An aftercare intervention programme for employees returning from substance use rehabilitation in South Africa

The global prevalence and impact of SUDs have been steadily increasing, with significant implications for public health, social welfare, and economic development, as evidenced by numerous studies and reports from international organisations such as the World Health Organisation and the United Nations Office on Drugs and Crime (UNODC, 2016). SUDs, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 2013 (DSM-5), are characterised by impaired control over substance use, social impairment, risky use, and pharmacological criteria. They encompass a wide range of psychoactive substances, including, but not limited to alcohol, cannabis, opioids, stimulants, hallucinogens, sedatives, hypnotics, and anxiolytics. According to the World Health Organisation (2024) Global Statistics Report on Alcohol and Health and the Treatment of SUDs, approximately 5.3% of the global population aged 15 and older is affected by SUDS, with illicit drug use disorders impacting around 0.9% of this demographic. Alcohol use disorders (AUD) are prevalent among 3.2% of the global population, with a notable disparity between genders—5.1% in men compared to 1.3% in women. The report further indicates that SUDs contribute to approximately 450,000 deaths annually, with opioids responsible for about 70% of drug-related fatalities. In addition, alcohol consumption is associated with over 3 million deaths each year, accounting for 5.3% of all global mortality. Despite the significant health burden posed by SUDs and AUDs, treatment coverage remains inadequate, with only 14% of individuals with drug use disorders and 7.1% of those with alcohol use disorders receiving any form of treatment, underscoring critical gaps in access to care. In South Africa, alcohol remains the main substance of abuse, accounting for approximately 59% of substance use cases (SACENDU, 2018; SANCA, 2018).

The workplace is not spared the negative consequences of SUDs and is considered an important site where issues associated with the treatment and remedying of substance use must be addressed. The workplace provides a convenient and accessible place for receiving aftercare support. Aftercare in the context of substance use refers to the range of follow-up services and support provided to individuals after they have completed in-patient treatment to maintain their recovery and prevent relapse (National Institute on Drug Abuse, 2020). In the workplace context, aftercare support fosters a sense of community and social support between colleagues. It also offers a structured environment, making it easier for individuals to integrate their recovery efforts into their daily routine. Workplace support programmes like EAPs are valuable resources but, however, often fall short in addressing the complex needs of employees with substance use disorders. Further investigation is required to enhance these programmes, ensure comprehensive and individualized care and promote a supportive workplace environment. Despite the importance of aftercare services, there is a lack of effective measures being taken in workplaces to address substance use issues (Greco and Sanchez, 2018; Smook et al., 2014). Legal obligations placed on employers concerning managing responses to substance use in the workplace are multifaceted and can vary significantly depending on industry regulations (McCann, 2011). Employers are typically required to maintain a safe and healthy work environment for all employees, which includes addressing substance use issues effectively (ILO, 1981). Aftercare is an essential component of substance use rehabilitation, providing continued support to individuals in recovery. Research indicates that comprehensive aftercare significantly enhances the effectiveness of primary treatment interventions by addressing ongoing challenges and reducing the risk of relapse (NIDA, 2020; Jason et al., 2013). Integrating aftercare services into the workplace promotes holistic recovery by addressing both personal and professional aspects of people’s lives, ultimately fostering long-term success in sobriety (Pidd and Roche, 2014).

In South Africa, employee wellness programmes, also EAPs, are commonly used to address substance use recovery in the workplace (Burnhams and Parry, 2015). However, no legislative guidelines offer specific recommendations on the management of SUDs or aftercare support in the workplace. EAP practitioners need to be equipped with a clearly formulated and deliverable intervention programme to support employees recovering from SUDs. This paper presents such a programme and reports on the underlying research and consensus-seeking processes undertaken to validate its relevance and credibility. The programme theory underpinning the intervention is the ecological systems theory model, emphasising the role of various ecological systems in human development (Bronfenbrenner, 2005). Systems theory provides a comprehensive framework for understanding the complex interactions and interdependencies among various components within a given system. In the context of developing a substance use aftercare programme for the workplace, applying systems theory can offer valuable insights into the multifaceted nature of SUDs and the intricate dynamics involved in addressing them effectively. By considering the broader ecological context, the aftercare programme can address not only individual needs but also systemic difficulties to recovery.

