Promoting Economic Self-Sufficiency Among Women with Co-Occurring Disorders and Histories of Violence: PROTOTYPES Systems Change Center May 2003 Innovations From the Sites Women with substance abuse and mental health problems who have histories of violence face a variety of challenges when trying to establish and maintain economic self-sufficiency. To address these challenges, PROTOTYPES Women’s Center has created a comprehensive program to support women in achieving this goal. One of nine SAMHSAfunded Women, Co-Occurring Disorders and Violence Study sites, PROTOTYPES, Centers for Innovation in Health, Mental Health, and Social Services, the parent organization for the Women’s Center, incorporated welfare reform issues within its proposed project for the study. PROTOTYPES saw the “crisis” of welfare reform as a core concept in readiness to change systems. Therefore, preparing the women for the challenges of TANF (Temporary Assistance to Needy Families) was an integral part of PROTOTYPES’ work from the beginning of the project. PROTOTYPES, a large multi-services agency in Los Angeles County, provides residential, outpatient, and day treatment services for substance abuse, mental health, HIV/AIDS, and domestic violence and other trauma services to women and children. Promoting financial self-sufficiency is central to its treatment philosophy. By incorporating a comprehensive treatment approach that includes income and job support, the program helps women work towards economic independence. Support mechanisms assist them throughout the different stages of the process. The program addresses women’s changing needs around income and employment as they progress through treatment. IMPACTS OF SUBSTANCE ABUSE, MENTAL ILLNESS, AND TRAUMA There are generally four stages to establishing economic self-sufficiency for women with co-occurring disorders and histories of violence: • Accessing welfare and other benefits while women are in treatment • Preparing for workforce entry through job training and on-site vocational tracks • Active job seeking and entry into the workforce • Ongoing support to maintain employment Passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 transformed a 60-year federal commitment to income support for needy families into a temporary assistance program granting states the authority to determine eligibility and benefits. This law emphasizes workforce entry and establishes time limits that mandate work after two years (or as short as two months in some states), and creates a lifetime cap on benefits after five years. Strict time requirements on welfare benefits can be problematic for women with co-occurring disorders and histories of violence. Recent research has found that women who have experienced severe violence over their lifetimes are more likely to remain on welfare for longer periods (Tolman & Rosen, 2001; Honeycutt & Marshall, in press; Barusch, Taylor & Derr, 1999). Research has also examined the impact of violence on women’s capacity to gain and maintain employment. Raphael (1995, 1996) has documented how interference from an abuser (such as keeping a woman up all night with arguments before a job interview, inflicting visible facial injuries, threatening to kidnap children, and in-person harassment on the job) can impinge upon a woman’s ability to work. A report by the Urban Institute (1996) on a multi-site study of welfare-to-work programs revealed that many women were struggling with depression, learning disabilities, low self-esteem, and fear of failure. Substance abuse and mental health issues may also impact women’s abilities to obtain and maintain employment (Danzinger, et al., 2000; Browne, Salomon & Bassuk, 1999; Allard, et al., 1997). The Urban Institute (1996) found substance abuse and mental health issues to be significant barriers to employment. One study showed that mental health disorders reduced a woman’s chance of maintaining work by approximately one-half (Browne, Salomon & Bassuk, 1999). Without adequate support, women with experiences of substance abuse, mental health problems, and histories of trauma struggle to achieve economic independence (Browne, Salomon & Bassuk, 1999; Lloyd, 1997). BARRIERS TO ACCESSING TANF BENEFITS Upon admission to PROTOTYPES, many women are already receiving some form of welfare benefit. Those who are not enrolled are encouraged to apply for California’s Temporary Assistance to Needy Families (TANF) program, otherwise known as California Work Opportunity and Responsibility to Kids (CalWORKs). One of the largest barriers in seeking TANF benefits is women’s fear of losing their children. If they admit to having substance abuse, mental health, and trauma issues, women worry that the state will remove the children from their care. In addition to their fears, the complex application procedures for TANF benefits can also be intimidating for women who are just beginning treatment. Already dealing with many issues related to their recovery, the