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Targeting benefit payments to people who misuse alcohol: positive or punitive?

An exploration of the views of front line workers regarding the implication of the new Employment and Support Allowance for people who misuse alcohol.

Introduction

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

INTRODUCTION

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 continue to fund their dependency after benefits were removed would then be a concern, as would the impact of financial difficulties on the individual's family. Individuals with alcohol dependency problems require financial stability to find, undergo and disengage with treatment. Critics argue that any threat that welfare benefits will be removed or reduced simply adds to the risk of relapse (Hunter, 2009). Furthermore, problems could also emerge whilst working with individuals if workers are not kept up-to-date and trained with any new support systems in place.

People drink for many different reasons. In relation to women, Petersen and McBride (2002) highlighted that more disposable income and less responsibilities for women in the 18-25 age range could explain why this group has been drinking more. Women with young families often continue to work or return to work earlier. The pressure of working full time then returning home to care for children results in increased tiredness and a desire for a quick fix to unwind; this too has been cited as possible reasons for an increase in alcohol consumption. Research has shown that if a person believes alcohol will help them to unwind, it probably will. In relation to women who are older and whose children have left home, increased drinking may occur to deal with feelings of loss. What is evident is that gender is important in relation to alcohol abuse. Thom (1987) suggested that problems experienced by women seeking help can be divided into two types;- internal and external. Shame and guilt are examples of what could be classified as internal. For example, a woman with children who is experiencing problems with alcohol may dually feel guilt and shame in relation to her alcohol misuse and related perceptions about her ‘failure' as a mother. Fear of condemnation can prevent women seeking help from drug and alcohol services and cause difficulties with on-going engagement. External problems affecting women seeking help unfortunately relate to failures on the part of the professional to recognise the problem.

Galvani (2006) highlights the overlap between domestic abuse and substance misuse, pointing out that among women with substance problems estimates consistently suggest that approximately two-thirds of women have suffered domestic abuse in their lifetime. Women who drink excessively also face dangers of sexual attack and unsafe sex. Goodman (2007) found that for social workers working with these clients abstinence may lead to the client, facing up to painful events from the past.

A further challenge of drug and alcohol services is to identify the psychological and physical harm to family members caused by an individual who is alcohol or drug dependent. Services tend to focus on the individual; however, research has shown that when services identify, assess and respond to the needs of family members, it helps the individual with the substance misuse problem to reduce his or her physical and psychological suffering and has a positive impact of the substance use of the person with the drug or alcohol problem. (Copello et al, 2000). Taking into consideration the importance of the need for services to focus on family members as well as the individual gives rise to concerns about the proposed idea that service users should have benefits withdrawn unless they agree to go on government treatment programmes., For example, the risk of poverty to children of alcohol dependent service users would increase if benefits were withdrawn.

A significant challenge of working with people who misuse substances relates to working with someone who is denying their alcohol problem or is unable to see the problems or harms related to it. As a result of the stigma and shame attached to problematic alcohol use, problems can arise with individuals disclosing sensitive information. Fear can cause individuals to withhold information or prevent them from seeking help., For example, if a person has children he or she may fear that they will be removed or if threats are made to withdraw benefits the person may not seek help. People are unlikely to disclose information if they feel threatened or defensive (Goodman, 2007). In view of this information, again concerns arise in relation to the new benefit system in place and the increased conditionality and penalties.

CONCLUSION

In reviewing previous sections, it is evident that attitudes towards alcohol use are fluid, with political attitudes being tightly linked with economic conditions. Defining alcoholism is problematic with interventions at present accepting a ‘disease' model approach. The cost of alcohol abuse is a government concern alongside related ‘worklessness'. As a result the government has introduced the Welfare Reform Act (2009) which aims at providing support to disabled people or people with ill health to move from benefits into employment. The Act allows for restructuring the benefit system with an increased focus on personal responsibility. In relation to drugs and alcohol, Jobcentre advisers have been given the power to ask individuals claiming JobSeeker's Allowance or Employment and Support Allowance and whether alcohol or drug misuse or dependencies will affect their ability for seeking employment. Individuals may also be required to undertake a "substance related assessment" and undergo a drug test. Non compliance with any stage of the process or any resulting rehabilitation plan could result in up to 26 weeks of benefits being lost (Hunter, 2009).

While the government may wish to support alcohol dependents into treatment, critics are concerned with the affects that making welfare benefits conditional on treatment or work will have. The training Jobcentre advisers have to identify individuals who need access to services has been questioned and with there being no simple test or threshold you could apply in relation to alcohol dependency the potential for discrimination is high. There are serious concerns that people will not seek help because of the fear that benefits could be stopped. Alcohol charities highlight that alcohol treatment services in the UK is extremely patchy and that plans like these will only work if there is a treatment place available. There is a demand on government that alcohol misuse is treated as serious as the misuse of illegal drugs, and that investment is equal in alcohol and drug treatment services (Hunter, 2009). The questionnaire used in this study has been devised in order to incorporate the views and perceptions of front line workers in relation to alcohol treatment provisions.

Chapter 2 METHDOLOGY

Introduction

The main aim of this study is to hear 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. This chapter examines the methodological approach used including the method of data collection and data analysis. Careful consideration is also given to ethical issues and the strengths and limitations of the study.

