Interest in and obstacles to pursuing work among unemployed dually diagnosed individuals

Preference for Competitive Employment in People with Mental Disorders: A Systematic Review and Meta-analysis of Proportions

PURPOSE

The inclusion of people with mental disorders (MD) into competitive employment has become an important political and therapeutic goal. The present paper investigates meta-analytically to which extent people with MD who were unemployed or on sick leave due to MD prefer to work in a competitive job environment.

METHODS

For this systematic review and meta-analysis of proportions, we searched Medline, PsycInfo, Cinahl, Google Scholar, and reference lists for peer-reviewed publications from 1990 to Dec 2023, which provided data on the job preferences of people with MD. Two authors independently conducted full-text screening and quality assessments. Pooled proportions of job preferences were calculated with a random-effects meta-analysis of single proportions, and subgroup analyses were performed to examine characteristics associated with job preferences.

RESULTS

We included 30 studies with a total of 11,029 participants in the meta-analysis. The overall proportion of participants who expressed a preference for competitive employment was 0.61 (95%-CI: 0.53-0.68; I2 = 99%). The subgroup analyses showed different preference proportions between world regions where the studies were conducted (p < 0.01), publication years (p = 0.03), and support settings (p = 0.03).

CONCLUSION

Most people with MD want to work competitively. More efforts should be given to preventive approaches such as support for job retention. Interventions should be initiated at the beginning of the psychiatric treatment when the motivation to work is still high, and barriers are lower.

TRAIL REGISTRATION

The protocol is published in the Open Science registry at https://osf.io/7dj9r.

Do adverse experiences predict unemployment and need of psychiatric help after treatment for drug use disorders?

Background: This study prospectively examined the association between adverse experiences (physical abuse, sexual abuse and parental substance use problems [SUPs]), not being employed, in education or training (NEET) and being in need of acute psychiatric help among patients receiving treatment for substance use disorders. Methods: A total of 580 adolescents and early adults aged 15-25 years enrolled in treatment for drug use disorders were included in the analyses. Treatment data were linked to participants' register data on employment, education and acute contact to psychiatric services for the following two years. Multivariable logistic regression models were used to examine associations between the three adverse experiences, NEET and need of acute psychiatric help, adjusting for confounders such as age, gender, ethnicity, treatment response and treatment condition. Results: More than half of the participants were NEET two years after treatment enrolment. After controlling for demographics and treatment conditions, NEET was predicted by parental substance use problems (odds ratio [OR] = 1.89, 95% confidence interval [CI] 1.31- 2.70), exposure to physical abuse (OR = 1.48, 95% CI 1.03-2.13) and non-abstinence (abstinence was negatively associated with NEET, OR = 0.53, 95% CI 0.37-0.76). Being exposed to two (OR = 3.17, 95% CI 1.93-5.21) and three types of adverse experiences (OR = 3.14, 95% CI = 1.47-6.70) predicted NEET more strongly than exposure to one type. One out of 10 participants sought acute care from psychiatric services at least once within two years after treatment. Only sex and ethnic minority status were associated with contacting psychiatric services acutely. Conclusion: The present study suggests that adverse experiences, such as being exposed to parental problematic substance use and physical abuse, may be important predictors for NEET after treatment for SUDs.

Health-related selection into employment among the unemployed

BACKGROUND

Successful transitions from unemployment to employment are an important concern, yet little is known about health-related selection into employment. We assessed the association of various physical and psychiatric conditions with finding employment, and employment stability.

METHODS

Using total population register data, we followed Finnish residents aged 30-60 with an unemployment spell during 2009-2018 (n = 814,085) for two years from the onset of unemployment. We predicted any, stable, and unstable employment by health status using Cox proportional hazards models. The data on specialized health care and prescription reimbursement were used to identify any alcohol-related conditions and poisonings, psychiatric conditions and self-harm, injuries, and physical conditions. We further separated physical conditions into cancer, diabetes, heart disease, and neurological conditions, and psychiatric conditions into depression, anxiety disorders and substance use disorders.

RESULTS

The likelihood of any employment was lower among those who had any of the assessed health conditions. It was lowest among those with alcohol-related or psychiatric conditions with an age-adjusted hazard ratio of 0.45 (95% confidence interval 0.44, 0.46) among men and 0.39 (0.38, 0.41) among women for alcohol-related and 0.64 (0.63, 0.65) and 0.66 (0.65, 0.67) for psychiatric conditions, respectively. These results were not driven by differences in socioeconomic characteristics or comorbidities. All the included conditions were detrimental to both stable and unstable employment, however alcohol-related and psychiatric conditions were more harmful for stable than for unstable employment.

