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Bauld L., Carroll C., Hay G. et al.
[UK] Department for Work and Pensions, 2010
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Substantial barriers to employment were revealed by interviews with alcohol service clients in Britain and with staff working in or with treatment agencies. Holistic recovery rather than just completing treatment was the key. Reviews relevant international research.
Summary This study was commissioned by the Department for Work and Pensions (DWP) to explore the experiences of adults with alcohol misuse problems in the UK in relation to employment, unemployment and benefit uptake. A separate report contains the findings of a study to estimate the number of people who are accessing DWP benefits and who have a problematic relationship with alcohol.
The Coalition Government has stated that it is committed to tackling drug and alcohol addiction, which is one of the most damaging root causes of poverty. The Government has also stated that it advocates an approach to addressing addiction that is firmly rooted in the concept of recovery and reintegration; a process through which an individual is enabled to overcome the symptoms and causes of their dependency, and reintegrate back into society. DWP have responsibility for the ‘recovery and reintegration’ strand of the 2010 Drug Strategy. This strand acknowledges that recovery does not begin or end with treatment, but encompasses employment, education and skills, family support, probation and wider health services around treatment in an holistic fashion to support sustained recovery. This report will inform the development of this strand of the strategy.
The report has two main elements: a systematic review of the literature on alcohol misuse, employment and benefits; and a qualitative study involving depth interviews with 53 problem drinkers who were clients of alcohol treatment agencies and 12 professionals working in or with treatment agencies in five study areas in England, Scotland and Wales.
A systematic review of the literature was conducted that identified 93 relevant articles and reports published since 1990.
The 2007 Adult Psychiatric Morbidity Survey showed that just under a quarter (24%) of the adult population in England could be classified as hazardous drinkers, of which 4% are harmful drinkers. The survey also found that 6% of the population aged 16–74 could be classed as dependent drinkers. The 2008 General Lifestyle Survey (GLF) suggests that those employed in managerial and professional roles exhibit the highest levels of weekly alcohol consumption, with the lowest consumption seen in routine and manual worker households. The report also notes that the economically inactive tend to drink less than those who are working. A 1990 study found that fewer unemployed men drink alcohol than employed men, but there are more moderate and heavy drinkers amongst the unemployed. Men are more likely than women to become problem or excessive drinkers whereas women are more likely to suffer drink-related problems, relative to their level of use. Mortality from alcohol-related conditions is associated with increasing age, being male, unemployment and previous employment in an alcohol-related business.
Literature from the US suggests that the receipt of benefits does not encourage or increase drug or alcohol dependence, and recommends that alcoholism and drug addiction be considered a serious limitation on employment. UK literature flags up the lack of availability of suitable treatment programmes and support services, especially for those with multiple and complex needs including drug as well as alcohol misuse problems and/or additional health issues. UK studies highlight the need for alcohol users to address their other problems, including housing and health issues, before attempting to (re-)enter employment, despite identifying a strong desire amongst many to return to the labour market.
Significant negative health impacts can arise as a result of unemployment, both for the unemployed and their families, and this impact is exacerbated when alcohol misuse is also involved. Poor health behaviours, such as high alcohol consumption, are exacerbated by unemployment. Research suggests that the prevalence of mental health problems for those dependent on alcohol is more than double that of the general population . However, specialist treatment for clients with dual diagnosis is not always available, and cross-referral between mental health and substance misuse treatment services is low. The evidence suggests that mental health problems and alcohol misuse are not always a barrier to finding work, but they can make it harder to sustain employment.
Socio-economic factors both influence the onset and continuation of alcohol misuse, and can be influenced by it. The level of impact of alcohol misuse on employment varies, and can be contradictory. There is evidence that the quantity of consumption and the extent of physical symptoms affect employment. A number of studies, including two from the UK, have identified a negative relationship between alcohol dependence and employment. However, two US studies found alcohol misuse had no impact on employment. There is also some evidence that moderate alcohol consumption may have benefits for some people in terms of job attainment and remuneration.
Studies from Europe and the US conclude that there is a negative correlation between problem drinking and unemployment, suggesting that alcohol misuse (particularly binge drinking) is more likely to start or escalate after unemployment begins.