Research design

In order to gain answers to the research question, the development of a methodological design which is logical, clear and unambiguous is needed. O'Leary (2004) highlights that science needs structure and logic and that the methodological design of the study needs to incorporate the methodology, methods and tools needed to carry out the research. Green and Browne (2005) points out that there tends to be a bias towards quantitative research in, for example, the area of public health, where most of the research studies reported in academic journals are quantitative in design. However there is a noticeable rise of interest in the contribution that qualitative studies can make. Silverman (2006) importantly argues that basic social processes are not considered by quantitative research, as the answers received are not suitable for numerical or statistical analysis. Qualitative research ‘focuses on words rather than numbers as the unit of analysis' (Denscombe, 1998:174). Royse (2004) notes that qualitative research seeks to understand life experiences of those who may not be visible or well known to ‘mainstream society' for example, they may seek to examine the social worlds of people who misuse substances. Consideration of these points has been given when deciding the design of this research.

O'Leary (2004) highlights that in relation to choosing between different research methods one approach is not necessarily better than the other. What is of importance is that the research methods should fit the aims of the researcher. Contrasting to quantitative approaches with their ‘confirmatory' analysis focusing on trying to confirm (or disconfirm) a theory, qualitative research is a more inductive approach, focusing not only on exploring the data but also on making connections within the data through comparing patterns in accounts of attitudes, behaviours and experiences (Green & Browne,2005). Qualitative researchers thus seek to understand the experiences of selected individuals, not to test hypotheses (Kalof et al, 2008). Qualitative approaches are more ‘naturalistic', meaning research is not as structured in the sense of knowing what question will be asked of whom and in what order (Royse, 2004). Green & Browne (2005) highlight that qualitative research uses methods such as in depth interviews, participant and non participant observations and focus groups in order to obtain information and study social interactions in a natural context to explore the meaning and significance people give to their actions. This approach suits the social phenomena being studied as it differs from physical phenomena studied by positivistic approaches used in physical sciences (Gilbert, 2001). Qualitative methods are characterised as those that aim to explore meaning and that produce non-numerical data. This study is a detailed review of the experiences of nine frontline workers involved with individuals who misuse alcohol in a medium sized town in Scotland using a qualitative approach.

In this study, semi-structured interviews were used to allow the researcher some structure in relation to collecting data relevant to the research but also to enable prompt questions, where appropriate, to be asked with interviewees to probe for further information. There could be flexibility in discussion when gathering the main points of view in order to establish a good rapport. Green & Browne (2005) highlight

“In qualitative interviews, often the aim is to recreate the flow of a ‘natural' conversation, which requires additional skills in listening and asking appropriate questions.”

(Green & Browne, 2005, p55)

In line with this, the use of face to face interviews, rather than surveys or postal questionnaires, was deemed more appropriate. In relation to building rapport, the student status of the researcher was disclosed with clear information being provided to the research project. Each interview was recorded in order to avoid constant note taking and possible distractions. Issues of anonymity and confidentiality were discussed beforehand. Having had to visit the agency on four separate occasions and continually make contact to reschedule interviews due to a lack of room availability, a rapport was built up between the researcher and the respondents. Research highlights that the amount of data collected during the interview can be influenced by the condition of the relationship between the researcher and respondents (Seale 2004). The research benefited from this, in that it allowed the opportunity for issues of difference and diversity to be explored further. Respondents sought information about the researcher's academic background and work history. The researcher verbally provided this information. Respondents being interviewed were from very different backgrounds: from different professions, genders, ages and social status. Green & Browne (2005) note;

“These differences have an effect on all aspects of the interview: how likely it is someone will agree to be interviewed, how much they feel they can disclose and how they frame their answers to your questions.”

(Green & Browne, 2005, p56)

Data collection and interviewer bias

Qualitative research is sometimes viewed as not being “serious” research as it does not produce generalisable knowledge (Marshall & Rossman, 1995:5) Counter-arguments exist and in some cases depending on what is studied, qualitative methods are superior to quantitative and remain very popular (Royse, 2004). This qualitative research was based on semi structured face to face interviews which were recorded and lasted no more than one hour. Respondents could be interviewed at their place of work or at a location of their choice. The respondents were given the opportunity to be as relaxed as possible with the interview process.

The agency was provided with an information pack which contained the research proposal, information sheet and interview schedule. The respondents were provided with information on the subject matter and type of questions to expect but were only provided with the interview schedule immediately prior to interview. Gilbert (2001) suggests using open ended questions in order to gain spontaneity and to maintain reliability and validity, relevance and clarity (Gilbert, 2001). Multiple questions were thus asked in relation to the new Employment and Support Allowance covering different points of the new system in order to understand things in depth from the respondents perspective. Alston & Bowles (2003) suggest that a qualitative approach is automatically valid as the researcher is at the mercy of the participants' world views. They also suggest that rigorous taking of field notes and consistent questioning improve the reliability of qualitative research. The questioning technique was conversational in style, the interviewer saying as little as possible.

Gomm (2004) highlights that the data collected during qualitative research is shaped by the way the questions are posed and the manner and the context in which they were asked. Research has shown that trust must be established during the interview process in order that participants can freely give their answers without the fear of seeming foolish. The researcher was aware of her actions and how these could affect the information collected. The researcher was careful to understand the theories and values of the participants separate from her own (Seale 2004).

The researcher explained that there was no right or wrongs answers and was careful to maintain an open and transparent relationship with respondents. Seale (2004) highlights that body language can indicate that the researcher is truly hearing and understanding respondents so the researcher adopted an interested pose and maintained eye contact with respondents.

Shapiro and Eberhart, (1947 in Gilbert, 1993: 134) deemed ‘verbosity' of the respondent to be a result of the willingness of the researcher to probe. Using a semi-structured interview, the researcher was able to seek additional explanation or clarification without in any way leading the respondents. Further probing also served to encourage the respondents that they were being listened to. The researcher chose to wear smart but casual clothes to maintain consistency and research integrity. If questions had already been answered, the researcher avoided repetition of questions to maintain relevance (Gilbert 2001).