addition of a complicated enrollment process may feel overwhelming. According to Marta Munoz, Assistant Director of the Vocational and Employment Services Program at PROTOTYPES, women often “do not get the information they need and do not know how to apply for the funds. They may not understand what signing their welfare-to-work contract means.” Further complicating matters, TANF workers may be unaware of the issues women are facing. For example, they may not know that trauma and abuse experiences are often the primary reasons for substance abuse and mental health problems in women. Furthermore, the TANF program is frequently seen as a “work first” program, which can lead to on-going tension between the women’s needs for treatment versus their need to find gainful employment. Finally, without an understanding of their clients’ experiences, TANF workers may be less sensitive to the challenges women face, particularly those with children. Criminal records may also be a barrier, since many women with substance abuse histories have also been involved in the criminal justice system. California residents with felony convictions, depending on the nature of the crime, are not eligible for certain welfare benefits. Finding employment also can be difficult with a criminal record. Thus, a vicious cycle is created: without the options of welfare assistance or employment, a person may be more likely to engage in illegal activity to gain income to survive. Perhaps the most significant barrier is the time limits on benefits imposed by welfare reform. California’s mandate to enter the workforce within two years may be unrealistic for many women in recovery. Laurie Pendroff, Deputy Director of the Women’s Center at PROTOTYPES, notes that “many of [our clients] are struggling with addiction and have very poor work histories. When they come through our doors, they need much more than what the timelines require. We’re finding we have to adjust our treatment accordingly.” Former PROTOTYPES client Terry Wright, now the Food Services Coordinator for the program, speaks from her experience as a recovering addict, “I was a woman with a 21-year addiction. When I got here, I had to learn to do everything all over again, and that’s basically learning how to live all over again. After 21 years of usage, there were a lot of things I wasn’t necessarily ready to address at that time. We deal with women with multiple disabilities and recovery is a long-term process.” THE PROTOTYPES APPROACH TO ACCESSING TANF BENEFITS PROTOTYPES has responded to many of the challenges women face when trying to access TANF funds by implementing unique strategies to address both systems issues and the individualized concerns of their clients. ¦ Welfare Department Buy-In PROTOTYPES has established good relationships with local welfare department staff. The head of the local Los Angeles County office serves as a member of PROTOTYPES’ Coordinating Body, otherwise known as the Local Experts Group. In this role, she gained a detailed understanding of the needs and challenges for these women, and the goals of the treatment program. The local TANF office has become more responsive to PROTOTYPES’ clients as a result of this collaboration. In addition, PROTOTYPES has access to both administrative and caseworker staff at the TANF office, allowing them to address systems and client-level issues more effectively. ¦ Cross-Training Training of welfare department and PROTOTYPES employees has alleviated many barriers. Training for welfare department employees focuses on sensitivity and awareness, and the impact of trauma on the lives of women with substance abuse and mental health issues. Dr. Vivian Brown, President and Chief Executive Officer at PROTOTYPES explains, “It is important to let them know that most women who are substance abusers also have some sort of mental illness and are almost always traumatized. Since substance abusing moms tend to be looked at negatively, knowing that trauma is a driver of substance abuse has really improved sensitivity towards the moms.” In turn, PROTOTYPES staff are trained on TANF procedures and regulations. CalWORKS organizes a bi-monthly forum for all local service agencies to provide the opportunity to work through some of the challenges associated with accessing TANF. Other training for PROTOTYPES staff focuses on a variety of topics, including application procedures, time limits, receiving treatment under welfare-to-work contracts, and work requirements. ¦ Client Orientation Sessions PROTOTYPES staff conduct orientation sessions to familiarize their clients with the welfare system. These are intended to simplify the TANF application process, and alleviate anxiety about procedures and regulations. These sessions are often conducted at the local welfare office in the presence of TANF employees. PROTOTYPES staff feel the orientation is helpful, noting that women appreciate hearing from people who are familiar and more sensitive