The relationship between alcohol dependence and other factors (such as education) and barriers to employment has been explored in various studies. Research with both substance users and service providers found that they advocate a ‘step-wise’ (re-)integration into the labour market, involving voluntary, part-time, and short-term work. The importance of support programmes employing staff with an understanding of local labour markets and close links with employers, so that they can successfully match clients to job opportunities in their areas, was also highlighted.
Almost all the identified literature on alcohol misuse and benefits comes from the US, with just two studies coming from the UK. One of the US studies aimed to determine whether the receipt of benefits was associated with increased drug or alcohol use. It found that new benefit recipients showed reduced levels of alcohol use and concluded that being on benefits did not trigger substance misuse. Alcohol misuse was found by another study to be a predictor of longer-term benefit receipt in the case of some benefits, but not others. This suggests that the relationship between benefit use and alcohol misuse may vary depending not only on the characteristics of recipients, but also the form of benefit received.
Those seeking treatment for alcohol misuse are more likely to have taken this step only after experiencing other problems in their lives, including family breakdown, and mental health problems. Substance abuse treatment alone can result in positive employment-related outcomes. Treatment completion and length of time in treatment are good predictors of positive employment-related outcomes.
Some studies indicate that employment programmes (on their own or part of substance abuse treatment) which are intensive and offer a structured approach, but can also be flexibly adapted to meet individual need, have promise in terms of a range of outcomes. Intensive individual case management support seems to be important as does vocational rehabilitation and a focus on developing an individual’s ‘employability skills’. Predictors of an individual being able to return to work include employment history, employment immediately prior to treatment entry and the proximity of clients to the services available to them.
For programmes to meet multiple needs, a strong degree of inter-agency communication and collaboration is necessary between alcohol treatment and employment services. However, overall there is a lack of robust research in the area of employment-related interventions and little evaluation of programmes in the UK. More evidence is therefore needed in this area.
Participants reported mixed experiences in terms of childhood, family life and education, but problems during childhood, for example family break-up or bereavement, living with parental alcohol problems, bullying, truanting or other problems at school, were common across the sample. Many participants discussed gaining multiple qualifications at school but many others left with none. On leaving school, most participants went on to either further education, employment or an apprenticeship, although not all interviewees were able to sustain these long-term.
Although all but one interviewee was unemployed at the time of the study, their previous work experience was extensive and varied. Some had worked for very long periods in the same job or industry, whilst others had had a variety of different jobs. The types of jobs undertaken ranged from unskilled to semi-skilled and very high skilled occupations. Few interviewees had little or no work experience.
The most common reason cited by participants for leaving previous employment was problems with alcohol, though some had also lost jobs due to ill health or becoming redundant. Most participants conveyed a positive work ethic, although many reported that ongoing physical and mental health problems prevented them from seeking work at the time of interview. Some participants admitted that they had previously done cash in hand, casual work in addition to receiving benefits.
Two broad groups emerged from the interview data. For the first group, alcohol problems developed during their younger years, sometimes as a result of exposure to parental drinking problems or workplace alcohol culture. For the other group, alcohol problems developed over longer periods of time, or in response to a particular trigger, such as bereavement, redundancy or unemployment, or mental health problems. Interviewees talked about the breakdown of significant relationships, often related to their alcohol misuse and other problems. As a result, many of the study participants were single and lived alone, often in rented or supported accommodation.
Most of the sample were abstinent at the time of their interview; some had been abstinent for a while, whilst others had very recently entered alcohol treatment. Almost all interviewees said that they had experienced at least one, and usually several, relapses in their attempts to stop drinking.
Interviewees were in receipt of, or in the process of applying for, a number of benefits, including Incapacity Benefit and/or Disability Living Allowance (DLA), Income Support (IS), Employment and Support Allowance (ESA) and Jobseeker’s Allowance (JSA). Some interviewees had only become unemployed for the first time, or first significant amount of time, recently because of their alcohol misuse. Others had a long benefit history, with only sporadic periods of employment. A number of clients were claiming benefits for reasons of co-existing mental health issues or other health problems, and only in some cases was alcohol the primary reason Alcohol (or drug) dependence does not of itself confer entitlement to disability-related benefits including IB and ESA. To qualify for these benefits claimants have to undertake a medical assessment of incapacity which assesses the effects of their condition on their ability to carry out a number of everyday activities relevant to work. People with alcohol or drug dependence may have other diagnoses, for example mental illness, which result in their incapacity for work. for claiming.