The Pilot Study

The pilot study was carried out in a one to one setting. Community facilities local to the social work practitioner were used to carry out the pilot study. The pilot study consisted of the researcher asking the interview questions once to each social work practitioner on separate occasions. Each practitioner provided responses to the questions and feedback on completion. This information was recorded by the researcher. The pilot study was informal and recording's were destroyed.

Kalof et al (2008) highlight that pilot testing allows the researcher to test how well their questions work to make sure they will gather the relevant information they are seeking. The researcher was able to meet with two social work colleagues working in different Scottish towns who read the interview schedule and gave feedback. The researcher was made aware that the use of vocabulary in certain questions could be made more familiar and that general questions could be used at the beginning. From their feedback the researcher added four general questions at the beginning of the interview schedule and a small number of questions were changed to use appropriate everyday wording.

The pilot study carried out with social work professionals was beneficial in raising the researcher's awareness and created an opportunity for comments to be made on the suitability of the research questions.

Access

The researcher was unable to secure access from the first Local Authority approached due to the death of the person the researcher first contacted. The researcher approached a second Local Authority's Drug and Alcohol Partnership initiative and was invited to present the aims and objectives of the proposed research at a monthly multi agency group meeting. The researcher was given details of a contact within the local authority and emailed the research proposal and information leaflet. The researcher was then required to complete a questionnaire for the local Authority before being provided with a contact person who gave details of a local addiction service that met the criteria for the study. The researcher was given access and contact details to 16 addictions workers who agreed to participate. The researcher gained the views and experiences of nine addiction workers; three workers were unable to participate due to their administrative role, two were unable to participate within the researcher's time scale and two workers did not have the required work experience to participate in the study.

Ethical considerations

Silverman (2006) highlights that to ensure as ethical a process as possible, it is necessary for the researcher to reflect on any ethical dilemma which may arise. Ethical considerations are, according to Gilbert, a matter of principled sensitivity to the rights of others.

“While truth is good, respect for human dignity is better” (Gilbert, 2001, p45).

Respondents were able to choose between the agency or community based facilities in order to increase a higher degree of participation. Royse (2004) highlights that the principle of “implied consent” is applied in interviews conducted with adults who are not in a vulnerable population with the act of participation being seen as giving informed consent (Royse, 2004, p51). The researcher was required by the Department's Ethics Committee to request that interviewees completed a consent form before each interview. In line with this consent was also given in writing.

My ethical approach was in line with the guideline offered by the British Sociological Association which:

“implies a responsibility on the sociologist to explain as fully as possible, and in terms meaningful to the participants, what the research is about, who is undertaking it and financing it, why it is being undertaken and how it is to be disseminated”

(in Gilbert, 1993, p63)

Research involving workers can help them identify their tacit knowledge, that is, the intuition, common sense or practice wisdom [which] is the implicit store of knowledge used in practice (Zeira and Rosen, 2000 in Gardner and Lehmann, 2002: 18). Ethical issues arise however if social workers divulge ‘insider information' as there could be implications for them if the researcher was found to know (Gardner and Lehmann, 2002:18). Dealing with such dilemmas and the unexpected elements of research, requires decisions to be made about the intellectual, emotional and social issues arising and the implications for data. Academic, professional and political demands must be balanced (Gardner and Lehmann, 2002).

The Department's Ethics Committee approved the research proposal (Appendix 1). Therein the researcher had considered the following issues:

Selection of participants

The researcher had decided to seek access to frontline workers involved with alcohol dependent service users. Workers had to have at least 12 months experience in order to compare and contrast welfare systems in place. Workers also had to be specialised, hold relevant qualifications and have case responsibility, for example, they could not be support workers. All participants worked in a medium sized Scottish town.

Consent

The research proposal and an information leaflet detailing the research area, expectations of involvement and the right to withdraw from the research at anytime, was sent to the integrated addiction agency. A follow up phone call to the line manager ascertained front line workers' willingness to proceed with the interviews. The researcher was provided with access and contact details to 16 workers within the addiction team. The contact details of addiction workers who did not meet the research criteria were destroyed. The respondents were informed that the research was being carried out as part of an MSc in Social Work Studies and were provided with a copy of the research information leaflet.

Confidentiality and anonymity

Absolute confidentiality was not guaranteed. It was explained to respondents that confidentiality would be carefully considered and that any information provided which caused concern would be passed on to the relevant person within the organisation with the respondent's knowledge (as per the SSSC Code of Conduct, 2002). Respondents were given a letter of the alphabet which did not reflect the order of the interview sequence in order to protect their anonymity. The researcher assured that all identifying details would be annoymised.

Data storage and dissemination

Respondents were informed that all voice recordings and transcripts as well as all other interview materials would be kept in a secure place within the researcher's family home. Respondents were also informed that the researcher would be the only person involved in transcribing the interviews and have access to the research information. Respondents were made aware that the data collected would be presented in the dissertation which will be available in the University of Stirling library and a summary of findings would be given to the local council. The researcher explained that all material would be destroyed once assessment procedures were finalised by the University.

Prevention of harm/ distress to respondents

The risk of harm was reduced in this study as it was a practice focused interview with workers. As there was a possibility that some questions might evoke personal memories and in turn may cause stress, the prevention of harm or distress to respondents was considered with front line workers only being asked questions which were relevant to the research project. The researcher made it clear that participants had the opportunity to opt out of particular questions or the entire project at any point. No interview was ended prematurely. The researcher explained the purpose and duration of the research and met with respondents at their place of work. To promote the safety of the researcher and the respondents, the researcher informed a friend of the times and location of each interview.