to their issues, particularly at this early point in the recovery process. ¦ On-Site Welfare Department Staff A welfare department staff member is available on-site at PROTOTYPES to work individually with PROTOTYPES clients to ensure they have a solid understanding of TANF application procedures and regulations. Terry Wright explains that the welfare department worker “takes one person at a time, and she’s very specific in terms of what she’s explaining. That’s a big plus.” ¦ The “Buddy System” PROTOTYPES has established a “buddy system” for women traveling to the TANF office. Women who feel nervous about going to the TANF office alone can “pair up” with a PROTOTYPES staff member who will accompany them to ease their anxiety and serve as a “bridge” between the two worlds. JOB TRAINING AND SKILLS DEVELOPMENT Many women with co-occurring disorders and histories of violence have limited work histories and are unfamiliar with meeting the responsibilities associated with maintaining employment. Clients entering treatment have frequently either been supported by a partner or have supported themselves by engaging in sex work. With gaps in their work experience, they must learn or relearn the skills necessary for the workplace. This may be difficult for women just entering recovery. The amount of time needed to acquire new work skills can also be frustrating, particularly as women attempt to learn quickly to meet the constraints of welfare benefits limits. Furthermore, when working with trauma survivors, the need for trauma-informed vocational training is critical. Staff must always be cognizant of situations that might trigger traumatic reactions. As women prepare for the workplace through job training, gaining mastery of work behaviors can be challenging. Laurie Pendroff explains, “The issues for our clients are responsibility and obligation. These concepts don’t come easily for several reasons. Some women have been out on the streets for many years. Frequently, our job is really re-training people, working with them to wake-up on time, figuring out what you are going to do with your children, working with co-workers you may or may not get along with, and dealing with a supervisor who may or may not be the best match. Learning new work behaviors while focusing on treatment and recovery is hard.” VOCATIONAL AND EMPLOYMENT SERVICES: A CORE COMPONENT OF THE PROTOTYPES TREATMENT PLAN The Vocational and Employment Services Program is a core component of the PROTOTYPES treatment plan. By integrating vocational training and skills development into treatment, clients are helped to understand the value and demands of work, learn or reestablish skills and work behaviors, and develop the independence necessary to obtain and maintain employment. The program is divided into four components: the first two focus heavily on training and skills development; the later stages are geared towards active job-seeking strategies and integration into the community. An Orientation and Assessment Phase provides an introduction to work. Following this, women move on to the Work Adjustment and Training Phase. Here, they are exposed to real-life work experiences via onsite simulated work environments called vocational tracks. These tracks combine classroom instruction with didactic 10 to 12-week work placements to promote job training and skills development. Areas covered include: communication skills, problem solving, values and feelings, interpersonal relations, managing stress, resume building, job applications, and interviewing techniques. The program offers a variety of on-site options or vocational tracks in several different fields: computers, office skills, horticulture and landscape, parenting and childcare, food services, and reception. The women can also learn retail skills at the off-site PROTOTYPES thrift stores. Integrating work experience as a core component of treatment has been very beneficial, according to PROTOTYPES staff. Certain aspects of the program have been particularly helpful in addressing the needs of women with co-occurring disorders and trauma histories as they prepare for work. ¦ A Structured Environment The program’s structure and consistency is intended to keep women committed to treatment and recovery. Though initially difficult, women eventually become accustomed to the structure and, in some cases, appreciate it. As the Food Services Coordinator within the Food Services vocational track, Terry Wright notes, “After ten weeks, my girls are committed to me and to working. That’s what makes it so special for me. They love the structure after a time, but you have to get them to like where they’re at and what they’re doing. You look at one person coming in telling you ‘I don’t want to be here,’ and by the end, you can’t get them out of the kitchen. That’s the miracle of it all. That’s the blessing.” ¦ Ongoing Staff Support Support and encouragement from program staff is essential as women prepare themselves for