CONCLUSIONS

The prospects of the unemployed finding employment are reduced by poor health, particularly alcohol-related and psychiatric conditions. These two conditions may also lead to unstable career trajectories. The selection process contributes to the health differentials between employed and unemployed people. Unemployed people with health problems may therefore need additional support to improve their chances of employment.

Employment Stress and Couple Adjustment among Clients With Disorders of Gambling and Alcohol Use: Themes of Transfers in Congruence Couple Therapy

Background

Individuals with problematic gambling, alcohol and substance use commonly report lower employment rates and more employment-related problems such as job loss, work conflicts and poor performance.

Method

A thematic qualitative analysis was conducted to extract employment-related themes from 21 sets of addiction counselors' case notes of couple therapy sessions (average 10 sessions per case) from a randomized controlled trial of Congruence Couple Therapy (CCT). Case notes were examined for the types of employment issues to answer the research question: What are the interconnections of employment, couple adjustment and addictive behaviors as revealed in the CCT counselors' case notes?

Results

Five key areas of employment-related stress were identified: (1) unemployment, (2) financial concerns, (3) history of crime, (4) overworking and workaholism, and (5) workplace conflict. These themes interacted negatively with couple adjustment and addictive behaviors. Using CCT as an intervention, clients gained skills in 4 areas transferred to employment: (1) awareness of self, other and family of origin, (2) congruent communication, (3) work-family balance, and (4) enlisting spousal support. These themes intersected with enhanced work functioning and reduced stress, alcohol use and gambling.

Conclusion

Employment problems negatively impacted addictive behaviors, couple adjustment and well-being of partners and clients. Skills and awareness gained in CCT promoted changes in addicted clients' employment functioning and coping with employment stress. The domains of work and couple adjustment are mutually influential in increasing or reducing stress with implications for addiction recovery. CCT as a viable intervention for enhancing employment function should be further studied.

"And then the rest happened"- A qualitative exploration of the role that meaningful activities play in recovery processes for people with a diagnosis of substance use disorder

Background: In this qualitative exploration, we report on a thematic analysis of the key role that engaging in meaningful activities may play in recovery processes for people with a diagnosis of substance use disorder (SUD). Methods: We conducted semi-structured, individual interviews with 30 participants and analyzed the parts of this material that were related to meaningful activities. Results: The findings are summarized through the development of three broad themes: (a) the central role of work-"The wages suck, but the job is gold"; (b) mastery and commitment-"I had to get up early, find my spot, I had to be present and fully functioning all day"; and (c) repairing the bridge to community life-"It's my job and working out that has made this possible, really, I see that now." Conclusion: We discuss these findings in relation to a recovery perspective and relevant empirical studies, highlight some important implications for research and practice, and consider the strengths and limitations of the present study.

The role of occupational meaningfulness and citizenship as mediators between occupational status and recovery: a cross-sectional study among residents with co-occurring problems

Purpose

Engagement in meaningful occupations and being included as full citizens of the community, is essential in everyday life, and may be of considerable relevance for recovery and quality of life. However, persons with co-occurring substance use and mental health problems experience extensive obstacles to engagement in occupations and citizenship. The relationship between objective measures of occupational status and subjective experiences of occupational meaningfulness, citizenship and recovery, is scarcely researched in the context of co-occurring problems. As such, the purpose of this study is to examine associations between occupational status, occupational meaningfulness, citizenship and recovery and quality of life and to examine the roles of occupational meaningfulness and citizenship as possible mediators between occupational status and recovery and quality of life.

Design/methodology/approach

The study used a cross-sectional design with a sample of 104 residents at supported housing sites across six Norwegian cities.

Findings

Linear regression analyzes indicated that occupational status was significantly associated with the citizenship domains caring for others and community participation and with the quality of life measure positive affect. Occupational meaningfulness and citizenship were significantly associated with different domains of recovery and quality of life. Furthermore, mediation analyzes showed that the relationship between occupational status and recovery and quality of life was mediated by caring for others and community participation.

Originality/value

The results suggest that emphasizing opportunities for occupational meaningfulness and citizenship in practice may have positive implications for recovery among persons with co-occurring problems.