Data analysis

Simply reporting the participant's responses to each question in the interview is not analysis. The researcher is rather involved in a ‘translation process' identifying themes, patterns or recurring issues. (Royse, 2004, p275) Green & Browne (2005) highlight that one of the most difficult stages of research for qualitative researchers is that of analysis; what to do with data produced. The questions in this qualitative research were asked in a way which enabled the researcher to identify themes and recurring issues. Recording individual interviews allowed the researcher to listen to the interviews again as required to construct the transcripts. The researcher transcribed each individual interview and recordings were listened to repeatedly to ensure accuracy of transcript. For this reason, tape recording data is seen as superior to other methods of recording data (Silverman, 2006). The researcher also produced a matrix of responses as a visual aid to assist with data analysis.

Limitations of the study

The experiences of alcohol dependent service users vary, Goodman (2007) points out that substance misuse is a social problem that affects all social classes, gender and races. The literature review reveals that over the years, individuals who misuse substances have received inconsistent services from the helping professions. As the research was required to be carried out within a specific time scale it was not deemed possible to interview alcohol dependent service users or family members due to the time it would take to gain access. The sample size therefore does not make generalisable conclusions possible but will give insight into the experiences, perceptions, meanings and views of the front line addiction workers who were interviewed. The data would have certainly been influenced by the time limitations of the interviews.

Goodman (2007) highlights that there is an urgent need to develop services that are able to advocate on behalf of individuals involved in substance misuse. It is hoped that this research would contribute to identify where the formation of issues both helping and hindering alcohol dependent service users lie in relation to the introduction of the new Employment and Support Allowance. Gilbert (2001) highlights the necessity of this in relation to influencing any future changes amongst policy makers.

Chapter 3 Findings

Introduction

This chapter discusses and analyses the qualitative data gathered from one-to-one interviews with nine frontline workers involved with working with individuals who are alcohol dependent. Data has been analysed and themes relevant to the study's core aims are presented. As stated in the introductory chapter, the research questions cover three areas:

* 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?

These research questions had been designed to meet the core research aim which was to explore the views of front line workers regarding the implication of the new employment and support allowance for people who misuse alcohol. The researcher aimed to hear the voices of frontline workers in order to gain an insight into the effectiveness of the new system. Their views were sought on any information or training they had received on the new system, whether they believed the new system to be more effective than the previous system i.e. incapacity benefit, perceived benefits or disadvantages of the new system and their views about benefits being conditional on service users having to attend government funded programmes. The viewpoints about current levels of service and support for people with alcohol problems was gathered from respondents' so will also be addressed in this section on findings.

The addiction team accessed consisted of 16 workers, three administration workers and 13 frontline workers. The sample consisted of nine respondents, seven female and two male. Ages ranged from 31 to 62 years old. Eight workers described themselves as White British and one worker as White Irish. Seven respondents were educated to degree level whilst two had vocational qualifications and managerial experience. All respondents had a key worker role with alcohol dependent service users. Two respondents had medical backgrounds and were Registered General Nurses whereas seven respondents had social care backgrounds. Length of service in relation to current posts held ranged from six months to 11 years; respondents' experience within the field of addiction ranged from two to 26 years. Only one respondent worked across two local authorities. Frontline workers who participated in this study will be identified by the letters ‘FW' and numbered 1 to 9.

1 Viewpoints on the new system

Eight respondents said they had received no information or training on the new Employment and Support Allowance and one had attended a half day briefing. All respondents said they knew very little about the new system but were aware that service users were required to satisfy certain conditions in order to receive the new allowance.

I don't know a lot other than unless you're dying people will be forced into work….. FW5

I'm aware there's conditions being attached to service users to attend services to make progress in getting back to work..... FW1

Eight frontline workers were involved with service users who were in the process of going through the new system, with one worker unsure. All respondents believed there was a need for change but only one thought the new system would be more effective in assessing what an individual is capable of and what help and support service users need to manage their condition.

It moves away from ideas that people can never work. It's solution focused looking at unmet needs to get people back to work, it's more beneficial as it addresses needs..... FW2

The majority of respondents, when asked to compare how beneficial they thought the new system was in helping people back to work compared to the previous system, commented that they were concerned that it was more coercive and could do more damage than good.

I think they are forcing people into it a lot quicker than if they were on incapacity. But it's one of these situations where I think there will be quite a few people who were on incapacity who shouldn't be and were in a position to look for work and went through the net. But there are certainly service users and a good few I'm working with who are nowhere near in a position to look for work and I think they are going to get forced into it....... FW6

In exploring what impact the new system has on alcohol dependent service users, all workers highlighted that service users were unaware of the reasons why such changes were taking place. Respondents indicated that service users had received letters indicating that their current benefits were being withdrawn and advising them to apply for the new Employment and Support Allowance. All respondents indicated that service users were experiencing significantly increased levels of stress and anxiety.

It's absolutely terrifying them and confusing them and they don't know how to deal with it. There's a lot of paperwork involved, which they have difficulty with. A lot of clients have issues with literacy as they have been addicted since they were fourteen or fifteen and have missed a lot of schooling......... FW7

Concerns around literacy skills were common as were concerns around mental health. Four respondents commented that the increased levels of fear and anxiety experienced by service users in relation to welfare reforms was actually diverting attention away from addiction work.

Some of them are turning up to their appointments and are very preoccupied with talking about their welfare and benefits and things like that. That seems to be their main issue rather than them focusing on their addiction........ FW4

2 Viewpoints on whether conditions should be attached

In exploring whether the implementation of the new Employment and Support Allowance should be subject to specific conditions, all workers agreed that the expectations being put on service users were not realistic.