Despite international conventions, commissions, and extraordinary measures implemented by the research community, practitioners, and government agencies, the global trend in substance use continues to increase (Bala and Kang’ethe, 2021). This situation is no different on the African continent, Dumbili (2015) reporting that alcohol abuse is widespread in African nations, and South Africa is one of the most affected countries. In South Africa, the National Drug Master Plan was drafted following the stipulations of the Prevention and Treatment of Drug Dependency Act 20, 1992, and reflects the country’s response to addressing substance use and its adherence to guidelines set by various international bodies, like the United Nations (Department of Social Development, 2019).

Responding to SUDs within the workplace is a concern typically addressed within the arena of occupational social work. As a subfield within the profession of social work, the principles of occupational social work attempt to harness an employee’s personal resources and address their needs within the workplace (Kruger and Van Breda, 2001). EAPs and Wellness Practitioners (WP) rely on these principles and play a central role in the provision of SUD support and substance use referrals emanating from the workplace (Braaf et al., 2022). Despite the existence of EAPs in many South African workplaces, a prevalent view among practitioners is that substance use at work and its harmful consequences are often overlooked. Smook et al. (2014) report that the large number of workplace accidents and their underlying causes linked to SUDs necessitates companies to focus more on the problem and actively work to find viable solutions. Research conducted by the National Institute on Drug Abuse (NIDA) suggests that employees who misuse drugs or alcohol are more likely to be involved in workplace accidents, resulting in injuries or fatalities. Many organizations fail to provide adequate support for employees returning from substance use treatment, which can impede their recovery and negatively affect their job performance and well-being (Burnhams and Parry, 2015). Therefore, workplaces must address this issue and implement measures to support employees in recovery, promoting successful reintegration into the workplace.

While there are some guidelines on managing alcohol and drug-related issues in the workplace, notably the code of conduct provided by the International Labour Organisation, within the South African context, such guidelines can merely act as a resource available to the organisation. Additionally, no legislative guidelines recommend how SUDs, substance use recovery, or aftercare should be addressed in the workplace (Burnhams and Parry, 2015). Reporting on their study into the state of interventions in South African workplaces to respond to SUDs, Burnhams and Parry (2015) argued for the need for comprehensive substance use policies and workplace programmes to adopt a public health approach when developing prevention and treatment initiatives. The National Drug Master Plan describes how the world drug problem and its response continue to present challenges to the health, safety, and well-being of people in South Africa (Department of Social Development, 2019). An extraordinary change in the approach to drug policy recognises that the punitive approach has not yet tackled substance-related problems successfully. Instead, the emphasis should be placed on evidence-based principles of public health and social justice that focus on individuals, families, communities, and society and must prioritise social protection and health care instead of judgement and punishment (Department of Social Development, 2019). To address the specific limitations placed on EAPs and WPs in how they responded to or attempted to address SUDs and specifically aftercare provisions on the job, an aftercare intervention programme was developed that could be implemented by EAPs.

This section describes a qualitative study design focused on understanding the perspectives of key stakeholders in the workplace involved in SUDs. The development of this intervention forms part of a larger research project. The study addressed a specific practice-based problem associated with the inadequacies faced by employees returning to work after substance abuse rehabilitation. The study aimed to develop a workplace support programme for employees returning from substance abuse rehabilitation for specific use within Employee Wellness/EAP Programmes. It was based on a qualitative research methodology and was implemented within an intervention mapping framework. The research was divided into two phases: Phase 1 focused on understanding the problem in the workplace environment. Stage 1 consisted of a qualitative enquiry conducted with employees who returned from substance abuse rehabilitation, professional wellness practitioners, and a focus group with concerned significant others/family members. Phase 2 focused on developing the workplace support programme. Stage 1, the problem development phase, involved three data collection activities with various role players affected by SUDs in the workplace. The programme development phase involved developing the workplace aftercare intervention programme and consisted of consensus-seeking activities that took the form of two workshops. The phases were sequential, with the qualitative inquiry and data collection activities providing the foundational data that informed the programme development task. A carefully structured workplace support programme was developed as a result of this research study, consisting of three distinct phases: Phase 1: Pre-reintegration, Phase 2: Reintegration, and Phase 3: Care and Support. Research and consensus seeking activities involved person with substance use disorders, their family members, and professionals in the field of SUDs. These stakeholders were crucial in informing and finalising the Aftercare Intervention, confirming its content and feasibility.

