Government policies and assistance for people who misuse alcohol raise controversial issues for legislators, policymakers and practitioners alike. Goodman (2007) highlights that government policy adopts both a ‘carrot’ and ‘stick’ approach. While individuals who misuse substances are encouraged to seek treatment, there is also the threat that for those who choose not to engage in programmes, they run the risk of being targeted if they continue in their addiction. Thus those whose alcohol addiction has caused them to become involved in criminal/illegal activities and who refuse to engage with alcohol interventions face agencies using enforcement and prosecution if they continue with their behaviours.
Harm caused by alcohol is Scotland’s biggest health challenge. Changing Scotland’s Relationship with Alcohol: A Framework for Action was published to address Scotland’s £2.25 billion alcohol misuse problem. The government’s focus is on reducing costs, recovery and making sure that people who need help are identified sooner and directed towards the right services (Scottish Government, 2009). In line with this, there have been significant changes in welfare policies for people who misuse alcohol.
There is no clear of the number of people with drug and alcohol problems receiving social work interventions. Research is usually based on specialised practice teams, for example, teams working with children and families. Research suggests that approximately 25 per cent of children on child protection registers involve parental alcohol and or drug use. (Advisory Council on the Misuse of drugs (ACMD) 2003) while Hayden (2004) points out that higher estimates have been found among children and families services more broadly. Further research highlights that drug and alcohol misuse is prevalent with the many groups of people social workers often work with, for example, 44 per cent of people with mental ill health use substances in harmful or hazardous ways (Weaver et al, 2003) and among young people aged 14-15, research has shown that drinking alcohol is a regular occurrence (Institute of Alcohol Studies, 2009). Gender is also an important area in the field of substance misuse with research showing that it is often thought for it to be worse for a woman to be drunk than a man (Sandmaier, 1992). It would appear that the experience of alcohol abuse may be different for a man and a woman.
My interest in addictions developed whilst on placement with a voluntary organisation working with young people involved with offending and/or anti social behaviour. The placement demonstrated the increase in the extent to which drug and alcohol use influences the involvement of young people in offending (Rutter et al, 1998). An opportunity whilst on a mental health placement to work with a woman experiencing severe emotional, behavioural and financial difficulties who was alcohol dependent alerted me to the profound effects of addiction, the effect of proposed policy changes and to some of the difficulties experienced whilst working with this client group.
By 2009, the harm caused by alcohol and the cost to UK society had become a topical debate. Current downturns in the UK economic climate coupled with large number of economically inactive individuals and an increase in worklessness created much cause for concern. It was decided to focus this study on alcohol dependent service users in light of the new legislation in the UK which aimed to support individuals with health difficulties in getting back to work.
Aims of the Research
This research aim is to explore the experiences and perceptions of front line workers regarding the implication of the new Employment and Support Allowance for people who misuse alcohol and the implications this has for social work practice and will broadly cover issues such as:
- What difference, if any, has the introduction of the new Employment and Support Allowance made to work carried out with alcohol dependent service users?
- Should the implementation of this Allowance be subject to specific conditions?
- What is the experiences of working with alcohol dependent service users?
Outline of the dissertation
A review of the relevant literature is presented in chapter two in order to set the study in its legal, political and practice context. The approach and methods used to collect the data will be explored in chapter three. Chapter four presents and discusses the findings and chapter five presents the final analysis, draws some conclusions and makes some suggestions for future practice and research. All names including the name of the organisation in which the research is based have been changed in accordance with confidentiality agreements.
Chapter 1 Literature Review
This literature review is divided into four sections. Section one addresses, understandings of alcohol abuse. Political responses to alcohol abuse is the focus of section two. Section three explores the reasons for change and section four discusses practice issues, challenges and dilemmas.
The terms alcohol addiction, alcoholism, and alcohol dependence have the same meaning. No one term is more serious than the other. Different terms have evolved over the years to overcome the negative stigma of addiction. Some people are not addicted to drugs or alcohol, but abuse them. The American Psychiatric Association (DSM-IV) uses specific criteria over a 12 month period to differentiate between dependence and abuse. If an individual fulfils the criteria for substance dependency then a diagnosis of substance abuse does not apply (Petersen & McBride, 2002). For the purpose of this research, the term alcohol abuse will be used to describe individuals who abuse alcohol as well as those who are categorised as alcohol dependent.