I think they will have to prove themselves a lot more, go down to get medicals etc and quite a few of our service users struggle to actually get out their house. They suffer from panic attacks; they are not in a position as sometimes they are too incapacitated through alcohol or drugs to do that. I think they are putting themselves in a position where they might just get written off anyway because they can't actually carry out the tests the DWP will want them to do........ FW6

Respondents highlighted that even the way in which service users are required to apply for the new allowance was unreasonable and caused concern. One respondent detailed what was involved:

The amount of adults I've had that have had their incapacity benefit withdrawn and have been asked to apply for the new employment and support allowance over the phone. It's taken 40 minutes to do the application over the phone, it's taken 2 weeks because there's a backlog because of it, for there to be a decision made and in that time period they have been asked to apply for a crises loan. Straight away we have 3 different phone calls that they have to make for one benefit and the majority of our clients don't have landline numbers where the call is free, its mobile numbers........... FW1

The respondent then went on to describe the impact on service delivery:

It's taken up a lot of addiction services time because we are having to do that with them or try and link them into another service such as citizens advice but even that is very difficult to then ask them to use another agency, its continuous demand on them and their time when there is alcohol dependency and mental health issues....... FW1

A common theme to emerge was that respondents did not believe the new system was individualized or as “focused on support” as the DWP claimed. Respondents believed that it was driven by service outcomes rather than being needs lead. Concerns were raised that the new system did not look at the whole picture when it came to addiction. Workers commented on the nature of assessments and how the focus was on physical health. It was thought that assessments did not take into consideration binge drinking, chaotic lifestyles, mental health and that addiction is a chronically relapsing condition. Furthermore, it was not seen to take into account unseen difficulties, for example, hepatitis C attacks and how these can incapacitate someone.

With the new system, there's no recognition for individuals with addictions as it's a specialized area. People who don't know about addiction and who've never worked in the field assume that when someone has a period of abstinence that they're miraculously cured and that's not the case because it's a chronically relapsing condition. They can have periods of abstinence, short bursts when they are really goal directed and motivated and then they can go back again, worse than ever. There's no recognition in this new system for that. Also if they push someone into a job too quickly that would be a huge trigger for relapse in our opinion….. FW7

The point made here was also echoed in responses from other frontline workers;

A major disadvantage is that benefit agency staff are given a lot of power to decide if someone is getting benefits. These people need more training, if someone is forced into a job when they are not ready they could relapse. Relapse is very common and workers (specialised addiction workers) are non judgemental. It's a big challenge to get service users to be honest and tailor support around it..... FW3

Significantly, when asked about any benefits of the new system, the majority of respondents highlighted that as long as the new system considered specific needs and did not force anyone into work who was unable to, the rewards of getting increased numbers of individuals back into work would be not only be beneficial for the individual but society also.

As long as they take into consideration specific needs, for example, learning disabilities or physical disabilities, before work commitments there shouldn't be disadvantages. The previous system was disempowering. The new system addresses learned helplessness. The previous system reinforced negative stereotypes..... FW2

If assessment is accurate it will have a good effect. Programmes that work, can empower and build confidence for the service user.......FW

However as previously highlighted workers did not believe the new system considered fully the nature of addiction or related specific needs.

When respondents were asked their viewpoint on whether benefits should be conditional on service users having to attend government funded programmes and whether this idea was good or bad, opinion was divided. Three respondents thought it was a good idea:

It's a good thing as it will motivate people but assessments need to be accurate, for example, specialised help for literacy problems may be needed first or people might not even turn up if they can't read or write out of fear or embarrassment.... FW7

However, two respondents opposed it:

No, it's a bad thing as it's setting people up to fail! Support needs to be individual, it won't be effective if individuals are forced to comply. The reality is that services set up to address alcohol issues won't work if the person is not ready to address it...... FW1

Finally, there were four respondents who were undecided:

It depends on the individuals. To treat all alcohol dependent service users the same would be wrong..... FW3

The majority of respondents did not believe that forcing people into services would create positive outcomes. All respondents highlighted that the new system needs to be individual and that it could do more harm than good if it was not tailored to individuals needs. For example, it could cause relapse, financial difficulty, further exclusion and strain on family relations.

3 Experiences of working with alcohol dependent service users

The majority of workers commented that an individual's own motivation to change plays a key role in addiction work. The reasons why people want the service are significant, with success rates being higher when a service user has decided to access the service independently. If an individual believes that they have been pressured or ‘forced' to engage with the service, for example, from family or external agencies, such as children and families social work or have conditions to attend in relation to probation work, levels of motivation and success are lower.

Like I said, I have 50 people on my case load and I'm genuinely content with about 15 to 17 as they actively want to be here, they want to engage with the work, they take on board what you suggest and actively want to evidence change. The bulk are forced to be here, they don't turn up basically. I think last month I had about a 60% attendance rate and that's kind of very general and the same for everyone........ FW 4

The findings in this study support the idea that using coercive measures within the addiction field does not yield positive results and that self motivation is important. Respondents believe that the use of force can often have detrimental effects. Respondents believed that the new system is set up in a way that will force individuals into work by placing conditions on them and removing financial assistance if such conditions are not met. Respondents did not believe that such tactics will bring about change but rather will bring about a different set of difficulties for alcohol dependent service users.