work. Vocational and Employment Services staff work intimately with clients to teach them skills, address their concerns about work, and support them throughout the job training process. As Food Services Coordinator, Terry Wright spends much of her time during the early stages of the program emphasizing the positive aspects of work. She teaches problem-solving skills and empowers women to make decisions for themselves. If a client happens to make a choice she regrets, Terry encourages her not to be hard on herself, but rather think about how things could be done differently the next time. She teaches a full range of food services skills from the basics of food preparation and safety and sanitation, to more universal job skills such as communication, self esteem, self-advocacy, and time management. At the end of the training, Terry notes, “It’s not about who’s the greatest cook, it’s about the commitment, and after ten weeks my girls are committed.” ¦ Incorporating a Focus on Trauma The Vocational and Employment Services Program was modified to meet the needs of women with histories of trauma. Certain tracks that were once mandated components of treatment are now optional for women with histories of violence and abuse. This provides women with choices about participation in activities that might make them uncomfortable. For example, the childcare track was found to be anxiety-provoking for some women, particularly those who had been victims of childhood abuse. Food service was also found to trigger traumatic memories for some clients. Therefore, women choose which vocational tracks they wish to participate in. ¦ Choice of Work Roles Women are encouraged to explore a variety of roles to determine the best fit. Since many women have limited work experience or skills, PROTOTYPES staff encourage them to consider jobs that might be seen as non-traditional for women. Dr. Elke Rechberger, Director of the Systems Change Center, states, “These vocational paths provide a different conceptualization for women about what types of work they can do, and what their strengths are. Non-traditional jobs such as plumbing, welding, and mechanical repair also provide women a living wage that may be more difficult to obtain in other work environments.” PROTOTYPES seeks to provide training for women wishing to pursue these skill areas. For example, when a building at the PROTOTYPES facility was being remodeled to create extra bathrooms, a group of women learned how to tile and install plumbing during the process. There are additional therapeutic benefits associated with this type of work: Dr. Vivian Brown, CEO, who participated in the remodeling project, states, “Women feel a sense of accomplishment when they can manually create something that takes creativity, dexterity, and skill.” THE CHALLENGES OF COMMUNITY INTEGRATION AS WOMEN ENTER OR RE-ENTER THE WORKFORCE At the completion of the 10 to 12- week vocational track, both the supervisors and the women themselves conjointly determine who is “work-ready.” These women then move onto the next phase of the program, Community Integration, where they learn job-seeking strategies, develop individualized job search plans, and participate in peer-support activities. They also prepare for the Community Re-Entry Phase, during which they take on temporary placements or internships that may be either volunteer or paid positions. As women begin the process of accessing employment opportunities, several new challenges emerge. Many clients have been out of the workforce for several years and are intimidated by the thought of work. They fear failure and worry about appropriate work roles. Additionally, they may not have a wardrobe suitable for the workplace. Physical appearance can also inhibit their ability to access employment. Terry Wright explains, “Say, for instance, you have a person with several tattoos, a lot of piercings, tear drops down the eyes indicating gang affiliation, or disfigurements in her face because of domestic abuse. You know in your heart that the client can do the work, but the employer doesn’t want to take the risk. She might say all the correct things but if she doesn’t look the part, that becomes one of the biggest barriers.” In Los Angeles County, one of the most significant barriers for women is transportation. The area is large and spread out geographically with substandard public transportation. Women typically do not own cars, and view the bus system as inadequate and unsafe. Pomona, the location of PROTOTYPES, is situated at the county line, requiring public transportation passengers to transfer to a different transportation system. Travel to a job that might take 20 minutes by car can take two hours by public transportation. After women enter the workforce, job retention becomes a major challenge. Clients who have been unemployed for several years may be overwhelmed by the responsibilities imposed by work. PROTOTYPES staff are cognizant about the potential