SECTION 1 Understandings of alcohol abuse
The use of alcohol is long standing within Western culture. As the research has a focus on alcohol abuse, consideration must be given to the reasons why such a growth in excessive drinking emerged. The social changes stemming from the industrial revolution are therefore significant. Previous to these, ideas centred on the view that human beings were thought to be rational and exercised free will in relation to self enjoyment. Individuals were seen to exercise choice;
“Drunkenness was a choice, albeit a sinful one, which some individuals made.”
(Levine, 1978, p146)
The movement of people from rural to urban areas because of the need for organised labour together with the growth in population meant that there were significantly high concentrations of people. Social problems emerged on an exceptional scale with excessive alcohol consumption and related safety at work issues causing great public concern. Problems relating to alcohol abuse thus became more socially significant.
Many theories exist in relation to understanding the causes of alcohol abuse. Early explanations to problems with substance misuse focused on moral issues and the idea that alcohol consumption and ungodliness were linked. Individuals who had problems with drink were viewed as being ‘weak willed’ or ‘sinful’ with ‘treatment’ focusing on punishment or religious conversion (Petersen & McBride, 2002, p34*). During the nineteenth century, scientific explanations began to emerge in relation to understanding the spread of excessive drinking behaviour in society; this was the first time that the idea of alcoholism as a disease was considered (Collins, 1990). Applying such a medical analysis allowed for a new awareness, understanding and even sympathetic attitude towards alcohol consumption and its related problems. Pressure on the State to ensure that alcoholism was recognised as a disease which required specific medical attention was now evident.
Petersen & McBride (2002) highlight that substance use is different from dependence or addiction. When a person tries a substance once or for the first few times, it is seen as ‘experimental.’ Substance misuse can also be ‘recreational’ meaning a person may misuse a substance, for example, alcohol, occasionally or on a social basis. The individual is seen as ‘dependent’ if they have developed a dependent pattern on a substance and misuse it continually. Critics argue that the disease approach focuses the attention only on the dependent problem drinker, the drinker who is experiencing severe physical and social consequences. Problems can occur at any of these stages with different interventions available, for example, the ‘disease model’ supports the argument for total abstinence and is broadly supported by Alcoholics Anonymous. However this model will not work for everyone. Alternatively, models which focus on harm reduction through controlled drinking, for example, the ‘wheel of change’ model, are also accepted within drug and alcohol services (Goodman, 2007).
Difficulties arise when categorising individuals and in relation to the language used; for example what constitutes recreational use? What is the difference between dependence and addiction? The language used within alcohol literature varies greatly. It is possible for someone to be in all three stages at once; for example someone who is dependent on alcohol may recreationally misuse cannabis. There appears to be a move away from socially constructed terms such as addiction, with research highlighting that terms such as ‘addict’ or ‘alcoholic’ carry with them a negative connation and are powerful labels. Goodman (2007) points out that it is better to call a person drug dependent, where the dependency is the compulsion to keep taking drugs.
There is no one clear definition of alcohol abuse as a disease. Kessel & Walton (1989) highlight that ‘alcoholism’ is a difficult subject to study and alcoholism is a term with multiple and sometimes conflicting definitions. Defining what constitutes an ‘alcoholic’ and what constitutes a ‘non-alcoholic’ is difficult. Collins (1990) highlights that;
“It is now accepted that problem drinking exists on a continuum, with normal or non-problem drinking at one end and severe dependence at the other”
(Collins, 1990, p49*)
Developments in research into dependency have led to risk factors such as stress, social environment, emotional health, genetic predisposition, age, and gender being identified. For example, studies have shown that children born from alcohol dependent parents who are adopted into families with no dependency issues are at greater risk of becoming alcohol dependent than the rest of the population. This would suggest that there is some genetic predisposition to alcohol dependence. Children born and raised by alcohol dependent parents have an even greater rate of becoming alcohol dependent, although here learnt behaviour may also be a factor (ref).
