Getting a Job as an Addict

As I described in an earlier post, the vocational educator at PSI invited me to help facilitate the "transition groups" she leads. These groups are designed for the patients who are getting ready to graduate from the treatment program and need to learn practical skills to help them succeed once they reenter society. This week, the transition group focused on filling out a job application and preparing for a job interview. As if the job market weren't tough enough already, many of the patients here face additional obstacles to finding employment. First of all, they have all been unemployed for at least the year they have lived at PSI. Many have not graduated from high school or earned a GED. Some have been fired from previous jobs for performance issues or drug problems. The majority have been incarcerated at some point in their lives, and some have serious charges, like felonies, on their criminal record.

During the group, the vocational educator gave the residents advice for how to address negative aspects of their background on the job application and in the interview. Here are some of my favorite tips:

• Do not offer any information that was not specifically asked about. For example, if a job application asks if you have been convicted of a felony in the last 5 years, but your felony was 7 years ago, it is perfectly acceptable to answer 'no' and leave it at that.
• Whenever you can, try to make the reason you were terminated from your previous job sound as neutral as possible. For example, if several people were let go at the same time as you, you can state the company was downsizing. If you moved to a different state after you were fired, you can say that you relocated. If you did not get along with your supervisor, you can say you were let go for political reasons. You can stretch the truth, but whatever reason you give must have some truth to it in case your new employer checks up on you.
• If asked directly about negative information by an interviewer, you should acknowledge it, briefly describe it, and then move on to talking about something positive. For example, "Yes, I was laid off from my previous job because of a drug problem. At that time, my addiction caused me to be late or absent frequently. However, I have been clean and sober for two years now, and I have a reference from my treatment program that states my attendance and punctuality have been perfect."

I am impressed by this advice. I think they are all great strategies to help the patients present themselves in the best possible light. At the same time, I am trying to view this situation from an employer's perspective. If I had two equal job candidates, except one was an addict with a criminal record, and the other was neither of these things, I think I would be inclined to pick the latter. If you didn't take the time to get to know the patients - how they are truly reformed, and very kind, hard-working individuals - I can see how you might be disinclined to hire them. The patients here are going to have to work incredibly hard to show future employers how dedicated they are, perhaps by first interning or volunteering at the company where they want to work. Hopefully their employers will see the potential that I see in them, and these patients will be able to support themselves and lead sober, healthy lives.

Rx: Optimism

In order to live at PSI, the patients must have a dual diagnosis of full-blown AIDS (not just HIV), as well as substance addiction. Other psychiatric diseases, such as major depression, are also very frequently co-morbid conditions with AIDS and addiction. As I mentioned in a previous post, the majority of the patients here have also spent time in prison. You would think that the patients here, having all of these odds stacked against them, would be jaded, hardened, and unhappy. But you'd be wrong.

An example of a journal response written by one
of the patients in my Health Literacy group.

Many of the patients here have incredibly positive attitudes, despite the myriad hardships they have experienced. For example, the patients love to write about their recovery in their journal responses (see the example on the right). They welcome me every day with an enthusiastic Good morning, Marianne! when I enter the building. They offer to help me carry my materials from class back to my office. They tell me about their goals to become HIV peer educators, mechanics, or bus drivers in the future. They even share their good news about their health with me.

One patient in particular is perhaps the most optimistic person I've ever met. This is remarkable, considering she was born with intellectual disabilities, she started hanging out with the wrong crowd as a teenager and got hooked on drugs, and then she was infected with HIV when she was raped during her twenties. She is enrolled in my Health Literacy class, but frequently becomes frustrated and pulls me aside during class, asking if she can come in later for extra help. Our tutoring sessions together tend to take a while since she is a fairly slow learner, but she always leaves with a smile on her face. Last week, she stopped by my office, and I assumed it was for extra help on the material we learned that day. Instead, she simply came in my office and handed me a piece of paper, grinning ear-to-ear. I looked at the paper, and on it was her latest T cell count, which was very high. It's because I've been focusing on my recovery, she told me. She may well be right - a quick Google search shows that there has been a multitude of studies linking optimism and better health outcomes. Maybe we should all take a cue from this patient and others like her at PSI, and adapt a more positive outlook on life.

Pacing Problems

It's been a little while since I gave an update on how my Health Literacy class has been going. In a word, it has been wonderful. The averages on the quizzes have been around 90%. Attendance is still somewhat spotty, but many patients will come to me on their own if they missed a class to make up the work. The patients are very willing to do the work during group, even when we're doing something kind of boring.