surfacing of trauma dynamics while on the job. Systems Change Center Director Dr. Elke Rechberger states, “Educating personnel across all points of the benefits and employment process to realize that concomitant job training in a supportive environment leads to better outcomes has been helpful.” Other logistical barriers can challenge a woman’s ability to maintain work. Since most clients are still undergoing treatment when they enter the workforce, coordinating their treatment schedules with work hours can be difficult. Laurie Pendroff explains, “Since our clients are returning to work more quickly because of welfare reform, the whole timeline is more difficult. A person may still have some core treatment to continue and also have to go to work. Maybe the group that a client needs is offered at 1:30 in the afternoon, but she’s at work from 10 to 5. Being able to get the treatment she needs while being productive at work is difficult.” Lack of childcare further complicates the situation. TANF has helped alleviate some of the cost, but there are too few providers to serve all the women who require help. PROTOTYPES’ SUPPORT FOR ACTIVE JOB SEEKERS AND NEW EMPLOYEES PROTOTYPES has developed useful strategies to overcome some of the barriers associated with job placement and retention. ¦ On-Site Employment Counselors Women are assigned employment counselors to assist them with every aspect of job preparation and employment. If necessary, these staff members work with women individually throughout their time in the Vocational and Employment Services Program. When women are employed, staff follow-up extensively to monitor their progress, and address individual needs and concerns. ¦ Job Club The Job Club is a peer support group for clients who are actively seeking employment or working that is facilitated by Vocational and Employment Services staff. Here, women share their experiences about job seeking, job leads, and frustrations about the challenges of working. Staff believe the group has been extremely beneficial. Marta Munoz, Assistant Director of Vocational and Employment Services states, “It helps keep women focused from week to week and they can encourage each other. Maybe somebody just secured a job and they can talk about that.” ¦ On-Site Resources PROTOTYPES offers a variety of resources and supports to assist women with job training and job seeking. An on-site computer center allows women to develop computer skills. They receive help with resume preparation and interviewing techniques. Recognizing that many of the women do not own appropriate business attire, PROTOTYPES provides two outfits for all newly employed women as part of their “Working Women’s Wardrobe.” Additional professional attire and accessories can be obtained at the PROTOTYPES thrift stores. ¦ Connections with Local Employers PROTOTYPES has established relationships with many local employers and has tried to raise awareness about the challenges facing women with co-occurring disorders and trauma histories. Their connections within the community have helped in securing job placements for women. They have also collaborated with a local university to sensitize employers about the issues women with co-occurring disorders and histories of violence face. Funding is being sought to continue this work. As clients enter the workforce, and prove their capabilities and commitment, employers take notice and show greater interest and willingness to hire women in recovery. One example is the relationship PROTOTYPES has established with a local Holiday Inn. As Marta Munoz states, “If employers have any problems or issues with our clients, they can contact us. If there is anything they need to support clients, we can provide it. This way, the employers also have support.” ¦ Staff and Employer Flexibility PROTOTYPES has worked to alleviate some of transportation and logistical issues. If a group of women is working in the same area, a staff member might provide them with transportation to and from the bus line. This helps with safety concerns, as women do not have to ride public transportation alone. The PROTOTYPES thrift stores have been able to obtain donated cars that are safe and sell them to women at the lowest possible price. Coordination of treatment with work schedules and childcare has been best addressed by helping women find jobs that offer some degree of flexibility. The relationships PROTOTYPES has developed with local employers has helped with this. ¦ Job Coaching To alleviate the anxiety sometimes experienced during the first few weeks in the workplace, a staff member accompanies women to the job site to offer support as they adjust to the new work environment. On-site job coaching has been very helpful with many clients. Among all the supports PROTOTYPES has implemented to help women in recovery succeed at making the transition from welfare to work, their dedicated staff has been most critical. Women have access to teams of caring individuals