Psychological theories such as Social Learning Theory relate behaviour to processes that take place within the individual’s mind rather than the physical structure of the brain. Behaviour is believed to be conditioned by the expectations of the individual in carrying out a particular action, for example, immediate short term effects of alcohol can create feelings of enjoyment or eliminate unpleasant withdrawals. In the long term the advantages of stopping may be less rewarding than the short term gratification of prolonged misuse.
Certain studies question the idea of rewarded behaviour and that addiction is a consequence. Chein (1964) found that when normal subjects were given narcotics, although they found the experience pleasurable, they did not become compulsive drug users, suggesting that drugs are not inherently rewarding as Social Learning Theory purports. Furthermore, it was found that a percentage of people who developed dependencies became dependent anyway despite having found the initial drug experience unpleasant. Regardless of these concerns, the conditioning model is well supported and highlights once again that addictive behavior is complex and difficult to place into a single model.
Social Learning theory is helpful in explaining the differences in social attitudes to alcohol abuse in women. Sandmaier (1992) surveyed attitudes towards alcohol abuse among four hundred women and men of varying socioeconomic classes, ethnicity and age in the United States and found that the majority thought it to be worse for a woman to be drunk than a man. Labelling someone as an ‘alcoholic’ can be stigmatising and affect an individual’s self-efficacy and self-esteem (Goodman, 2007). Attitudes towards drinking are not homogeneous, however the stigma attached to female alcohol abuse significantly shapes the experience, rendering it different from the experience of a man. Alcohol abuse for women threatens society’s formed image about women being good mothers or good wives. Problem drinking often goes undetected amongst women due to a fear of condemnation by society. Women experiencing alcohol problems can be viewed as ‘repulsive and disgraceful.’ Such cultural judgments can therefore adversely affect women seeking help (Sandmaier, 1992, p8).
Theories of personality are located somewhere between the biological and psychological with suggestions that certain types of people will experience problems with alcohol dependency. The term ‘addictive personality’ is sometimes used but critics have questioned this, concluding that there is no one type of personality more likely to abuse substances or develop substance dependency (Nathan, 1988). What appears to be more accurate is that specific personality traits have been linked to substance misuse, for example, sensation seeking has been identified as a personality trait that may be common in those who choose to abuse substances (Zuckerman, 1979).
Two main schools of thought appear to be evident in relation to understanding alcohol abuse; the biological standpoint and a more psychosocial belief structure. It is important to understand that theories provide useful contributions to understanding substance dependence but that no integrated theory exists.
“As there is no one substance use experience and no one encompassing theory, there can be no one specific response.”
(Petersen & McBride, 2002, p36)
What looks apparent is that society, for many years, has had an ambivalent attitude towards alcohol consumption. Confusion of attitudes inevitably result from shifts among policy makers in line with changes in dominant viewpoints. Predominant medical understandings of alcohol abuse which consider ‘alcoholism’ as a disease justify state intervention such as help through health care to address the damage caused to the body. Whatever the reasons behind substance abuse and dependency, research has shown there to be a huge cost, both financially and to human life.
SECTION 2 – Political responses to alcohol abuse
In order to explore the State’s approach to tackling alcohol abuse, ideas around welfare are significant. As a result of the development of ‘alcoholism’ being recognised as a disease which requires treatment, distinguishable welfare needs have been identified. In reviewing ideas around welfare, the ‘welfare state’ in the UK differed from previous schemes of poverty relief due to its relatively universal coverage. The Social Insurance and Allied Services Report (1942) (the Beveridge Report) provided the proposals which allowed for the creation of the welfare state. The idea was to provide universal benefits to all and to address issues such as unemployment, poverty and disease.
