outcomes than other individuals who use illegal substances (Magura, Staines, Blankertz, & Madison, 2004; TOPPS-II Interstate Cooperative Study Group, 2003). Low employment rates are clinically and economically costly.

From a clinical perspective, employment can improve substance abuse treatment outcomes, even for opioid-dependent outpatients in methadone-maintenance treatment (Kidorf, Neufeld, & Brooner, 2004). Employment enhances clinical outcomes by reducing rates of relapse, criminality, and parole violation (Fisher & Anglin, 1987; Hubbard et al., 1989; Jenner, 1998; Platt, 1995; Platt, Widman, Lidz, Rubenstein, & Thompson, 1998; Room, 1998; Vaillant, 1988). For methadone-treatment patients, employment is associated with lower rates of drug use during treatment as well as longer retention in treatment programs (Gerra et al., 2003).

For many patients, employment has become an economic imperative. Federal disability payments for individuals who use illegal substances have been eliminated, and many of them face the withdrawal of welfare benefits. Federal welfare reform legislation (e.g., the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) requires that patients who are being treated for drug use achieve work readiness to attain self-sufficiency in specific time frames established by the states. Patients not in compliance forfeit their benefits and can face socially undesirable alternatives such as homelessness and criminal behavior. In addition, there is an increasing tendency for societal institutions (e.g., legislatures, state and federal agencies) that provide funds for substance abuse interventions to consider the employment of individuals who have abused substances as a return on investment for publicly funded services (TOPPS-II Interstate Cooperative Study Group, 2003).

Historically, vocational services for individuals who abuse substances, especially methadone-maintained patients, have had limited positive results (see Magura et al., 2004, and Platt, 1995, for reviews of studies). To avoid negative outcomes for patients and society, innovative methods of serving this population must be developed and piloted. A new vocational model for methadone-treatment patients, Customized Employment Supports (CES), is currently being tested in a 5-year randomized field trial in two methadone programs in New York City. Preliminary results show that methadone-treatment patients who received CES services have significantly better employment outcomes than those who received standard vocational counseling (Staines et al., 2004). During implementation of the model, counselors began to deliver services outside of the clinic in the community, a counseling technique referred to as "fieldwork." The goal of this article is to report on a pilot study that assesses the impact of fieldwork on service delivery.

BACKGROUND

CES for Methadone-Treatment Patients

The services provided by the CES vocational program are intensive and targeted to meet the needs of the population. These services are very different than those provided in standard vocational preprograms. CES counselors work intensively with small caseloads of methadone-treatment patients to overcome both the vocational and nonvocational harriers that can severely hinder employment efforts (Arella, Deren, Randell, & Brewington, 1990; Blankertz et al., 2004; Brewington, Deren, Arena, & Randell, 1990; Speigelman, Fujiwara, Norris, & Green, 1999). The vocational barriers faced by methadone-maintained patients go beyond limited job search skills and job experience. Many patients have poor academic skills, functioning at levels that require remedial education. Frequently, they have extensive criminal records. Because they often have backgrounds in which few family members or peers have been regularly employed, methadone-treatment patients may lack work-oriented role models and an accurate conception of what working is like. Thus, the processes of acquisition and internalization of work ethics and values that are standard in mainstream society have not occurred. In addition, repeated past failures in their lives, as well as the internalized stigma of substance abuse, can result in low self-efficacy, low self-esteem, and high levels of anxiety, psychological conditions that can block productive change such as employment-seeking activities (Blankertz et al., 2004).

Although the goal of CES for patients is competitive employment (i.e., work that any person can apply for. Income from competitive work is reported to federal and state tax authorities.), their employment does not have to be continuous. Holding a job for any period is considered a qualified success, as well as being a...

NOTE: All illustrations and photos have been removed from this article.



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