who support them throughout the duration of treatment. As Dr. Vivian Brown, President and Chief Executive Officer, explains, “with every challenge, there is a committed group of people to support and encourage the women.” This multidisciplinary team effort seems to make the process a little easier. For more information please contact: Elke Rechberger, Ph.D. PROTOTYPES Director, Systems Change Center 5601 W. Slauson Avenue, Suite 235 Culver City, CA 90230 (310) 641-7795, ext. 152 erechberger@prototypes.org www.prototypes.org ~ “With every challenge, there is a committed group of people to support and encourage the women.” —Dr.Vivian Brown, President and Chief Executive Officer, ~ The Women, Co-Occurring Disorders and Violence Study is generating knowledge on the development of integrated services approaches for women with co-occurring substance abuse and mental health disorders who also have histories of physical and/or sexual abuse. This Innovation From The Site was written by Brandy D’Ambrosio of the National Center on Family Homelessness, and is a product of the Women, Co-Occurring Disorders and Violence Coordinating Center which is operated by Policy Research Associates, in partnership with the National Center on Family Homelessness and the Cecil G. Sheps Center for Health Services Research. The Coordinating Center provides technical assistance to program sites, conducts cross-site process and outcome evaluations, and develops a range of application products from the study sites. The Women, Co-Occurring Disorders and Violence Study is funded by the Substance Abuse and Mental Health Services Administration’s three centers – The Center for Substance Abuse Treatment, The Center for Mental Health Services, and The Center for Substance Abuse Prevention. For more information on this Initiative, please contact Policy Research Associates, 345 Delaware Avenue Delmar, NY, 12054, 518-439-7415, e-mail: wvcc@prainc.com, web: www.prainc.com. RESOURCES: Barriers to Employment of Welfare Recipients S. Danziger, M. Corcoran, C. Heflin, A. Kalil, J. Levine, D. Rosen, K. Seefeldt, K. Siefert, and R. Tolman In R. Cherry and W. Rodgers (Eds) The Impact of Tight Labor Markets on Black Employment Problems, Russell Sage, 2000 Designing Welfare-to-Work Programs for Families Facing Personal or Family Challenges: Lessons from the Field L. Pavetti, L.Olson, N. Pindus, M. Pernas, and J. Isaacs Washington, DC: Urban Institute and American Institutes for Research, 1996 (202) 833-7200 www.urban.org Domestic Violence in the Lives of Women Receiving Welfare: Mental Health, Health and Economic Well-Being R. Tolman and D. Rosen In Violence Against Women, 2001, 7(2), 141-158 Domestic Violence: Telling the Untold Welfare-to-Work Story J. Raphael Chicago, IL: Taylor Institute, 1995 (773) 342-4532 Prisoners of Abuse: Domestic Violence and Welfare Receipt J. Raphael Chicago, IL: Taylor Institute, 1996 (773) 342-4532 Ethnic Differences in Public Assistance, Employment, and Victimization by Men T.C. Honeycutt and L. Marshall In Violence Against Women, in press In Harm’s Way? Domestic Violence, AFDC Receipt, and Welfare Reform in Massachusetts M.A. Allard, R. Albelda, M.E. Colten, and C. Cosenza Boston: University of Massachusetts, McCormack Institute and Center for Survey Research, 1997 (617) 287-5550 www.mccormack.umb.edu Patterns of Substance Abuse and Substance-Related Impairment Among Participants in the Aid to Families with Dependent Children Program Washington, DC: U.S. Department of Health and Human Services: Office of the Assistant Secretary for Planning and Evaluation, National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration, 1994 The Effects of Domestic Violence on Women’s Employment S. Lloyd In Law and Social Policy, 1997, 19, 139-167 The Impact of Recent Partner Violence on Poor Women’s Capacity to Maintain Work A. Browne, A. Salomon, and S. Bassuk In Violence Against Women, 1999, 5(4), 393-426 Understanding Families with Multiple Barriers to Self-Sufficiency Submitted to Utah Dept. of Workforce Services A. Barusch, M.J. Taylor, and M. Derr Salt Lake City: University of Utah, Social Research Institute (801) 581-4857 www.socwk.utah.edu Center for Law and Social Policy 1015 15th Street, NW Suite 400 Washington, DC 20005 (202) 906-8000 www.clasp.org The Welfare to Work Partnership 1129 20th Street, NW Suite 800 Washington, DC 20036 (202) 955-3005 www.welfaretowork.org The Center for Women’s Employment and Education 1175 Osage Street Suite 300 Denver, CO 80204 (303) 892-8375 www.cwee.org Welfare Law Center 275 Seventh Avenue Suite 1205 New York, NY 10001 (212) 633-6967 www.welfarelaw.org This publication was made possible by grant number 5 UD1 TI11404 from the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment, Center for Mental Health Services, and Center for Substance Abuse Prevention. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Center for Mental Health Services, and Center for Substance Abuse Prevention.