Substance Abuse and Vocational Rehabilitation: A Survey of Policies & Procedures

Abstract

This study examined public VR agencies (n = 27) throughout the United States and examined agency barriers when alcohol and other drugs of abuse (AODA) was involved. Specifically, state Directors were asked to identify the procedures of handling coexisting disabilities (e.g., screening, formal policy and procedures on referral for substance abuse treatment services) and eligibility of services for clients with substance use disorders (SUDs). The results of this study showed that VR agencies have limited knowledge of the importance of screening for SUDs and the procedures that are needed when AOD issues are present. Discussion and implications are provided.

Full text

Journal of Rehabilitation Volume 80, Number 4
THE JOURNAL OF
Rehabilitation
Oct./Nov./Dec. 2014
Volume 80, Number 4
NATIONAL REHABILITATION ASSOCIATION
Substance Abuse and Vocational Rehabilitation:
A Survey of Policies & Procedures
Matthew E. Sprong, Bryan Dallas, Ann Melvin, and D. Shane Koch ...................................................... 4
Barriers to Traumatic Brain Injury Services and
Supports in Rural Settings
Tatiana I. Solovieva and Richard T. Walls ................................................................................................ 10
Pain Assessment in Adults with Intellectual
Disabilities
Rosellen Reif, Andrea Hobkirk, LaBarron K. Hill, Jay Trambadia, Abigail Keys,
Camela S. Barker, Arianna Timko, Melanie McCabe, Miriam Feliu, Elwood
Robinson, W. Jeff Bryson, Angela Phan, Patience Chuku, and Christopher L. Edwards ......................... 19
It Takes a Village: Inuences on Former SSI/DI
Beneciaries Who Transition to Employment
Marjorie F. Olney, Charles Compton, Mark Tucker, Deborah Emery-Flores, and
Reyna Zuniga ............................................................................................................................................ 38
Severe Substance Use Disorder Viewed as a Chronic
Condition and Disability
Lloyd R. Goodwin, Jr. and Shari M. Sias .................................................................................................52
Expanding Frain, Bishop, and Bethel’s Rehabilitation
Model to Address Needs of Female Veterans
Meritza A. Tamez, and Richard J. Hazler .................................................................................................60
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Journal of Rehabilitation Volume 80, Number 4

Journal of Rehabilitation Volume 80, Number 4
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Substance Abuse and Vocational Rehabilitation:
A Survey of Policies & Procedures
Matthew E. Sprong, Bryan Dallas, Ann Melvin, and D. Shane Koch ................... 4
Barriers to Traumatic Brain Injury Services and
Supports in Rural Setting
Tatiana I. Solovieva and Richard T. Walls .............................................................10
Pain Assessment in Adults with Intellectual
Disabilities
Rosellen Reif, Andrea Hobkirk, LaBarron K. Hill, Jay Trambadia,
Abigail Keys, Camela S. Barker, Arianna Timko, Melanie McCabe,
Miriam Feliu, Elwood Robinson, W. Jeff Bryson, Angela Phan,
Patience Chuku, and Christopher L. Edwards .......................................................19
It Takes a Village: Inuences on Former SSI/DI
Beneciaries Who Transition to Employment
Marjorie F. Olney, Charles Compton, Mark Tucker, Deborah Emery-
Flores, and Reyna Zuniga ......................................................................................38
Severe Substance Use Disorder Viewed as a
Chronic Condition and Disability
Lloyd R. Goodwin, Jr. and Shari M. Sias ..............................................................52
Expanding Frain, Bishop, and Bethel’s
Rehabilitation Model to Address Needs of Female
Veterans
Meritza A. Tamez and Richard J. Hazler ...............................................................60
THE JOURNAL OF
ARTICLES
Rehabilitation
1

Journal of Rehabilitation Volume 80, Number 4
Individuals with physical disabilities are likely to expe-
rience Alcohol and Other Drugs of Abuse (AODA) at
rates far in excess of the general population (CSAT, 1999;
Koch, 2002, 2008; Koch & Dotson, 2008; Sprong, Upton,
& Pappas, 2012). As noted by the Ofce of Disability-Sub-
stance Abuse and Disability [ODSAD] (2010), substance
use disorders (SUDs) [i.e., abuse or dependence] occur two
to four times more often among persons with disabilities in
comparison to the general population (Koch, Nelipovich, &
Sneed, 2002; Moore, 2003; Substance Abuse Mental Health
Services Administration [SAMHSA], 2009; Sprong et al.,
2012). SAMHSA suggested that approximately 4.7 million
Americans with disabilities experience co-existing substance
use disorders and physical or mental disabilities (ODSAD,
2010), and approximately 22.3 million individuals in the U.S.
