Substance Use Disorders and Employability Among Welfare Recipients

Abstract

The 2006 welfare reform legislation (Deficit Reduction Act of 2005) imposed more stringent work requirements and defined the amount of time cash assistance recipients are allowed to be exempted from the work requirement because of substance use treatment. As there is little empirical literature on the employability of substance users, it is difficult to know whether it is realistic to expect individuals with substance use disorders to meet the increased work requirement. Based on a comprehensive evaluation of nearly 9,000 substance-misusing welfare recipients from 2001 to 2007, University Behavioral Associates (UBA) Comprehensive Services Model program in Bronx, New York, found that 60% of recipients were not exempted from the work requirement owing to substance misuse at the outset, and an additional 24% were found nonexempt after 3 months of intensive outpatient treatment coupled with case management, resulting in a total of 84% of the UBA clients not being exempted from the work requirement because of substance misuse by Day 90. UBA also found that 25% of substance-misusing clients were able to obtain employment, and most successfully retained those jobs over the course of 6 months. These findings are discussed in relation to the new law's work requirements and the issue of the employability of substance misusers. Finally, the value of case management in serving this hard-to-engage population is discussed.

RESUMEN

La empleabilidad entre los beneficiarios de asistencia con un trastorno por consumo de sustancias

La legislación de Reforma de Bienestar Social (Deficit Reduction Act of 2005), estableció requisitos más estrictos de trabajo y se definen la cantidad de tiempo de asistencia en efectivo (CA) los beneficiarios se les permite estar exentos de la obligación de trabajar debido a un tratamiento de uso de sustancias. Como hay poca literatura empírica sobre la empleabilidad de los consumidores de sustancias, es difícil saber si es realista esperar que las personas con trastornos por consumo de sustancias para satisfacer el requisito de aumento de trabajo. Sobre la base de una evaluación global de cerca de 9000 sustancias mal uso de beneficiarios de prestaciones sociales desde 2001 hasta , de la Universidad de comportamiento Associates (UBA) Modelo Integral de Servicios (CSM) del programa en el Bronx, Nueva York encontró que el 60% de los receptores no estaban exentas de la obligación de trabajar debido a una sustancia mal uso, en primer lugar, y otro 24% se encontraron no eximir a los tres meses de tratamiento ambulatorio intensivo, junto con la gestión de casos supone un total del 84% de los clientes de la UBA no está exento de la obligación de trabajar debido a abuso de sustancias por Día 90. UBA también encontró que el 25% de la sustancia de uso indebido de los clientes fueron capaces de obtener un empleo y con más éxito mantenido los puestos de trabajo en el transcurso de 6 meses. Estos hallazgos se discuten en relación a los requisitos de trabajo de la nueva ley, y la cuestión de la empleabilidad de hacen un uso indebido de sustancias. Por último, se discute el valor de la gestión de casos en el servicio a esta población.

L’employabilité des bénéficiaires d’aide sociale avec un trouble de consommation de substances

RESUME

En , Welfare Reform législation (Deficit Reduction Act de 2005) a imposé des exigences plus rigoureuses de travail et a défini le montant de l’aide ponctuelle de trésorerie (CA) personnes sont autorisées à être exemptés de l’exigence de travail due au traitement de la toxicomanie. Comme il ya peu de littérature empirique sur l’insertion professionnelle des toxicomanes, il est difficile de savoir s’il est réaliste d’attendre des individus avec des troubles liés aux substances utiliser pour satisfaire à l’exigence de travail accrue. Basé sur une évaluation globale de près de 9000 usagers de la substance aux assistés sociaux de 2001 à , Université Associates Behavioral (UBA), des services complets de modèles (CSM) de programme dans le Bronx, New York a révélé que 60% des bénéficiaires ne sont pas exemptés de l’obligation de travailler en raison de la substance utilisation abusive au départ, et qu’un autre 24% se sont révélés non exemptés, après trois mois de traitement ambulatoire intensif couplé à la gestion des cas qui donne un total de 84% des clients UBA ne pas être exemptés de l’obligation de travailler en raison de l’abus de substances par jour 90. UBA a constaté que 25% de la substance abuser les clients ont pu obtenir un emploi, et le plus réussi à maintenir ces emplois au cours des 6 mois. Ces résultats sont discutés en relation avec les exigences du travail de la nouvelle loi, et la question de l’employabilité des usagers de drogues. Enfin, la valeur du case management au service de cette population est discutée.