Purposive sampling techniques were used, selecting participants based on specific criteria relevant to the research objectives. In this case, the researchers selected stakeholders who were instrumental in the substance use system, including person with substance use disorders, family members, and professionals in the field of SUDs. This sampling technique allows researchers to gather rich and diverse perspectives that are relevant to the research questions and objectives. The research question aims to determine what the components are of a workplace aftercare intervention to support employees on their return from substance abuse rehabilitation. How can workplace support programmes be improved to effectively accommodate and assist employees returning from substance use rehabilitation programmes, considering the perspectives and experiences of persons with substance use disorders, their families, and professionals in the field of SUDs?

A key objective of these activities was to develop and design an aftercare intervention programme to support post-rehabilitation employees in the workshop. Therefore, this aftercare intervention programme represents a significant outcome of the larger research study. A primary impetus of this study attempted to address the needs of employees, first when they return from rehabilitation, considering the impact of SUDs on the family system, and finally also considering the perceptions and experiences of EAPs and WPs when dealing with SUDs and recovery and aftercare of substance use. It has been well established that there are various areas for improvement in the provisioning and support of workplaces for employees during the recovery and aftercare phases of their post-rehabilitation experience. To address these concerns, the larger research was guided by the following objectives:

• (1)

  Explore support programmes offered to workplace employees who returned from substance use.

• (2)

  Explore how the workplace accommodates or supports employees who return from substance use rehabilitation programme rehabilitation.

• (3)

  Establish the needs of employees when they return from substance use rehabilitation.

Conceptually, the study was informed by an understanding of SUDs that views the individual, the family and the workplace as interrelated, and the research investigation took a holistic approach to gain insight into the perspectives and experiences of various stakeholders who are directly and indirectly affected by the negative impact of SUDs on the workplace. The design and development process that informs the Aftercare Intervention Programme described in this document was supported by different data collection activities and organised into two distinct stages (see Figure 1). Stage 1 involved three data collection activities with three stakeholder groups, and Stage 2 consisted of two consensus-seeking engagements with the intended audience of the intervention programme.

Three separate data collection activities were carried out and included specific groups of role players, namely, employees who recently returned from substance use rehabilitation, family members affected by SUDs, and finally WPs tasked with supporting employees with SUDs. Semi-structured interviews were used with employees and WPs, while a focus group interview was conducted with family members. The overarching approach that defined these research activities was a qualitative one that sought to explore the perception and experiences of the various players in the SUDs. Thematic analysis approaches were used to describe and report on the findings of these activities.

The main objective of the consensus-seeking activities was to gain feedback and commentary on the validity and relevance of the design and development processes that informed the Aftercare Intervention Programme. Therefore, it sought the input and expertise of practitioners and academics working in the field of SUDs and the programme’s intended audience, namely, WPs, employees recovering from SUDs, and their affected families. Two engagements were held: (1) an Initial Programme Design Review and (2) a Pilot Workshop. The Initial Programme Design Review was conducted with five (5) SUDs expert practitioners and academics (see Table 1 for an overview of participants).

Five professionals and academic experts participated in a virtual workshop in which the initial design ideas for the intervention programme were presented. The session was online due to lockdown restrictions and COVID-19 alert level 1 rules. Questions posed to participants focused on what comes to mind when thinking about a substance use support programme in the workplace. Three questions were asked on, how a substance use programme should look like, what it should include and the role of the family. Participants were specifically asked to comment on and offer suggestions for improving specific content inclusions in the programme. Commentary and advice on how to structure the pilot workshop were also sought.