Critics argued that the creation of a ‘welfare state’ under Beveridge’s original proposal was excessively expensive, could not be financially maintained after the post war boom period and would create an unwillingness to work. Since 1979, reforms have been evident across all government sectors with more of an emphasis being placed on the responsibility of the individual. The Social Security Act (1986) brought about major structural changes to the social security system. In relation to benefits, means testing and compulsory conditions to specific benefits were established. For example, invalidity benefit for those who were unable to work due to ill health, which included alcohol dependent service users, was changed to incapacity benefit requiring all but the severely disabled, below pension age, to become job seekers.
This brought about a new culture towards welfare which the ‘New’ Labour government elected in the 1997 election were quick to embrace. Alcock et al (2008) highlight that in analysing current political attitudes, an account of social policy now is an account of the shape it has been given by the New Labour Government in power. The Government believes that paid work has many rewards, for example, it increases independence, health and well being. The government wants to provide the opportunity for as many people as possible to access employment and share such rewards. Employment policies occupy a central but controversial place in debates about the future of welfare. Welfare-to work programmes for those who are able to work have been introduced in an attempt to move away from the ‘old passive benefit system’ (Alcock et al, 2008, p342). Developments have seen groups that had previously not been expected to find paid work, for example, people with disabilities, now being included in this approach. The Welfare Reform Act (2009) which applies to England, Wales and Scotland sets out the framework necessary for the future abolition of Income Support, and the movement of claimants of that benefit to Jobseeker’s Allowance with differing degrees of conditionality, or to Employment and Support Allowance. The Act provides for those who have problems with alcohol to be directed to make, and comply with, a rehabilitation plan.
Concern about the negative consequences of alcohol abuse has reached a significantly high point on the current political agenda. At a national level the problems associated with alcohol abuse is recognised as a priority by the Government. Local governments have developed their own frameworks for addressing alcohol related harm, for example, ‘Changing Scotland’s Relationship with Alcohol: A Framework for Action’ (Scottish Government, 2009).
The role alcohol plays in the UK’s economy can be both positive and negative. There are wide-reaching economic benefits derived from alcohol and alcohol consumption such as the provision of employment and tax revenues. The total value of the UK drinks market exceeds £30 billion. The justification for alcohol excise duties ensures that the consumer directly contributes to any costs that alcohol consumption imposes on society as alcoholic drink is subject to both excise and VAT. Revenue for the Exchequer is substantial and has been increasing for the last 30 years. The alcoholic drinks industry reports to generate approximately one million jobs across the whole supply chain. The British Beer and Pub Association reports that there are over one million people employed in hotels, restaurants, pubs and clubs (Institute of Alcohol Studies, 2008). It is evident that alcohol plays an important role in the success of certain parts of industry in UK society.
In relation to the harm caused by alcohol in Scotland, there were over 40,000 hospital admissions in 2007-8 due to alcohol related illness and injury and deaths related to alcohol have more than doubled in the last 15 years. Rates of liver cirrhosis in Scotland are growing faster than anywhere else in the world and life expectancy in some parts of Scotland has fallen significantly short of life expectancy elsewhere. Research suggests that alcohol plays a significant part in these inequalities (Scottish Government, 2009).
Research has shown that drinking alcohol in Scotland is a common occurrence for the majority of young people between the ages of 12 and 15 and that the problem with underage drinking is rising (Institute of Alcohol Studies, 2009). If people are drinking at a younger age they are at greater risk of developing dependencies, experiencing health difficulties or becoming economically inactive, all of which will have a detrimental effect on the economy. To address the problem of underage drinking initiatives and proposals are ongoing. In 2008, certain councils piloted local bans on under-21s using off-licenses. Results indicated that the level of assaults, vandalism and general complaints about young people fell significantly. These pilots were viewed successfully but critics argue that governments need to focus on wider issues such as poverty in order to change Scotland’s attitude to alcohol (The Times, 2008).