aged 12 or older (9% of general population) met DSM-IV TR
diagnostic criteria for substance abuse or dependence in 2007
(Walls, Moore, Batiste, & Loy, 2009).
Within specic disability groups, the rate of SUDs vary.
For example, a report by SAMHSA (2011) indicated that 40-
50% of persons with spinal cord injuries, orthopedic disabilities,
vision impairments, amputations and traumatic brain injuries
might also have substance abuse problems. Furthermore,
SAMHSA (2009) stated that over 8.9 million persons have co-
occurring mental health disorders and substance use disorders.
ODSAD suggested the high prevalence of substance abuse
among persons with disabilities is because of (a) medication
and health problems, (b) societal enabling, (c) lack of
identication of problems, and (d) lack of identication of
accessible and appropriate prevention and treatment services.
Furthermore, people with substance use disorders may have
an underdeveloped vocational identity particularly if the
substance abuse occurred prior to the development of a work
history (Benshoff & Janikowski, 2000). As a result, persons
with SUDs may have not developed the necessary work-
related skills or behaviors needed for vocational success and
accordingly, “knowing how to successfully function in a work
environment is a mystery to them” (p. 340).
Vocational Rehabilitation & Substance Abuse
The primary goal of the state/federal VR program is
to help persons with disabilities to obtain employment by
identifying individual needs and making appropriate referrals
for services to address these needs. VR is a program that
provides individualized and supportive services to consumers
to increase the likelihood that a consumer will obtain and
maintain employment compatible with their skills, abilities,
This study examined public VR agencies (n = 27) throughout the United States
and examined agency barriers when alcohol and other drugs of abuse (AODA)
was involved. Specically, state Directors were asked to identify the procedures
of handling coexisting disabilities (e.g., screening, formal policy and procedures
on referral for substance abuse treatment services) and eligibility of services for
clients with substance use disorders (SUDs). The results of this study showed that
VR agencies have limited knowledge of the importance of screening for SUDs and
the procedures that are needed when AOD issues are present. Discussion and
implications are provided.
Substance Abuse and Vocational Rehabilitation:
A Survey of Policies & Procedures
Journal of Rehabilitation
2014, Volume 80, No. 4, 4-9
Matthew E. Sprong
Montana State University - Billings
Bryan Dallas
Northern Illinois University
Ann Melvin
University of Illinois-Springeld
D. Shane Koch
Southern Illinois University
4
Matthew E. Sprong, Department of Rehabilitation Counseling
& Human Services, 1500 University Drive, Montana State
University, Billings, MT 59101.
Email: msprong@msubillings.edu

Journal of Rehabilitation Volume 80, Number 4
and interests (Sprong et al., 2012). Eligibility for state VR
services include having a physical or mental impairment that
impedes ability to secure employment and a consumer must
be able to benet from VR services in terms of an employment
outcome in an integrated setting (Parker & Patterson, 2012).
Consumers with severe disabilities that are unable to obtain
and maintain competitive employment are eligible for trial
work settings/simulated work experiences (e.g., vocational
training, sheltered workshops, supportive employment),
or skill development (e.g., educational training) that may
eventually lead to an employment outcome.