Its setting people up to fail, asking them to use public transport and attend more services is a big challenge. For a start anybody moving about here needs money as the bus fares are horrendous and it might be the difference between a couple of cans of beer and a bus fare…… FW3

External influences are important in relation to addiction work. Respondents commented that family involvement can be positive but at times can prove to be negative. Abusive relationships can affect addiction work. Pressure from families for individuals to stop drinking completely and immediately can be dangerous as a controlled gradual withdrawal is a significantly safer method. Workers commented that it can be difficult for individuals to address their alcohol dependency if they are not in employment and when drugs and alcohol play a huge part in their social/family circumstances and that an individual's addiction can put a huge strain on families. Workers commented that it can be difficult to address the needs of the family versus the needs of the service user.

At the older end of our client group where there is the inability to do these forms and keep up with what is being asked of them, it's really difficult. Therefore there's a lot of pressure being put on families, there's a real family impact because these forms haven't been done and benefits have been stopped because adults are illiterate. It's a viscous circle..... FW1

The main challenge at this moment is keeping women with children in service. When child care social work become involved with a child, they can sometimes be a little heavy handed. If there's not a child protection order on that child and they're working voluntarily, women high tail it out of service very, very quickly because the relationship can be destroyed by over zealousness, if you like, by child care social work. Women can opt out of service for that, when they do really want/need the service. We need to get together and find some way of working together… FW7

It was thought that women with dependents were often frightened to come forward for help and support because they believed that any engagement with addiction services would automatically mean that their children would be accommodated by social work. Workers commented that some addiction work currently focused on reassuring women that this was not the case but that more work needs to be done in this area

We try to explain that we try to put support in place and to get people stabilized and offer support to the children as well, if its needed. But it does terrify a lot of people and drive them out of service. On the whole, we do a lot of work to mostly try and reassure people but I think more work needs to be done in that area….. FW 8

As discussed earlier, all workers commented on how literacy, financial and mental health issues can affect addiction work. Respondents expressed that such additional needs and required support added pressure to the addiction service. Workers reported that it was common for service users to come into addiction services having not been in receipt of any benefits for six months because they were unable to complete forms or did not understand what was required of them. In the words of one respondent, adult literacy was “a big thing” (FW1).

It was commonly believed by participants that service users often had unrealistic expectations of what addiction services could do for them. Frontline workers experienced that service users often wanted help to change immediately, on request. Workers reported that due to a lack of resources that it was not possible to offer support immediately and that the service aimed to assess individuals within a two week time period from when the initial referral was made. Workers also experienced service users who were seen as lacking responsibility when they engaged with addiction services.

I feel as if people come to us and it's like ‘fix us.' I think once they come into the service, they feel as if the responsibility is not theirs anymore and they put it onto us to ‘sort' their lives out. We've not got magic wands, we can't do that…… FW 9

It was recognized by all front line workers that some of the difficulties and challenges they experienced could be linked to a lack of resources. The lack of rehabilitation focused work was most commonly reported.

4 Current Levels of Service and Support

The majority of front line workers interviewed highlighted that the lack of rehabilitation work created a huge gap in service provision, leading to “a kind of band aid service” (FW2). Workers reported that rehabilitation workers were not active in their role due to the high levels of individuals requiring addiction services within the area. It is currently believed that there is no support in the area for people when they have stopped drinking.

Some of the rehab services they have in England are far, far superior to Scotland. Getting into a rehab here is horrendous. I think the government needs to take cognisance of that as well. There isn't a lot of places, classes or anything available. When people stop drinking, what do you offer them?.......... FW3

Apart from the main concern of rehabilitation work, participants responses in relation to current levels of service and support for people with alcohol problems in the area was generally positive. Front line workers thought that there was a good level of support, that child care concerns were picked up more quickly, the integrated approach was providing a more holistic effective service which offered a variety of support and that the service was meeting its objectives in relation to assessing individuals within a two week time period from when the initial referral was received.

Although all workers agreed that an integrated approach was beneficial, one worker expressed that significant improvements were needed in this area.

I've seen teams a lot more cohesive than our team. The NHS may have a different way of working from the council, their roles have changed and the nursing roles have changed and there's a high level of affliction about social work and children and families and stuff like that and there's a bit of resentment about how their role has changed. I think in terms of our council it's going to be possibly seven years down the line before we are fully integrated. I think we're integrated by name but there's a lot of creases to be ironed out and peoples job roles have to be cemented……….. FW 4

Respondents also believed more staff was needed alongside larger office facilities. Also it was expressed by some that other services such as benefits agencies needed more information about addiction services and what they can offer in order to prevent any confusion.

The majority of respondents did not believe that the use of coercion worked in relation to addiction work. All spoke about the individuals own motivation to change and the importance of this in relation to effectiveness. Respondents all expressed that they did not believe the new allowance took into consideration the true nature of addiction work with its evidenced relapses or patterns of behaviour, for example, binge drinking. Time taken to reapply for assistance in the new system, after relapses or binge episodes would inevitable cause financial difficulties. Workers believed the new system was setting people up to fail with unrealistic expectations and that further difficulties would ensue if financial assistance was stopped.

The main concern raised by workers related to the new system not been seen as individualised and that no rehabilitation work was included. Front line workers did not believe the new system will be more effective as a result of this. What is of interest to note from the findings is that there is also a major gap in service provision at present in relation to rehabilitation focused work. Front line workers had made suggestions that the Government needs to incorporate and provide funding for rehabilitation work in current services and for it to be an integral part of any new systems including the new Employment and Support Allowance if outcomes are to be positive for alcohol dependent service users.

The literature review identified that;

“As there is no one substance use experience and no one encompassing theory, there can be no one specific response.”