The regulation of the sale of alcohol has a long history in UK society. Whilst the minimum age of eighteen years old to purchase alcohol has remained the same, the variety of outlets licensed to sell alcohol and the opening times of these has changed dramatically. Tensions exist for government in relation to the deregulation of alcohol along with the wider availability of it and concerns about Scotland’s problematic relationship with alcohol. Current government policy appears to be tailored towards the health benefits of reducing alcohol consumption and dependency and addressing the detrimental effects on health services and other related social problems. This appears to be the Government’s focus regardless of the opportunity to raise substantial revenue through the taxation of alcohol. Such changes in political attitudes towards alcohol abuse have brought about firmer regulations governing the sale and possession of alcohol, for example, The Licensing (Scotland) Act 2005 represents the biggest changes to the Licensing System in Scotland in over thirty years. The Act increases responsibility for those who are involved in the sale of alcohol and places restrictions on drinks promotions, for example, Happy Hours and two-for-one promotions can no longer be used by licensed premises.
Recent reforms relate to the Scottish Government’s introduction of the Alcohol Bill. This Bill proposes a number of measures to tackle alcohol-related harm including a 40 pence per unit minimum price (Scottish Government, 2009). However critics argue that pricing measures will not tackle the underlying reasons why people drink harmfully. Changes in regulations have came about to address issues such as public disorder and underage drinking as alcohol abuse is significantly linked to these.
Law and order and health are just some of many Government departments which are affected by alcohol-related harm. The total cost to UK society is vast. The National Social Marketing Centre in 2007 estimated a cost £55.1 billion. This estimate was composed of £21 billion cost to individuals and families/households, £2.8 billion cost to public health and care services, £2.1 billion cost to the Criminal Justice System, Education and Social Services, £7.3 billion cost to employers (includes days lost to affects of alcohol abuse) and £21.9 billion in human cost (reduced quality of life adjusted years) (House of Commons, 2009). The increasing cost of alcohol abuse and related concerns are therefore key considerations for government.
SECTION 3 – Need for change?
During this time of economic recession, the government is paying significant attention to welfare reform. Government publications such as Raising Expectations and Increasing Support: Reforming Welfare for the Future (2008) detail plans for the future as part of New Labour’s vision for a personalised welfare state.
There appears to be a number of reasons why the government wants to increase employment levels, helping to explain why the government’s focus has been on welfare reforms. The rate of worklessness, that is, those detached from the labour market, for example, alcohol-dependent and economically inactive individuals is significant. The Office for National Statistics (2009) reported that the number of working-age people in workless households in April-June 2009 reached 4.8 million. This was a rise of 500,000 from the previous year. The number of workless households with children reached 1.9 million, highlighting a rise of 170,000. The percentage of households in which no adults worked also increased by 1.1 percentage points from the previous year. These s reflect the highest rates since 1999 and the highest year-on-year increase since 1997. Increasing the number of economically active in society is crucial for government as they fund the economically dependent.
Worklessness is linked to poor health and poverty and both poverty and worklessness are intergenerational; a working household is not only less likely to be in poverty, but also children living in the household are less likely to be in poverty as adults (Centre for Longitudinal Studies, 2007). Some argue that benefit payments accompanied with weak or no work expectations trap the very people they are supposed to help. Worklessness and the increasing cost of alcohol abuse are therefore key considerations for current government and help to explain reasons for change.
Recognition that the number of people over state pension age has exceeded the number of children has raised government concerns. The dilemma of an ageing population has caused alarm for both public and private sectors, for example, concerns relate to pensions, the size of the workforce and the capacities of the health and social services.
Alcock et al (2008) point out:
“For governments, high rates of employment boost tax revenues, reduce spending on social security benefits and make it easier to fund other social policies and meet the anticipated costs of an aging population”
(Alcock et al., 2008, p.311).
The Department for Work and Pensions (DWP) points out that the new Employment and Support Allowance focuses on enabling disabled people and individuals with a health condition to engage in appropriate work, if they are able. The government has indicated that over 2.6 million people depend on incapacity benefits in the UK and that nine out of ten new claimants say that they want to return to work. The government cites this as one of the reasons why change has occurred (DWP, 2008).