Sources of advice on benefits came from benefits advisers and jobcentre staff, health care professionals, support agencies and in some cases other clients, friends or relatives. Staff in alcohol treatment and other support services were a valued source of help in relation to benefits, particularly with form-filling and other forms of practical help.
Experiences of the benefit system generally were mixed, with some clients reporting very positive interactions with staff, and others expressing frustration with staff and systems. These included having to deal with more than one adviser and repeat the same information about their situation each time they saw someone different. A number of clients described negative, even distressing, experiences of medical assessment and subsequent appeals. To many the process seemed opaque and the outcomes arbitrary, and several felt that their assessments focused on their physical rather than mental health issues.
Many respondents were personally motivated to return to work and could identify the benefits of returning to employment. However, they were also keen to highlight that they saw this as something which could not happen overnight and that needed to be a gradual process. Others were quite fearful of returning to work, worrying that going back too quickly or taking the wrong kind of job might jeopardise their recovery. Generally, interviewees wanted to take their time to consider what returning to work meant for them. Many wished to try and engage with ‘meaningful’ employment rather than returning to the types of job they had had in the past. Some respondents felt that they lacked the necessary skills and qualifications to regain employment. Training and education opportunities, along with voluntary work, were seen as important stepping stones in the return to work.
Individual barriers to returning to work included wanting more time to deal with their alcohol problems, and fear of the stigma they may face as a result of their alcohol or mental health problems if they had to reveal them to a prospective employer. Significantly, many respondents indicated that they would be worse off financially if they returned to work. Some were concerned that they would be unable to earn sufficient money in a low paid job to cover all their living costs as they would lose the financial support of benefits such as housing and council tax. This was a particular concern for those in supported accommodation.
Most clients seen by these professionals had long-standing problems with alcohol. Some were in employment, or had been until a recent crisis or escalation in their drinking; others had a limited work history. Some were also drug users (including prescription drugs). Most were described as socially isolated. Female clients often had particular issues and needs including childcare, fear of losing their children, or over time, the loss of family life triggering alcohol misuse.
Professionals identified financial instability as a major barrier to engaging with support and treatment services either caused or exacerbated by issues around benefit claims, household budgeting and debt. Other barriers cited by professionals included the fear of losing benefits; chaotic lifestyles and mental health issues; difficulties with social interaction; denial of the seriousness of their alcohol misuse; pride or stigma; or simply not knowing that help is available.
Feeling positive, motivated and wanting to change is essential for recovery; a negative state of mind is a significant barrier. All the professionals stressed that recovery can take a long time, up to three years or more for those with more complex needs. Some professionals felt that clients would benefit from continuity of support from a treatment professional during this period. Several emphasised that coercion and compulsion were counterproductive; recovery primarily requires self-motivation. People have to want to engage with services, become abstinent and return to work. In addition to treatment needs clients had a wide range of economic, social and practical support needs. Professionals stressed the importance of dealing with these complex ‘life issues’ as part of recovery and before a return to employment.
Relapse is common if not inevitable. Potential triggers include the threat of or actual loss of benefits; financial and housing issues; stress around returning to work too soon; bereavement; family problems; the availability of alcohol and the lack of an (alcohol-free) social life.
Professionals helped clients with benefit forms but did not feel knowledgeable about benefits, and usually referred clients on to specialist advice services. Most described positive experiences of jobcentre services, although some acknowledged that clients’ experiences were less positive. They reported clients’ misconceptions of the benefit system and entitlements, and difficulties caused by their alcohol problems and stress/anxiety. Some benefit requirements (eg. job-search activities for JSA recipients) were seen to potentially hinder recovery and return to work. Some negative experiences of the ESA medical assessment were reported, particularly for clients with mental health issues and chaotic lifestyles.
Withdrawal of benefits was seen as particularly problematic for those with alcohol misuse problems, as the loss of benefits could lead to health problems, disengagement from treatment, and relapse. In addition, the payment of backdated benefits in a lump sum was identified as an issue for some recipients, for whom it may trigger episodes of binge drinking.