(Petersen & McBride, 2002, p36)

Participants responses also supported this and the need for support to be tailored to the individual. Thus it would seem that it would be imperative for the new Employment and Support Allowance to accurately assess specific needs in relation to alcohol dependent service users as they may differ from each other and from other service users classed as incapacitated by the DWP.

Chapter 4 Analysis & Conclusion

This study has explored 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. A qualitative approach was adopted, in which semi-structured interviews were used to gather data from nine front line addiction workers. They were asked questions covering the following areas:

* 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?

The use of semi structured interviews allowed an exploration of front line workers' experiences and perceptions regarding the implication of the new Employment and Support Allowance for people who misuse alcohol and thus achieve the aim of the study. Respondents' views were able to be communicated and explored in depth. Gomm (2004) highlights the benefits of recorded interviews in that they can be listened to again at leisure and that there is no need for the researcher to make split second decisions on what to record and what to ignore. Recording the interviews allowed me to listen again repeatedly to ensure accuracy when transcribing and analysing.

The questions that were formulated worked well, for example, respondents were able to answer each one and relate them to practice. Using a qualitative approach allowed for me to use prompt questions when appropriate. Respondents understood each questions and had no problems engaging or understanding the questionnaire.

Gender was identified as an important area in the field of substance misuse. The literature review identified that the stigma attached to female alcohol abuse shapes the experience, rendering it different from the experience of a man. Women with children experiencing problems with alcohol may dually were feel guilt and shame in relation to alcohol abuse and have perceptions about ‘failing' as a mother. A fear of condemnation can prevent women seeking help and/or engaging with addiction services (Thom, 1987). A consensus was found amongst workers that one of the main challenges for them was maintaining women with children in services. Workers reported that often women working voluntarily with addiction services would end involvement if child care social work became involved because they believed it would inevitably lead to children being accommodated by social work. The respondents experiences were thus in line with what was outlined in the literature review.

In analysing the data there was a range of views on the implication of the new Employment and Support Allowance for people who misuse alcohol and a degree of consensus that respondents did not believe that the use of coercion worked in the addiction field.

In relation to what works to motivate people to change, the literature review highlighted that scare tactics do not work. For example, scare tactics that point out death is inevitable if people choose to carry on with their addiction, threats and confronting individuals have been proven not to work. Many individuals who misuse alcohol appear to lack serious motivation to change behaviour which could be described as self destructive with research highlighting that successful assistance involves setting goals which are a shared aspiration between the individual and worker (Goodman, 2007). Responses reflected the idea that threats would be ineffective in addiction work with workers commenting on the importance of self motivation for service users and that the use of force often had detrimental effects. Workers discussed the difficulties they experienced in relation to working with people who were forced to comply with addiction services, for example, by conditions enforced by probation orders, and that these individuals would often fail to attend appointments. Low attendance rates was found to be common. There was a clear consensus that workers believed that the new system was setting people up to fail and that threats will not bring about change but rather will bring about a different set of difficulties for alcohol dependent service users.

The study found that the majority of respondents thought that the new system failed to acknowledge known features of addictive disorders, for example, relapse and periodic ‘down' periods. The literature review documented that if the new system does not recognise the particular nature of alcohol abuse then it is likely that it will achieve the opposite of its intended purpose. For example, removing or reducing benefits from an individual whose alcohol problem may already be an indication that they are struggling to cope could exacerbate their stresses, make their alcohol issues worse and would be less likely to help an individual in returning to work (Hunter, 2009). Respondents believed that the new system did not look at the whole picture when it came to addiction, neglected to include a rehabilitation focus and that it was driven by service outcomes rather than being needs lead. It was commonly thought that assessments for the new system had a focus on physical health and neglected to consider binge drinking, chaotic lifestyles, mental health and that addiction is a chronically relapsing condition. The viewpoints expressed by respondents thus reflect what was identified in the literature review.

Respondents also believed that the implementation of the new system was particularly problematic. The Welfare Reform Act (2009) gives Job Centre advisers the power to assess individuals for alcohol problems and to enforce rehabilitation plans for those who are alcohol dependent. Individuals who refuse will lose benefits. The literature review identified that critics question whether Job Centre advisers have adequate training for this role (Hunter, 2009). There was a consensus that workers thought that benefit agency staff are given a lot of power to decide if someone is getting benefits, that they do not have specialized training and that the potential for discrimination is high. It was thought by respondents that more training is needed in this area. Responses from respondents again echoed the findings of the literature review.

Summary

In summary the data revealed the following themes with respect to the viewpoints of frontline workers on the implication of the new Employment and Support Allowance for people who are alcohol dependent; agreement that if specific needs are taken into consideration increased numbers in work will benefit the individual and society, consensus that forcing people into work who are not ready and enforcing conditions with financial penalties will not yield positive results and create further difficulties, consensus that workers and service users do not have enough knowledge on the new system and that there is a serious gap in service provision in relation to rehabilitation focused work.

In listening to the experiences of frontline addiction workers, the enthusiasm for the work and commitment to achieving change was very apparent. The researcher found the data to echo the findings of the literature review. Enforcing conditions on alcohol dependent service users to get back into work is not viewed as effective, the type of services respondents desired with specific mention of rehabilitation work and a needs lead focus, raised some important questions for research, policy and practice.

Appendix I

List of Content

Name: Donna Marie Logue

Student Number: 1518058

Address: 58 Broomfield Street, Airdrie

Proposed Topic/Title: Targeting benefit payments to people who misuse alcohol: positive or punitive?

To explore the views of front line workers regarding the implication of the new employment and support allowance for people who misuse alcohol. What implications does this have for social work practice?