Once the input and comments from the initial review were incorporated into the design and development ideas, a pilot workshop was conducted. This was a face-to-face workshop with various stakeholders related to workplace support that addresses SUDs. The workshop used a consensus approach to ensure that all participants’ views were incorporated into the final intervention design. After introducing the purpose of the study, the question was posed to the group what comes to mind when thinking of substance use in the workplace after rehabilitation. This was to spark communication prior to dividing the focus group into three smaller groups where each group received 1 stage of the intervention programme to discuss in view of the initial question. They were then expected to discuss the stage and give inputs in writing and present the inputs to groups. Participants (see Table 2) were generally representative of the role players who participated in the data collection activities of the empirical research component of the study in that it included occupational social workers and other professionals working in the SUDs environment, individuals who recently returned from substance use rehabilitation, family members affected by SUDs, and community and faith-based leaders.

While participants were generally supportive of the content, inclusion, structural, and organisational arrangements of the three phases of the intervention, timeframes, and activities included in the intervention, they identified areas of omission and made the following specific recommendations:

• (1)

  Increase reliance on faith-based and spiritual support throughout the three phases of the intervention programme

• (2)

  Inclusion of community support structures

• (3)

  Workplace interventions should include the specific provision of counselling (psychologists or social workers), skill training, and the use of motivational speakers.

The following extracts from the discussions transcribed during the pilot workshop highlight the attention drawn to these specific areas. The final programme design presented in Table 2 indicates the inclusion of these vital activities and the participation of community and faith-based support structures. The inclusion of vital activities and the participation of community and faith-based support structures, as highlighted in the workshop discussions and final programme design, can be seen as an application of the ecological systems theory, influenced by different types of environmental systems. These support structures represent the microsystem, which includes immediate environments such as families and community, and the mesosystem, which refers to the interconnections between these immediate environments. Engaging these systems, the programme design leverages the supportive influences of both community and faith-based networks, promoting all-inclusive development and well-being in individuals.

Participants raised the importance and value of including faith-based and spiritual support in recovery and aftercare activities. Such activities were promoted as part of Phases 2 and 3 of the intervention programme.

Recognising the importance of spiritual support in the recovery process and incorporating it into aftercare programmes can significantly enhance the effectiveness of the rehabilitation effort. Partnering with community and faith-based organisations could provide beneficial support to individuals recovering from substance use disorders. The participation of family members who offer spiritual support can strengthen family bonds, allowing encouragement and motivation for individual recovery. This could also be useful as part of rehabilitation centre programmes.

Participants noted the importance of welcoming employees back to their workplace. This recommendation was included as part of Phase 2 Reintegration of the intervention programme.

Establishing a welcoming committee can create a supportive environment for employees returning from substance abuse rehabilitation. Involving a diverse group of colleagues in the welcoming committee ensures that the employee who returns from rehabilitation feels supported and valued by the entire organisation.

Participants recommended that counselling services provided by external professionals be included as part of the intervention programme. Additionally, motivational speakers and training workshops were considered valuable and a way of raising awareness and understanding of the challenges associated with SUDs. Furthermore, it was suggested that such activities might benefit employees, co-workers, WPs, and family members. These types of activities were included in Phases 2 and 3 of the intervention programme.

Integration of professional counselling services by private professionals can offer valuable support to employees returning from rehabilitation. Inviting motivational speakers and organising training workshops can raise awareness and understanding related to the challenges associated with SUDs among employees, co-workers, wellness practitioners, and family members.

This section presents the Workplace Aftercare Intervention Programme designed to support employees in their workplaces who returned from SUD rehabilitation. As described in the previous section, the programme was designed and developed after extensive engagement with various role players affected by SUDs in the workplace. The 10-week SUD aftercare programme intends to offer a systematic set of guidelines and a series of phased activities that EAPs and WPs can implement at different workplaces. The presentation of the programme will first provide a brief outline of the three distinct and chronological phases while also indicating the focal areas of support provision and the intended audiences for each phase (see Figure 2). Finally, a more detailed presentation of the 10-week programme is provided (see Table 3).

The workplace intervention programme for employees who return from substance use rehabilitation encompasses a 10-week programme consisting of three phases that follow chronologically and provides guidelines to EAPs and workplace stakeholders regarding the type of provision and support mechanisms that will allow the workplace environment to assist the employee to successfully reintegrate into their employment adequately. The programme outlines specific activities that should be undertaken before the employee returns to the workplace immediately after returning to work. It accommodates a period of ongoing support once the employee has reintegrated.