Review of Individual Placement and Support Employment Intervention for Persons with Substance Use Disorder

Objectives: Work is a critical part of recovery for many people with chronic health conditions, including Substance Use Disorders (SUD). Individual Placement and Support (IPS) is an evidence-based practice designed initially for adults with mental illness. Although the evidence for using IPS with individuals with severe mental illness is well documented, less is known about the efficacy of using IPS with consumers with substance use disorders, and the results have yet to be systematically evaluated and organized. Key components of zero exclusion, rapid competitive job search, and incorporation with treatment services as well as benefits are components that make IPS a strong practice to incorporate into substance abuse treatment. This study aims to evaluate and organize the evidence base of using IPS with adults with substance use disorders. Results: A systematic review was conducted of meta-analyses, reviews, and individual studies from 2000 through 2019, measuring the efficacy of IPS with individuals with SUD or comorbid SUD. Databases searched were Scopus, PubMed, and PsychInfo. Experimental and quasi-experimental studies are reviewed and critiqued for their application to a SUD population. Then, barriers and facilitators of IPS implementation with this population are discussed. Conclusions/Importance: There is a high evidence to support to application of IPS for persons with SUD, both singly and when combined with a mental health disorder. Barriers to IPS implementation including episodic treatment, risk of relapse, and housing or criminal justice instability make the IPS program a useful best practice to consider for this population.

Change in employment status and cocaine use treatment outcomes: A secondary analysis across six clinical trials

BACKGROUND

Unemployment is a chronic problem among treatment seeking substance users and is associated with poor treatment response. Most studies that have examined the relationship between employment and treatment outcomes for substance use disorders have done so by considering employment at only one specific point in time (e.g., upon entering treatment). There is a lack of research on how change in employment status over time is associated with substance use treatment outcomes. The aim of this study was to evaluate both static employment status and change in employment status over time as predictors of cocaine use treatment outcomes.

METHODS

We utilized data pooled from six randomized clinical trials evaluating treatment for cocaine use disorders (n = 553). Multiple general linear mixed models were conducted to determine the association of baseline, end-of-treatment, and change in employment status (from baseline to end-of-treatment) with treatment outcomes.

RESULTS

Treatment outcomes did not differ by baseline employment status but were significantly better for those employed versus unemployed at the end-of-treatment. In regard to change in employment status over time, those who were unemployed at baseline and acquired employment by end-of-treatment had significantly better treatment outcomes during active treatment and follow-up, as compared to those who were unemployed at baseline and remained unemployed by end-of-treatment.

CONCLUSION

Our findings suggest that end-of-treatment employment status may be an important marker of good outcome among those unemployed at treatment entry and support the incorporation of interventions designed to promote employment by substance use disorders treatment programs.

The Impact of Dual Diagnosis on Drug Court Failure

There is limited research investigating the relationship between dual diagnosis and drug court outcomes. The current study examines the relationship between dual diagnosis and drug court failure by specific failure type. Utilizing data from a large urban drug court in the Southwestern United States, the study finds mixed results regarding the impact of dual diagnosis on drug court failure. Specifically, while there was no evidence that dual diagnosis predicted overall success/failure, dual diagnosis significantly increased the odds of serious program failure (e.g., new offense, absconding, revocation). In contrast, dual diagnosis significantly decreased the odds of less serious failure (e.g., rule violation, relapse).

Validating the client-focused considering work model for people living with HIV and quantifying phases of change of commitment to work

The primary purpose of this study was to validate the client-focused considering work model and to gain a better understanding of the nature of the relationship among the four domains purported to influence the considering work process (medical, psychosocial, financial/legal and vocational). A second goal of the study was to quantify the relationship between these four domains and the phases of considering work (contemplation, preparation, action, resolution). Structural equation modeling was used to analyze data of 1702 diverse (43% Black, 31% White, 19% Latino 7% other) unemployed respondents who were recruited from AIDS Service Organizations (ASO) and networks across the United States to complete the National Working Positive Vocational Development and Employment Needs Survey (NWPC-VDENS). Overall the results of this study supported the validity of the client-focused considering work model and helped to provide a deeper level of understanding of the relationship among the domains of influence and their contribution to the level of commitment to the considering work process. Implications for Rehabilitation This model enables rehabilitation professionals to consider interventions for clients at different phases (contemplation, preparation, action) of considering work. Rehabilitation professionals are encouraged to provide prevocational services to engage people with HIV in the considering work process. When assisting PLWH within the considering work process, it is important to assess not only medical status but also psychosocial, financial and vocational concerns.