It's always more interesting to discuss what has not been going so smoothly, however. Tuesday was the first day all summer where we didn't finish what we were scheduled to in class. Our objective was to summarize a story about a patient's journey with HIV/AIDS. For you non-teachers out there, a good lesson goes through an entire "lesson cycle," which includes five steps:

My easel with a typical agenda
showing the lesson cycle.

1. Opening. You communicate the importance of the day’s objective and thereby engage the students.

2. Introduction to New Material. You model the new skill. This is abbreviated in my agenda as "I do."

3. Guided Practice. The students have an opportunity to practice the new skill in groups or pairs while I monitor their progress and provide feedback. Abbreviated as "We do."

4. Independent Practice. Students practice their new skill on their own so I will know if they have mastered the day’s objective. Abbreviated as "You do."

5. Closing. In my health literacy class, this usually takes the form of a journal entry reflecting on what we learned.

This way of planning a lesson was drilled into my head during my time with Teach For America, and I still use it for every one of my health literacy classes! Like some would say, I drank the Teach For America Kool-Aid. But like I mentioned, unfortunately, we didn't make it through all five steps of the lesson cycle on Tuesday. First of all, we didn't start class until 10 minutes into our allotted 45 minute time slot. Then the objective (summarizing a story) was just way too hard to fit into one class. We only got through the Guided Practice, and some people did not even finish that.

I never have been very good at pacing my classes so that what I have planned takes exactly the right amount of time. Usually, I err on the side of planning too much for one class (which I think is still better than the opposite situation, where you finish early and then don't know what to do with the students for the end of class). I'll never forget how I felt on my very first day in a classroom, in June 2007, at Scarborough High School in Houston. I was teaching ninth grade algebra in summer school, to students who already had an entire year of algebra but had failed their class. For my first lesson, I planned on reviewing how to solve one step algebraic equations (such as x+ 6=10). Imagine the horror I felt when I went through several examples, and was getting blank, confused stares back from the students. I tried to break it down as much as I could, explaining that to solve x+6=10, you had to first subtract 6 from both sides, but even that didn't make sense to them. That first day, I ended up having to teach them things that should be intuitive to ninth graders, like how a number minus itself equals zero. Needless to say, we didn't come close to getting through the lesson I had planned that day.

So here I am, more than three years later, and I still have not mastered the art of pacing a lesson. However, I'd like to think I've improved since my very first day as a teacher. I just need to remind myself what is and is not feasible to accomplish in a 45 minute period. Luckily, I've already planned on reviewing summary a couple more times, so all is not lost. The patients here will learn to summarize by the end of the summer!

The Face of the Epidemic

Another staff member at PSI noted that most of the patients are Latino or African American, which she said "reflected the face of the AIDS epidemic." I thought that this was an interesting comment, and it made me curious to see just how true this was. I checked out the statistics on the website for the Center for Disease Control and Prevention (http://www.cdc.gov/hiv, my source for all statistics in this blog post). Then I calculated the racial makeup of PSI. Interestingly, the demographics of PSI did not reflect the racial/ethnic breakdown of the prevalence of HIV in this country. As you can see from the charts below, there are disproportionately more Black and Hispanic/Latino people living at PSI than there are living with HIV in the United States. Additionally, there are very few white people at PSI, while they make up over one-third of people with HIV in this country.

Why doesn't the racial makeup of PSI match that of the HIV/AIDS epidemic?

Not only are people of color disproportionately affected by HIV (Blacks/African-Americans and Hispanics/Latinos make up 12% and 15% of the US population, respectively), but they are also disproportionately represented at PSI. Why should this be? Is it that there are relatively more people of color living in New York City? Is it that whites are less likely to enroll in treatment programs? I truly do not know the answer to this question, but I plan on informally surveying the people I work with, who I'm sure have greater insight than I do. I'll publish an update to this post afterwards. In the meantime, readers, what are your thoughts?

Update 7/21/10: After talking to my co-workers and doing a little internet research, I may have found a partial explanation.  Shockingly, 97% of people who are incarcerated in New York City are Black or Hispanic (http://www.nyclu.org/content/state-of-drug-policy-and-addiction-new-york-city-and-reform-of-rockefeller-drug-laws). Keep in mind that the majority of people admitted to PSI have come from prison and are mandated here by a judge. So, that is likely a major contributor to the racial breakdown of PSI.

HIV+ And Healthy Without Meds?

In addition to teaching the Health Literacy class this summer, the medical director of PSI asked me to help her complete a formal assessment of all 66 of the patients' health literacy levels to be included in their medical charts. I have been calling patients to my office one by one to give them the assessment, which consists of basic questions about health knowledge and HIV. For example, one of the questions I ask the patients is to recall all of the medications they are currently taking to treat their HIV. I then check what they have told me against their medical records to see if they answered correctly.