Phase 1 addresses activities that prepare the workplace and coworkers for the employee’s return to work. The pre-reintegration phase would typically occur within two weeks before the employee’s expected return to work after a substance use rehabilitation programme. Most activities are driven by EAP and Human Resources (HR) practitioners, but can also include union representatives and the legal department. This phase aims to ensure that a supportive environment is created for the employee and that coworkers, supervisors, and even family members fully understand the rehabilitation and recovery processes associated with SUDs. Specific training sessions could be facilitated addressing topics such as SUDs, empathetic responses to SUDs, and any organisational policies that address SUDs in the workplace.

During Phase 2, which typically occurs over one or two weeks, activities that promote employee reintegration into their workplace after their return to work are prioritised. A key outcome of the Reintegration phase is to ensure that the process of adjustment to and rebuilding social relationships is undertaken. The reintegration phase should ultimately contribute to reducing the negative impact of social exclusion. The final and third phases address specific care and support activities over four to six weeks. The main objective of this Care and Support phase is to offer employees the ongoing psychosocial support necessary to achieve long-term recovery, improve their quality of life, and prevent relapse. Key activities directed via EAPs and WPs involve the maintenance of various support provisions within the workplace. Family, community, and faith-based resources are incorporated into these provisions. Review and evaluation activities that seek to assess the beneficial effects of the intervention provisions while identifying areas of improvement are also undertaken. Core activities involve establishing and conducting an evaluation process related to the recovery intervention aftercare, as well as ensuring the review of procedures and processes related to the intervention programmes.

This paper seamlessly dovetails into its implications and conclusions by systematically addressing the critical aspects of SUDs recovery and aftercare in the workplace. Through a comprehensive analysis of qualitative data gathered from various stakeholders, including substance users, family members, and professionals, the study highlights the multifaceted needs of employees returning from rehabilitation. It identifies key areas such as the importance of community support structures, spirituality, professional counselling, and policy review as essential components of effective aftercare. By integrating these findings, the paper proposes a structured workplace aftercare intervention programme that not only supports employees in their reintegration but also emphasises a holistic approach involving the workplace, family, and community. The conclusions drawn underscore the necessity of a proactive, inclusive, and well-coordinated effort to address SUDs in the workplace, reinforcing the study’s implications for enhancing recovery outcomes and workplace productivity.

The study’s recommendations resonate with existing literature in several ways. Firstly, the holistic approach to aftercare aligns with the biopsychosocial model of health, which recognises the interconnection between biological, psychological, and social factors in recovery. The focus on integrating community and faith-based support aligns with research that highlights the positive impact of social and spiritual support on recovery outcomes. Secondly, the emphasis on proactive policy review and dynamic support systems mirrors literature on the importance of flexible workplace policies that can adapt to the diverse needs of employees. This adaptability is crucial for accommodating the unique challenges faced by employees recovering from SUDs and ensuring that support mechanisms remain effective over time. Lastly, the study’s advocacy for ongoing research and collaboration among employers, employees, healthcare providers, and stakeholders reflects a growing consensus in the literature on the need for a multidisciplinary approach to occupational health. Such collaboration can lead to the development of more comprehensive and effective interventions, ensuring that all aspects of an employee’s recovery are addressed.

• (1)

  Holistic Recovery Support: The study’s emphasis on incorporating spirituality, faith-based support, and community structures mirrors existing literature that advocates for a comprehensive approach to recovery. This holistic perspective addresses not only the physical and psychological aspects of recovery but also the emotional and spiritual dimensions, providing a more rounded support system for employees. Such an approach is beneficial because it recognises that recovery from SUDs is multifaceted and requires more than just medical or psychological interventions.

• (2)

  Proactive Policy Development: By recommending regular reviews of workplace policies related to SUDs, the study underscores the need for dynamic and adaptive management practices. This aligns with literature that suggests workplaces should continuously evolve their policies to meet the changing needs of their employees, particularly those recovering from SUDs. Proactive policy development ensures that support systems remain relevant and effective, which can lead to better outcomes for employees and reduce relapse rates.