Most professionals felt it was important for clients to ‘do something’ and to be socialised back into a work environment, even if employment was not initially paid. However, they felt it was unlikely that some clients would return to work as their problems were too complex, or their mental health issues were too great.
Facilitators to a return to work included a positive state of mind and social support, access to appropriate support services, retraining, and a staged return to the workplace, including ‘bridging’ services and voluntary work. Barriers to employment described by professionals included a lack of financial stability, confidence and motivation, and social support. Additional barriers included time out of employment, lack of appropriate work experience and skills, concerns over a criminal record, a ‘culture’ of not working within the family or locality, and alcohol misuse itself.
For some clients being on benefits can be a motivator to return to employment, but for others it can be a barrier. This is particularly the case for older clients, or in areas where employment opportunities are limited or inappropriate, and clients are reluctant to leave the ‘safety net’ of benefits as the alternative may be seen as significantly worse. It was felt that being ‘pushed’ into returning to work too soon was likely to be counterproductive, with a high chance of relapse.
Most professionals were generally positive about integrated working with other services, the voluntary sector, benefit agencies and jobcentres. Some felt more targeted provision of benefits advice would be helpful. Concerns were expressed about the perceived lack of services for adults with alcohol misuse problems. Specific gaps identified included outreach, aftercare, out of hours services, family therapy, and services targeted at binge drinkers and young people. Most argued for a wider view of treatment, to include social support and help with living an alcohol-free life.
A number of key themes and issues emerge from the study and there is a clear relationship between the literature and the empirical findings, as well as important gaps where more research is needed. In particular, there are a number of potential recommendations for policy and practice. These recommendations are intended to provide some practical suggestions for solutions to issues identified within the report. The current uncertainties about cost reductions within the public services may affect what can be implemented.
Treatment, recovery and employment Findings demonstrate that engagement with and completion of treatment is an important first step on the route to employment. However it is recovery (involving the resolution of other life issues and stresses such as housing problems) rather than treatment completion that is a key component of coming off benefits and securing employment. Interventions and policies need to recognise this distinction. A recovery allowance involving a relaxation of benefit conditionality that could be accessed by those who are undertaking or have recently completed a treatment course for alcohol or drug addiction would assist individuals in focusing on recovery and moving forward with more confidence and less fear of financial hardship.
A step-wise approach starting with voluntary work, part-time work or work experience to provide a gradual reintegration to the workplace, and ensuring that individuals are better off in work than they would be on benefits, would help this group make the transition to employment.
Further evidence is needed around longer-term employment outcomes from programmes, and the role that abstinence plays in helping those leaving treatment to gain and sustain employment.
Additional support from Jobcentre Plus staff Alcohol misusers face a number of barriers to both accessing appropriate benefits and moving off them and into employment, and some reported feeling that they didn’t receive the support they felt they needed from Jobcentre Plus staff . They would benefit from better access to those with specialist knowledge in order to negotiate the benefit system. A caseloading system in which alcohol misusing customers see the same Jobcentre Plus adviser every time they visit may help to improve the experience for this group by removing the need for them to repeat often sensitive and difficult personal information to different advisers.
Mandation to treatment The literature suggests that the receipt of benefits does not encourage or increase alcohol dependence. Alcohol misuse can cause unemployment which may result in being on benefits, but it is not the benefit receipt in itself that causes or escalates alcohol misuse. In our view there is inadequate evidence from either the literature or qualitative research that making treatment a condition of benefit receipt would improve treatment outcomes for clients or result in more alcohol misusers re-entering employment.
Interagency working One of the clearest findings from our study is that interagency working can result in better support for adults with alcohol misuse problems and better access to training and employment opportunities. The clients interviewed in our study expressed frustration about having to deal with multiple agencies and individuals and having to provide the same information repeatedly. They also reported that Jobcentre Plus staff were not always responsive to their needs, particularly when these were related to substance misuse. The professionals we interviewed also identified a need for benefit and employment advice for their clients in the context of some understanding of alcohol misuse. One model for increasing interagency working would be the introduction of Jobcentre Plus outreach sessions in treatment provider premises.
Last revised 19 December 2010
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