Yesterday, as I was completing an assessment with one of the patients, he told me he wasn't taking any medication to treat his HIV. At first I thought he was joking or mistaken, but he asserted that he has made the decision not to start antiretroviral therapy (against medical advice). Trying to hide my disbelief, I asked him why. He explained that he did not want the side effects from the medication, was not afraid of dying, and that he would pass away when God decided it was his time to go. He said he was diagnosed as HIV+ in 1996, and has been relatively healthy since (although, to live at PSI you must have full-blown AIDS). I asked him if he had any children, to which he responded that he had a 24 year old daughter. As a 24 year old woman myself, I told him I would want to see my own father live as long of a life as possible. He made the counterpoint that he didn't wish to extend his life if his daughter would have to watch him suffer and care for him for a longer period of time, and restated that God knew what was best for him and his family.

This patient has had the virus for at least 14 years; the average person will become very ill or die within 8-10 years of contracting HIV if untreated. Although the patient attributes his health to God's work, I think it is probably because he is what is called a "long-term nonprogressor." These people usually 1) have receptors on their T cells that do not easily bind to HIV so that it is more difficult for HIV to infect T cells, or 2) possess a specific immune protein that allows their immune system to more easily detect when HIV proteins are being made inside of cells. Both of these are due to beneficial mutations in the patient's DNA, and long-term nonprogressors can live with HIV for years and years without being affected by the virus.

As a medical student, it is hard for me to understand people who don't seem to care about improving their health when given the opportunity. And as an agnostic, it is hard for me to understand people who leave things up to "God" rather than take action to solve problems on their own. I found myself becoming incredibly frustrated with this patient's unwillingness to take medication, and this person is not even MY patient! I know that when I am a doctor, many of my patients will be non-adherent to their treatment and ignore my advice. I will have to learn how to effectively deal with this, so that my future patients are as healthy as possible and I can maintain my own sanity.

Back On Track

After an incredibly refreshing vacation visiting family and friends, I'm back, hard at work at PSI. My Health Literacy class resumed yesterday, with a great deal of success! A huge heat wave hit NYC yesterday, with temperatures in the triple digits. Since the location where I usually hold the class is not air-conditioned, I was a little worried that it would be cancelled on me again. I was not about to let that happen, so I made sure I could hold my class in a space with AC.

Yesterday our objective was to "look up information about HIV/AIDS medication side effects in a table." First we went over what the different side effects were, so the residents became familiar with medical jargon like "hepatotoxicity" (liver illness) and "lipodystrophy" (changes in fat distribution). Then I showed them how to read a table by first reading the column and row headings, then tracing over with your finger to find the correct information. The table we used was no joke - it was a pretty complicated and packed with information (see below, from http://www.health.state.ny.us/publications/9408.pdf).  I would ask them things like "Name 2 medicines that can cause both rash and sleeping problems," a daunting task for someone that is a struggling reader. The residents earned an average of a 95% on the quiz! They keep pleasantly surprising me with the hard work they put into the assignments I give them.

Relapse Prevention

Last week I had the privilege of observing a "transition group" that prepares the residents of PSI for various issues they'll face once they are living on their own in the community. This series of six classes is led by the vocational educator, who kindly asked me to help with the group. The topic for the first meeting was "Avoiding Triggers in the Workplace."

All of the residents of PSI are addicts. Even though to live at PSI they can not be currently using drugs, they still struggle with addiction and carry that diagnosis for the rest of their lives. I was completely unaware of the difficulties that addicts face in a place as seemingly innocent as at their job. As a group, we discussed what could happen at work to make someone want to use again, as well as what solutions to those problems could be. Some of the common workplace triggers to use include:

• Pay day. When an addict is handed a check, it can be hard to resist cashing it in to buy drugs. To avoid this, you can immediately hand their check over to a trusted friend, or set up direct deposit to distance yourself a little from the money.
• Having too much free time or too little supervision on the job. Being bored at work and having no one there to watch you can lead to temptations to use on the job. To avoid this, you can ask your supervisor for extra tasks to pick up, or attend meetings that you aren't necessarily required to be at.
• Working long hours or having too much supervision on the job. This can lead to stress and pressure to perform, which can lead to a desire to use. To avoid this, you can politely turn down tasks your supervisor asks of you, or kindly tell your supervisor you would like the opportunity to work more independently.
• Office holiday parties. There will be lots of alcohol and possibly drugs around, and co-workers may even unknowingly pressure an addict to drink. To avoid this, you can show your face to the VIPs at work, and then tell co-workers you have other plans and can't stay at the party.

I was fascinated by our discussion. It is so important for people to be sensitive to these issues, and I feel very privileged to have had the opportunity for the residents to teach me about the struggles they face.