1/ Background

Barber (1995) highlights that public concern about drug misuse is mounting right around the world. The World Health Organisation, for example, declared that the prevention of drug addiction (including alcohol and tobacco) must be a top priority. In relation to alcohol, the economic recession has made policy-makers look hard at the direct and indirect financial costs of alcohol misuse. The Office for National Statistics reported in November 2006 that the alcohol related death rate in the UK doubled from 4,144 deaths in 1991 to 8,386 deaths in 2005.

Reports by Alcohol Concern, claim that the real number of all deaths connected with alcohol misuse is closer to 33,000. Alcohol Concern estimates alcohol misuse is costing Britain £3.3bn a year. Kessel & Walton (1989) highlight that alcoholism is a difficult subject to study, alcoholism is a term with multiple and sometimes conflicting definitions. Modern medical definitions describe alcoholism as a disease and addiction which results in a persistent use of alcohol despite negative consequences. The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. Although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, stress, emotional health, genetic predisposition, age, and gender have been identified.

The UK benefit system, which is not a devolved function, provides additional income to people who are ill or have a disability. Previously people in the UK were entitled to claim incapacity benefit because they were alcohol or drug dependent. The number of people who misuse alcohol or drugs claiming incapacity benefit increased by 80 per cent from 76,200 in 1997 to 136,700 in 2007 (Guardian, 2008). From 27 October 2008, Employment and Support Allowance replaced Incapacity Benefit and Income Support claimed on the grounds of incapacity for new claimants. The new system considers what an individual is capable of, and what help and support they need to manage their condition and return to work.

This is in line with the current Labour government's Third Way approach. This approach can be described as a political position which attempts to transcend left-wing and right-wing politics by advocating a mix of some left-wing and right-wing policies. The Government wants as many people as possible to share in the rewards of work, because they believe that paid work is the best route to independence, health and well-being for most people. The Welfare Reform Bill published on 14 January 2009 supports the government's commitment to removing the barriers people face in maintaining employment. At a time of economic recession, significant attention is being given to welfare reforms. Government publications such as ‘Raising expectations and increasing support: reforming welfare for the future' (2008) outlines plans for the future as part of there vision for a personalised welfare state.

This vision for a personalised welfare state encompasses ideas about radical reforms of public services which they claim will put people first. The government believes that this will mean that people will be able to live their own lives as they wish; confident that services are of high quality, are safe and promote their own individual needs for independence, well-being, and dignity.

Critics argue that such models of personalisation with key themes including individualization, responsibilization and the transfer of risk from the state to the individual significantly neglect issues of poverty and inequality. It could be argued that it portrays a flawed conception of the people who use social work services and is a potentially stigmatizing view of welfare dependency. (Ferguson, 2007) Concentrating on people who misuse alcohol I propose to explore the views of front line workers regarding the implication of the new employment allowance and the idea that benefits should be withdrawn unless service users agree to go on government treatment programmes. My research will include what implications this has for social work practice.

2/ Research Topic and Key questions

In relation to research on alcoholism, I am seeking to explore the views of front line workers regarding the implication of the new employment and support allowance for people who misuse alcohol. I also plan to seek the views of workers in relation to the proposed idea that benefits should be withdrawn unless service users agree to go on government treatment programmes. The implications for social work practice will be explored as will contextual issues relating to problems in defining alcoholism, historical attitudes towards alcohol and current service challenges.

Research questions

1/ What difference if any has the introduction of the new employment and support allowance made to work carried out with alcohol dependent service users.

2/ Should the implementation of this allowance be subject to specific conditions e.g. should benefits be dependent upon service users attending programmes or would such conditions be counterproductive?

3/ What are current views about levels of service provision?

4/ What is the experiences of working with alcohol dependent service users e.g. challenges/dilemmas/managing relapses?

3/ Research Design

The research would use small scale qualitative research methods to search for the views and experiences of workers involved with alcohol dependent service users about the implication of the new Employment and Support Allowance which replaced Incapacity Benefit. I plan to interview approximately 12 workers and to record each interview. Interviews will only be recorded if permission has been granted. Does the new system do what it claims to do in relation to considering what an individual is capable of, is it more effective in assessing what help and support service users need to manage their condition and how beneficial is it in helping people return to work. I will also investigate the proposed idea that service users should have benefits withdrawn unless they agree to go on government treatment programmes. The implications for social work practice will significantly be covered.

i) Individual interviews would be carried out in order to gain front line workers views.

Open ended questions will be used in individual interviews to allow for more in-depth exploration of front line workers views. Access to participants will be sought from the Local Authority. The Local Authority offers support to people with addiction problems.

4/ Ethical Issues.

Careful attention will be applied to the ethical aspects of the study. The researcher will be guided by the Scottish Social Services Council Codes of Practice. Respondents consent to participate in the study will be gained. Respondents will be treated with respect and confidentiality will be upheld. Consent will also be sought in relation to recording interviews. The data will be appropriately annonymised and confidential information will be stored in a locked container throughout the research process. Only the researcher will have access to this. Permission will be sought from the Local Authority to interview drug and alcohol workers.

5/ Timetable

i) Research proposal - 18/05/09

ii) Gaining access - June/July 2009

iii) Ethics form - 18/05/09

iv) Literature review - August 2009

v) Data collection/devising tool - November 2009

vi) Transcribe data - November/December 2009

vii) Analysis - December 2009/January 2010

viii) Meeting Supervisor - Ongoing

ix) Transcription, analysis - December 2009/January 2010

Xii) Submission - 18/01/10

6/ Consultation.

The subject of the research proposal was has been discussed with my tutor, Cherry Rowlings.

Signature Date

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