The idea that alcohol dependent service users are required to find suitable work raises questions about the availability, types of jobs and the level of pay required to help families out of poverty. Alcoholism is seen to have both direct and indirect effects on earnings and employment. Productivity and reliability in the labour market can be affected by the physical and mental health problems linked with alcohol dependency. That is, sickness, hangover or late arrivals are work characteristics that lead to reduced reliability and productivity. Indirect effects relate to a possible lack of education if a dependency has prevented an individual from completing or advancing at school. This possible lack of education could lead to lower wages and a limited selection of jobs. Difficulties in maintaining employment may also be experienced by individuals who are alcohol dependent, as reduced reliability leads to job loss and decreased employability. Consequently the lack of work experience can lead to lower wages and earnings (MacPherson, 1998). However, having someone in work does not necessarily mean the household will not be poor; thus, debates continue in relation to the role that employment policies play in reducing poverty.
The new Employment and Support Allowance places obligations upon disabled people, including alcohol dependent individuals judged to be capable of work. Creating ideas that centre on having norms which is to be in full time paid work is perhaps stigmatising and disadvantaging to those people whose capabilities mean they have to work less or at a slower rate.
Critics would argue that the new system will make it difficult for individuals to refuse a job if they consider it beneath their dignity, thus raising questions about the value of autonomy in our society. Increasing the degree of conditionality in the benefit system could perhaps add strength to the argument that too often ‘poor’ people can be treated as though they have no right to pursue a career of their choice, how to allocate time between family responsibilities or work outside their home or how to meet their family responsibilities. Some would argue that ‘poor’ people do not receive the same minimum respect as other citizens (Young, 2002).
SECTION 4 – Practice issues, challenges and dilemmas
Some people with disabilities need extra resources, equipment or personal care to function independently and/or benefit from welfare-to-work government policies. In relation to people who misuse alcohol and claim Employment and Support Allowance on the grounds of incapacity, this section will examine some of the current practice issues and the main challenges and dilemmas that can arise.
Many people with substance misuse issues appear to lack serious motivation to change behaviour that could be described as self-destructive. In relation to what works to motivate people to change, research has shown that scare tactics and confronting individuals are likely to lead to a defensive reaction, whilst labeling an individual as an ‘alcoholic’ or ‘addict’ is unhelpful and does not support the person to change (Goodman, 2007). Setting goals is important, but for any assistance to be successful, such goals must be a shared aspiration between the individual and worker. How successful the new system will be in helping people who misuse alcohol return to work will perhaps be more related to how well it works with individuals in assessing what they are capable of and how effective it is in assessing what help and support service users need to manage their condition, rather than the increasing conditionality and penalties.
The Welfare Reform Act (2009) gives Job Centre advisers the power to assess individuals for alcohol problems and to force those with a dependency to undergo treatment. Individuals who refuse will lose benefits. Critics argue that job Centre advisers do not have the training for this role, and that specialised drug and alcohol professionals would need to carry out such assessments. There is also concern whether drug and alcohol services have the resources to deal with the increased number of perhaps, involuntary clients. The charity Alcohol Concern estimates that only one in 18 individuals who have an alcohol dependency can to access treatment (Hunter, 2009).
The focus on what works best with alcohol and drug problems is of great importance. Challenges arise from frustrations felt by workers seeing people with alcohol or drug problems repeatedly in and out of the ‘revolving door’ of services. Attempting to change a long term pattern of drinking is extremely difficult, with research showing that several or more attempts can be required. Petersen and McBride (2002) highlighted that:
“The inability to stop using drugs and especially the inability to avoid returning to use are at the heart of what we mean by addiction. In this respect, the problem of relapse is one of the defining features of the addictive disorders”
(Petersen and McBride, 2002, p189)
If relapse is a defining feature of the addictive disorder, how do welfare changes which make more condition and create more complex systems incorporate this known feature of the addiction cycle? Dilemmas arise in relation to the new system and the lack of sensitivity to the particular conditions such as alcohol abuse with its relapse and periodic ‘down’ periods. Critics point out that an individual’s alcohol dependency might be an indication that he or she is struggling to cope and that removing benefits could have detrimental effects. Removing or reducing alcohol dependent service users’ benefits could create more strain in their lives and make their alcohol issues worse. This, in turn, would be less likely to help individuals in getting back to work, and therefore the new system would have achieved the opposite of its intended purpose. How individuals would