Retention of consumers in rehabilitation agencies
increase when the needs of consumers are identied early
and services match specic problem areas (Carise, McLellan,
Festinger, & Klebler, 2005). A potential barrier to effective
services is that consumers who are diagnosed or may meet
diagnostic criteria for SUDS are not being identied by VR
counselors. This may lead to a lack of referral for SUDs
treatment and the additional barriers associated with this
disorder will not be met and continue to limit successful VR
outcomes (e.g., competitive employment). Substance use
disorders affect approximately 25-50% of all VR consumers
(Donnell, Mizelle, & Zheng, 2009) and a study observing
trends in the RSA-9/11 data set found that individuals with
AODA problems receiving VR services experienced a success
rate of 55% (McAweeney, Keferl, Moore, & Wagner, 2008).
Likewise, Wall, Batiste, Moore, and Loy (2009) found that
approximately 50% of 100,000 VR consumers with substance
abuse barriers had successful employment outcomes.
Researchers have collectively agreed that screening for
SUDs is not occurring at an acceptable rate within VR (e.g.,
Koch & Dotson, 2008; Moore et al., 2008), but have provided
different explanations for why consumers with SUDs are not
being appropriately identied. One researcher hypothesized
that the lack of identication of SUDs among VR consumers
may be due to time constraints for assessing substance abuse
related to large case loads of VR counselors, perceived or
actual lack of expertise in appropriately serving persons with
SUDs, and inconsistent guidelines of the evaluation and/
or referral for persons with SUDs (Sligar & Toriello, 2007).
Koch et al. (2009) identied four system barriers that may
explain the lack of consistent screening for SUDs, including
(a) system-specic screening and referral procedures, (b) lack
of identied case managers, (c) failure to create formal system
linkages, and (d) incompatible policies and procedures.
Likewise, Moore et al. (2008) found a lack of policies and
procedures among VR agencies to mandate screening for
SUDs of every consumer that receives VR services. It
appears that both hypotheses are plausible; however, Glenn
and Moore (2008) suggested that to address the SUDs barrier,
effective referral and collaboration between VR and substance
abuse agencies are crucial. Moreover, having an authentic,
equal partnership of these agencies is more likely to lead to
positive outcomes (e.g., employment, reduced substance use)
(SAMHSA, 2000).
Having open communication between agencies can be
benecial to the client and the VR counselor because SA
treatment can help in the vocational process (e.g., reduce
substance abuse-related barriers) and vocational services can
assist in treatment (e.g., employment can be empowering).
For example, Ginexi, Foss, and Scott (2003) found that many
participants were able to transition to work after treatment.
Other research has found that employment signicantly
predicted substance abuse treatment completion (Melvin,
Davis, & Koch, 2012) thus indicating that a collaborative
effort between VR and substance abuse treatment is mutually
benecial. Likewise, gainful employment has been one of the
strongest predictors of AODA recovery and substance abuse
treatment success (Platt, 1995; Magura & Staines, 2004; West,
2008). Unfortunately, even with the literature that showed
successful outcomes when treatment and VR services occur
concurrently, many VR programs continue to deem individuals
that actively abuse substances ineligible for services. Pack
(2007) further alleged that typical policy requires people with
substance use disorders to be “clean and sober” for six months
prior to receiving VR services. Researchers have argued
that individuals deemed ineligible for state VR services may
not receive the counseling services necessary to facilitate
successful adaptation to SUD barriers (e.g., Koch, 2002, 2008).
The purpose of this study was to explore the procedures of
state/federal VR programs’ handling of coexisting disabilities
(e.g., screening, formal policy and procedures on referral for
substance abuse treatment services) and eligibility of services
for clients with substance use disorders (SUD). Ong, Lee,
Cha, and Arokiasamy (2008) found that VR agencies typically
lack the competence needed to identify individuals with drug
and alcohol challenges. Therefore, it is vital to continue to
explore policies and procedures and screening mechanisms
within VR to observe if this pattern continues, and to answer
the following research question:
1. Do public vocational rehabilitation programs
routinely screen clients for alcohol and other drug-
related problems?