Women’s Employment Outcomes Following Gender-Sensitive Substance Abuse Treatment

Employment problems are common among low-income, substance abusing women. The present study links an empirically developed quantitative measure of gender-sensitive (GS) substance abuse treatment to employment outcomes among substance abusing women ( N = 5,109) treated in 13 mixed-gender intensive inpatient programs (IIPs) in the Washington State. Hierarchical linear models were used to test the relationship between GS treatment and subsequent employment. Propensity scores and receipt of public assistance were used to control for the preexisting differences among women. Men’s employment outcomes were used to control for potential confounding at the program level. The study found that women treated in more (vs. less) GS treatment programs were more likely to be employed 12 months after treatment admission, though not for the hypothesized 24 months. Treatment completion did not affect the relationship between GS treatment and employment. Findings point to recent progress in tailoring generic substance abuse treatment to women’s needs.

Rate and predictors of employment among formerly polysubstance dependent urban individuals in recovery

Employment is a key functioning index in addiction services and consistently emerges as a goal among individuals in recovery. Research on the employment status in the addiction field has focused on treatment populations or welfare recipients; little is known of employment rates or their predictors among individuals in recovery. This study seeks to fill this gap, capitalizing on a sample (N = 311) of urban individuals at various stages of recovery. Fewer than half (44.5%) of participants were employed; in logistic regressions, male gender and Caucasian race enhanced the odds of employment, whereas having a comorbid chronic physical or mental health condition decreased the odds by half. Implications center on the need to identify effective strategies to enhance employability among women and minorities and for integrated care for individuals with multiple chronic conditions.

Propensity to work among chronically unemployed adult drug users

Analyses were conducted to compare rates of employment before, during, and after employment at the therapeutic workplace, which is a novel employment-based treatment for drug misuse. Participants in two clinical trials attended the therapeutic workplace at higher rates than they worked before intake and six months after discharge. These data suggest that unemployed chronic drug misusers will attend work at higher rates at the therapeutic workplace than in the community when paid modest wages, and that the failure of chronic drug misusers to obtain employment in the community may not result from lack of interest in work.

Predictors of referral to Supported Employment among consumers with co-occurring mental and substance use disorders

Clinical trials demonstrate that Supported Employment is effective in assisting persons with severe mental illness in obtaining competitive employment. However, little is known about the factors related to consumers' decisions to pursue employment, especially for consumers with co-occurring substance and mental disorders. This study examines the demographic, socioeconomic and illness characteristics of consumers referred for Supported Employment services. Consumers were drawn from Integrated Dual Diagnosis Treatment programs in four community mental health agencies. Study participants included 113 consumers referred for Supported Employment services and 78 randomly selected non-referred consumers as the comparison group. Results suggest that consumers who have past work experience are more likely to be referred to Supported Employment, while consumers who perceive themselves as disabled or who are diagnosed as substance dependent are less likely to be referred to Supported Employment. Implications for agency practice and future research are discussed.

Mental Health as a Mediator of Gender Differences in Employment Barriers among Drug Abusers

Employment has been identified as an important drug abuse treatment outcome, but drug abusers often face a wide variety of barriers to securing stable employment. The employment barriers literature also reports that women and people with mental health problems have difficulty in obtaining employment. The current study examined gender differences in mental health and employment barriers in a sample of drug court participants. Hierarchical regression analyses were conducted to test the hypothesis that differences in employment barriers among drug-abusing males and females are mediated by differences in mental health problems. Women were found to have more mental health problems and employment barriers, and support for the mediation hypothesis was found. Implications for drug treatment providers are discussed.