• (3)

  Integration with Existing Programmes: The findings highlight the importance of enhancing EAPs and the roles of Wellness Practitioners (WPs). This complements existing frameworks within occupational health management, where EAPs are a critical component. The study’s recommendations for additional training and empowerment of EAPs and WPs ensure that these programmes are equipped to handle the specific needs of employees recovering from SUDs. This integration strengthens the overall support structure within the workplace, making it more robust and effective.

• (4)

  Awareness and Education Campaigns: The call for awareness and education campaigns is in line with existing literature that stresses the importance of creating a supportive work environment through knowledge and understanding. By educating both employers and employees about SUDs, these campaigns can reduce stigma and foster a more inclusive and supportive workplace culture. This can lead to increased empathy and support from colleagues, which is crucial for the successful reintegration of employees recovering from SUDs.

The workplace aftercare intervention programme outlines how the transition and reintegration of a post-rehabilitation employee can be systematically managed over ten weeks. This way, a key objective in reducing the ad hoc nature of current approaches to workplace aftercare can be achieved. The central role of the wellness practitioner is reinforced while also highlighting the importance of including other key role players within the workplace and others who are part of the employee’s family and community networks.

The study underscores several fundamental implications for management to better support employees who deal with SUDs during their recovery and aftercare phases. First, it highlights the significance of community support structures and suggests their involvement as part of support provisions. Second, it emphasises the importance of integrating spirituality and faith-based support into the aftercare intervention programme to warrant holistic recovery. Inclusion of professional counselling services on the job is recommended to provide essential support to employees dealing with SUDs. Furthermore, the study suggests providing awareness training and organising motivational speakers to raise awareness and understanding of the challenges associated with SUDs. Reviewing workplace policies related to SUDs is essential to ensure that they adequately support employees during their recovery and aftercare phases. Additionally, involving family members in preparing for the employee’s return through training and awareness programmes can create a supportive environment. Establishing communication and communication with the rehabilitation centre is crucial to ensuring a smooth transition and adequate support for employees returning from treatment. Considering a revised workload for the employee upon their initial return is also advised to facilitate a smoother transition. Addressing the psychological and emotional needs of employees through counselling is essential. Frequently checking in with stakeholders, both internally and in the community, ensures continued support and successful reintegration. Adopting a proactive approach, empowering EAPs and Wellness Practitioners (WPs), ensuring adequate and obligatory aftercare support, and developing legislative guidelines are vital steps to effectively address substance use in the workplace. Furthermore, awareness and education campaigns targeting employees and employers are essential to increase understanding of substance use and its harmful consequences. Lastly, the study emphasises the need for additional research to identify effective interventions and understand the expressed challenges and obstacles workplaces face in addressing substance use issues.

Creswell (2014) suggests that it is essential to acknowledge the potential limitations of a study. The following limitations were highlighted for this study. Due to the limited sample size of the study resulting from COVID-19 restrictions, the results may not be generalisable to other workplaces or populations. Regarding the scope of the study, the focus was on the experiences of a specific group of stakeholders, including employees, family members, and APS and WPs; other stakeholders (such as healthcare providers, policymakers, and insurance companies) may also have valuable insights to contribute. Lastly, the qualitative nature of the study was attributed to its resource intensive nature and limiting the depth of the study.

This article presents a workplace aftercare intervention programme to assist EAPs and WPs in managing the systemic and holistic care and support process for employees transitioning from substance use rehabilitation to full reintegration into the workplace. The intervention programme was developed as a critical outcome of a larger qualitative research investigation that involved various role players affected by SUDs in the workplace. A detailed description of two specific consensus-seeking activities conducted with key academic experts, practitioners, and those personally affected by SUDs on the job, such as employees who have returned from rehabilitation, WP, family members, and leaders of faith communities, was presented. The 10-week intervention programme, which consists of three distinct phases, namely pre-reintegration, reintegration, care, and support, was outlined. The programme offers a systematic and holistic plan to those working within the EAP environment to manage, support, and assist employees recovering from SUDs to maintain their recovery and return to productive work.