2. If SUDs are identied, what are the policies and
procedures for serving these individuals?
Methods
Participants and Materials
Program directors from 56 public VR agencies
throughout the United States were recruited to participate
in our study. A response rate of 48.21% was obtained, and
a total of 27 respondents that reported their position title as
program director participated in the study. A combined total
of 222,820 consumers were served for the agencies that
participated. A six-item survey was developed to gather
information on concurrent substance abuse treatment and
vocational rehabilitation services. The items included: (a)
quantity of individuals that were served by your agency in
past year, (b) does your agency record substance use disorders
as a coexisting disability in client’s records, (c) does your
agency use a standardized instrument to screen for substance
use disorders (e.g., Global Appraisal of Individual Needs
[GAIN], Substance Abuse in Vocational Rehabilitation-
5

Journal of Rehabilitation Volume 80, Number 4
Screener [SAVR-S], (d) what is your agency’s formal policy
or procedure addressing referral to substance abuse treatment,
and (e) eligibility of people referred for vocational services
that have substance use disorders. Finally, the survey asked
participants to provide 1-3 items they perceive to be essential
in implementing a concurrent substance abuse treatment and
VR program.
These questions were derived from previous hypotheses
on why consumers with SUDs are not successfully identied
and referred for substance abuse treatment services. These
included Koch et al.’s (2008) assertion that lack of screening
is due to (a) system-specic screening and referral procedures,
(b) lack of identied case managers, (c) failure to create
formal system linkages, and (d) incompatible policies and
procedures. In addition, Moore et al.’s (2008) claim that there
is a lack of policies and procedures that mandate screening
for SUDs, and Glenn and Moore’s (2008) statement that there
is a lack of effective referral and collaboration between VR
and substance abuse agencies were included. Finally, we
were interested in ascertaining if Pack’s (2007) nding that
six months of abstinence is required prior to receiving VR
services is still prevalent.
Procedures
After obtaining approval from the institutional review
board to conduct our study, state/federal VR agency addresses
and contact information was obtained via internet. A packet was
assembled that included brief demographic information (i.e.,
what is your position title with the VR agency), an informed
consent form, and the survey. Potential participants were
asked to participate in the study to gain a better understanding
of substance abuse issues as it relates to state/federal VR
programs’ screening for SUDs (e.g., policies and procedures),
and the policies on serving individuals with SUDs. A return-
envelope with appropriate postal stamps was provided to the
participants for easy return of the survey. An information
sheet was provided that discussed the study goals into greater
detail, and provided a statement that thanked them for their
participation. The agencies that did not return an envelope
were recorded and a follow-up packet that consisted of the
same material was mailed to attempt to increase response rate.
Unfortunately, the follow-up material was not returned and
this resulted in the conclusion of the data collection.
Results
A frequency distribution was conducted on the survey
questions and revealed that 40.7% (n = 11) of the agencies
indicated that they do not record substance use disorders as a
co-existing disability in client records, while 59.3% (n = 16)
indicated that they do record this information. Results also
revealed that 88.9% (n = 24) agencies reported that they do
not use standardized instruments to screen for substance use
disorders. The Substance Abuse Vocational Rehabilitation
Screening (SAVR) instrument was used by both agencies (n
= 2) that did report using standardized instruments. A total
of 70.4% (n = 19) of the agencies reported that they do not
have a formal policy or procedure, such as a memorandum
of understanding, which addressed referral of consumers with
coexisting disabilities to substance abuse treatment facilities.
Furthermore, it was found that only 37% (n = 10) reported
that they must complete treatment before receiving services.
However, the distribution also indicated that 74.1% (n = 20)
of the agencies reported they do not require a specic length
of abstinence from alcohol or other drug use prior to being
eligible to receive services. If a current consumer receiving
services that has a history of substance abuse and it was
discovered that they were currently using alcohol, 66.7% (n
= 18) of the agencies indicated that the consumers would still
be eligible to receive services from their agency. Likewise, if
a consumer were using illegal drugs instead of alcohol, 59.3%
(n = 16) of agencies said they were still eligible for services.