Effectiveness of dual focus mutual aid for co-occurring substance use and mental health disorders: a review and synthesis of the "Double Trouble" in Recovery evaluation

Over 5 million adults in the United States have a co-occurring substance use disorder and serious psychological distress. Mutual aid (self-help) can usefully complement treatment, but people with co-occurring substance use and psychiatric disorders often encounter a lack of empathy and acceptance in traditional mutual aid groups. Double Trouble in Recovery (DTR) is a dual focus fellowship whose mission is to bring the benefits of mutual aid to persons recovering from co-occurring disorders. An evaluation of DTR was conducted by interviewing 310 persons attending 24 DTR meetings in New York City (NYC) in 1998 and following them up for 2 years, in 1999 and 2000. The evaluation produced 13 articles in 12 peer-reviewed journals, the main results of which are summarized here. The sample's characteristics were as follows: mean age, 40 years; women, 28%; black, 59%; white, 25%; Hispanic, 14%; never married, 63%; live in supported community residence, 53%; high school graduate or GED, 60%; arrested as adult, 63%; diagnoses of: schizophrenia, 39%; major depression, 21%; or bipolar disorder, 20%; currently prescribed psychiatric medication, 92%; primary substance used, current or past: cocaine/crack, 42%; alcohol 34%; or heroin, 11%. Overall, the findings indicate that DTR participation has both direct and indirect effects on several important components of recovery: drug/alcohol abstinence, psychiatric medication adherence, self-efficacy for recovery, and quality of life. The study also identified several "common" therapeutic factors (e.g., internal motivation and social support) and unique mutual aid processes (helper-therapy and reciprocal learning) that mediate the influence of DTR participation on recovery. For clinicians, these results underline the importance of fostering stable affiliation with specialized dual focus 12-step groups for their patients with co-occurring disorders, as part of a comprehensive recovery-oriented treatment approach.

Measuring employment among substance-using offenders

Employment has been identified as an important predictor of drug abuse treatment outcome; however, employment has been measured in a variety of different ways in the drug abuse literature and typically with community samples. The present IRB-approved study used factor analysis to identify commonalities among several employment measures collected from a sample of drug court offenders who entered one of two Kentucky drug courts between March 2000 and November 2002. Measures included demographics, employment, substance use, and criminality. The factor analysis produced four employment factors: status, earnings, duration, and stability. These factors had different correlation patterns with substance use and criminality. Study limitations are noted.

Treatment for dual diagnosis patients in the psychiatric and substance abuse systems

The purpose of this study was to describe and compare the extent to which psychiatric and substance abuse programs treating dual diagnosis patients in the residential and outpatient modalities offered the components recommended for this client group. Surveys were completed by managers of 753 programs in the Department of Veterans Affairs that had a treatment regimen oriented to dual diagnosis patients. Programs within both the psychiatric and substance abuse systems had some of the key services of integrated treatment (e.g., assessment and diagnosis, crisis intervention, counseling targeted at psychiatric and at substance use problems, medications, patient education, HIV screening and counseling, family counseling and education). However, compared to psychiatric programs, substance abuse programs were more likely to offer some of these services and other critical components (e.g., a cognitive-behavioral treatment orientation, assignment of a single case manager to each patient). Outpatient psychiatric programs were particularly lacking on key management practices (e.g., use of clinical practice guidelines, performance monitoring of providers) and services (e.g., detoxification, 12-step meetings) of integrated treatment. Generally, differences between psychiatric and substance abuse programs appeared to involve difficulties in developing treatment that is fully oriented toward the co-occurring diagnosis. To improve the provision of high-quality dual-focused care, we recommend planners' use of cross-system teams and applications of recently produced tools designed to increase programs' ability to deliver integrated care to dually disordered individuals.

Which substance abuse treatment facilities offer dual diagnosis programs?

This report examines the distribution of specialized programs or groups for dual diagnosis clients in substance abuse treatment facilities across the United States and the availability of services often needed by this client population at these facilities. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were used to assess the geographic distribution and the characteristics of facilities that offer dual diagnosis treatment programs/groups and to examine the other clinical, social, and health services available in these facilities. Overall, 49.9% of all U.S. substance abuse treatment facilities offered dual diagnosis programs/groups. There were no clear regional variations on availability of these services. There were, however, clear variations based on facility ownership and treatment modality. Facilities owned by the federal, state, and local governments, and those offering inpatient treatment were more likely than were other facilities to offer dual diagnosis programs/groups. A large proportion of facilities with specialized dual diagnosis programs/ groups did not offer mental, social, or health services often needed by dual diagnosis clients. It is concluded that specialized programs for dual diagnosis clients are offered in many different substance abuse treatment facilities, attesting to the growing recognition of the special needs of this group of clients. However, dissemination of comprehensive services often needed to meet the special needs of these clients has not kept pace with the spread of specialized programs, highlighting the need for establishing and implementing standard evidence-based guidelines for dual diagnosis treatment programs in these settings.