Moreover, 77.8% (n = 21) of the participants reported that
they feel their state does have alcohol and other drug abuse
(AODA) services for persons with disabilities.
Concurrent Treatment and Rehabilitation
As noted earlier, participants were asked at the end of the
survey to provide 1-3 recommendations that they perceived
to be essential in implementing a concurrent substance
abuse treatment and VR program. Many suggestions were
provided from the participants and Thematic Analysis
techniques (Boyatzis, 1998) were utilized to identify common
or unique themes. Participants stated they were interested
in learning about evidence-based treatments of substance
abuse, (2) consumers must be screened properly and placed
in appropriate treatment (e.g., consumers are placed in
appropriate level of care consistent with the severity of their
substance use disorder [e.g., outpatient, intensive outpatient,
residential]), (3) VR counselors must be trained and have
knowledge of substance abuse, (4) family should be involved
in the process, (5) staff providing substance abuse treatment
must be licensed or certied as substance abuse counselors, (6)
an outpatient component that allows attendees to participate in
vocational assessments and job tryouts, (7) have a variety of
recreational and social activities in an integrated setting and
to include information of organizations in their community
so that clients can continue social activities to prevent relapse
after treatment completion. Three participants suggested that
to have effective concurrent treatment and VR services, there
needs to be zero tolerance for alcohol and drug use by the
consumer. More specically, if consumers are identied as
being current users, then they automatically become ineligible
for VR services.
Discussion
According to SAMHSA (2011), a large number of people
with disabilities in the United States (U.S.) are using or abuse
alcohol or other substances. Many consumers will seek state
VR services for help nding employment and successful
and long-term employment can be a positive inuencing
factor when looking at quality of life, life satisfaction, and
personal acceptance of disability among individuals with
disabilities (Smedema & Ebener, 2010). Therefore, screening
for SUD should be standard practice within state VR agencies
throughout the U.S. According to the results of this study,
6

Journal of Rehabilitation Volume 80, Number 4 7
59.3% of the agencies reported that they keep a record of
co-existing SUD; however, approximately 89% of agencies
reported they do not use a standardized instrument to screen
for SUD. Although the frequency distribution does not
allow for causal inferences to be made, it seems plausible
that professionals working in State VR may be unaware of
many of the issues presented for consumers with co-existing
disabilities. Furthermore, these professionals may also lack
the competencies needed to identify consumers with drug and
alcohol challenges, as demonstrated by earlier literature (e.g.,
Ong, Lee, Cha, & Arokiasamy, 2008). The barriers associated
with SUDS create problems with maintaining employment
(e.g., tardiness to work). Employment is often viewed not only
a desired outcome and element but as a means of establishing
a source of income and a way to boost self-esteem and re-
socialization (Ginexi et al. 2003). Employment has also been
shown to be a positive factor in the recovery process (see
Magura & Staines, 2004; Platt, 1995; West, 2008). The need
to identify individuals who are in need of AODA counseling
has created an opportunity for screening programs to be
developed and implemented in a wide variety of agencies.
This study also sought to examine how VR agencies react
when a consumer does have a coexisting disability. Programs
of the past would often subscribe to the model of treating the
SUDs rst before allowing a consumer to enter a VR program
(Benshoff & Janikowski, 2000). At least 37% of the agencies
represented in this study do require consumers to complete
substance abuse treatment before allowing them to enter VR
services; however, at least the same amount of agencies let
consumers complete both SUDs treatment and VR services
concurrently. Moreover, more than half of the responding
agencies would allow a consumer with a history of SUDs to
continue with VR services even if it was discovered that the
consumer was using alcohol or illicit drugs. This nding is
consistent with the literature that reported many VR agencies
still require sustained abstinence before services are rendered
(Ebener & Smedema, 2011). Perhaps this is because many
state VR counselors are not specically trained and certied
as AODA counselors, as described by Sligar and Toriello
(2007).
Specialized training in substance abuse counseling was
another recommendation by study participants in order to
facilitate concurrent SA and VR assistance. Furthermore,
a few participants suggested that consumers should be held
to a zero tolerance policy. It may be benecial to provide
educational interventions to discuss the addiction stages of
change model [Prochaska & Diclemente, 2005] (i.e., pre-
contemplation, contemplation, preparation-determination,
action, maintenance) and describe how relapse occurs in
addition to the other stages. Although it would be difcult to
provide training to VR counselors to help them obtain all of
the competencies needed to be substance abuse counselors, it
is imperative to provide them with the basic knowledge and
understanding on how to screen for SUDs, and the procedures
of how to work with a consumer that is identied as having
alcohol and drug barriers.
Limitations of the Study
Several limitations existed in this study. The results
of the study were based on a low sample size (N = 27),
therefore the results may not be generalizable to all state VR
program directors. Only one follow up mailing was sent to
non-respondents. Future studies may consider the use of
electronic surveys sent via e-mail with multiple follow ups
with non-respondents. The survey itself is also a limitation
as no pilot testing was utilized prior to deployment of the
survey. Survey items were created based on the absence of
information regarding these questions in previous literature
(see Glenn & Moore, 2008; Koch et al., 2008; Moore et al.,
2008, Pack, 2007) and were reviewed for face validity prior to
use in the study.
Recommendations
Based on previous literature, the authors recommend
public VR agencies perform routine screening for SUDs. If
SUDs are identied in new or existing consumers, they should
be referred for appropriate treatment while also being provided
with ongoing, parallel VR services (Koch et al., 2008).
Screening for SUDs can be completed in a manner of minutes.
No cost, quick assessments that VR agencies could utilize
include the CAGE, AUDIT, or the ASSIST. For example, the
CAGE (i.e., Cut, Annoy, Guilty, Eye) is a screening instrument
that has four questions (Ewing, 1984): (1) Have you ever felt
you should cut down on your drinking or drug use?, (2) Have
people annoyed you by criticizing your drinking or drug use?,
(3) Have you ever felt bad or guilty about your drinking or
drug use?, and (4) Have you ever had a drink rst thing in
the morning (i.e., eye opener) to steady your nerves or to get
rid of a hangover? Each question receives one point if they
provide a yes answer, and a total score of two or greater is
considered clinically signicant. These screening tools are
not meant to diagnose SUD as classied by the Diagnostic
and Statistical Manual (DSM IV-TR); however, they could be
used to detect potential SUDs and help determine if referrals
are needed. Only 7.4% of the current respondents reported
the use of a screening tool. Future research could examine the
reasons why public VR agencies do not routinely utilize these
assessments.
When SUDs are identied in consumers, the authors
recommend concurrent VR services to increases chances of
employment. This recommendation is consistent with Melvin
et al. (2012) who found that employment is a predictor of
substance abuse treatment completion. Although a majority
of respondents reported the possibility of concurrent treatment
and services, 37% reported that substance abuse treatment
must be completed prior to initiation of VR services. The
National Institute on Drug Abuse (NIDA) [2012] suggested
that addressing the individual’s drug abuse and any associated
medical, psychological, social, vocational, and legal problems
will lead to the most effective substance abuse treatment.
Moreover, NIDA suggested that replacing the drug abuse
behavior with an appropriate behavior (e.g., employment)
will lead to successful recovery from drug addiction. The
authors suggest reviewing the research-based main principles

Journal of Rehabilitation Volume 80, Number 4
of drug addiction treatment (see http://www.drugabuse.gov/
publications/principles-drug-addiction-treatment-research-
based-guide-third-edition/principles-effective-treatment).
Given the prevalence of SUDs among individuals with
disabilities, more research is needed on how public VR
agencies screen for SUDs and subsequently serve individuals
with SUDs.
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