Keywords :

• substance use disorders
• welfare
• employment
• disability
• treatment attendance, case management

THE AUTHORS

Dr. Scott Wetzler is the Vice Chairman of and a Professor in the Department of Psychiatry and Behavioral Sciences at Montefiore Medical Center and Einstein Medical School. He received his Ph.D. in clinical psychology from Duke University and completed his psychology internship at New York Hospital–Westchester Division. He has been elected a fellow of the New York Academy of Medicine and serves on the Citizen's Advisory Board for the NYC HRA. He has published over 100 scholarly papers and 3 books on various topics including anxiety and mood disorders, personality disorders, psychological assessment, substance misuse, and behavioral health services utilization. He is an international expert on relationships, and runs the Supporting Healthy Marriage program at Montefiore Medical Center. He is most widely known for the best-selling Living With the Passive Aggressive Man (Fireside, 1992), which has been translated into 10 languages, and Is It You or Is It Me: How We Turn Our Feelings Inside Out and Blame Each Other (HarperCollins, 1998). Dr. Wetzler is also the Chief Operating Officer for UBA, a behavioral management services organization. Dr. Wetzler has had numerous appearances and interviews on the TV and radio, including a segment on 20/20 and a recurring role on The View.

Dr. Bruce Schwartz is currently the Executive Vice Chairman for Clinical Affairs, the Clinical Director, and a Professor of Clinical Psychiatry in the Department of Psychiatry and Behavioral Sciences at Montefiore Medical Center, the University Hospital for Einstein Medical School. His responsibilities include oversight of all teaching, clinical and departmental practice, and research activities in the Department. Dr. Schwartz also serves as the President of the Montefiore Behavioral Care Integrated Provider Association and is the President, Chief Executive Officer, Medical Director, and founding member of UBA, a not-for-profit behavioral health management services organization. Dr. Schwartz has a national reputation in behavioral health economics and service delivery. He is a member of numerous organizations and serves on many committees including the Greater New York Hospital Association's Mental Health/Substance Abuse Services Committee, the New York Academy of Medicine's Committee on Admission and Membership, and the Mental Health Association of New York City's Professional Advisory Board (Chairman), Strategic Planning Committee, and Board of Directors. In addition he is a consultant to the American Psychiatric Association's Council of Healthcare Systems and Financing and the American Hospital Association's Governing Council of the Section for Psychiatric and Substance Abuse Services. Dr. Schwartz is an expert in the treatment of affective disorders and psychopharmacology. He regularly features as one of Castle Connolly's Top Doctors and New York magazine's Best Doctors.

Arthur J. Swanson, Ph.D. has been the Program Director of the UBA CSM program at Montefiore Medical Center since 2001. He is also an Assistant Professor of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine. In the first phase of his career, Dr. Swanson worked in various clinical settings for children and adolescents and published a book and professional articles on residential and day treatment, group therapy, self-control in children, and child behavior management. He was later appointed the Chief Psychologist at St. Barnabas Hospital in the Bronx and later at Rikers Island, the latter serving the mental health and substance abuse needs of over 13,000 inmates. In this capacity, he authored articles on therapeutic communities and methadone treatment and was the lead author on one of the first controlled studies demonstrating the effectiveness of motivational interviewing with psychiatric and dually diagnosed individuals. Dr. Swanson's current interests also include organizational development and the integration of substance abuse treatment and employment.

Rachel Cahill, M.P.P., is the Administrative Director at the Montefiore Medical Center's North Division Department of Psychiatry. Prior to serving in this position, Cahill was the Deputy Director of the UBA CSM program. She has more than 10 years of experience in program development and operations, including serving as the Director of Operations for the NYC HRA's WeCARE program, a multimillion-dollar program providing customized assistance and services to public assistance recipients with medical and/or mental health barriers to employment. She began her career as a Presidential Management Fellow at the Congressional Research Service. Cahill holds a bachelor of science degree from Cornell University and a master of public policy degree from the University of Chicago.

Notes

1 Treatment can be briefly and usefully defined as a planned, goal-directed, temporally structured change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (by culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help-based (AA, NA, etc.), and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—that are not also used with nonsubstance users. In the West, with the relatively new ideology of “harm reduction” and the even newer quality of life treatment-driven model, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Editor's note.

2 Substance use (as measured by survey or hair testing) among welfare recipients is much higher (i.e., 37%), but we know that many more people use substances than meet the diagnostic criteria for a substance use disorder (Grant and Dawson, 1996; Jayakody, Danziger and Pollack, 2000).

3 Based on the outcome of the clinical evaluation, the client may be (1) exempt from work activity participation owing to the need for more than 15 hr per week of intensive substance use treatment, (2) nonexempt from work activity participation but still require at least 7 hr per week of substance user treatment, or (3) nonexempt and require no substance user treatment.

4 We suspect that many other clients who became noncompliant with our program obtained “undocumented” employment (Young and Benoit, 2004), but we have no reliable data to support that speculation.

5 Clients commonly obtained jobs in the following sectors: maintenance, childcare, retail, security, and food service.

6 Since the population misuses multiple substances, we were unable to analyze data by drug of choice or link substance use characteristics with employability.

7 The fact that the majority of employed clients never reapplied or returned to CA may suggest that even without stable documented employment, they were able to achieve some kind of financial self-sufficiency.

8 The welfare think tank, MDRC, examined unemployment insurance (UI) data for the UBA CSM population (Martinez, Azurdia, Bloom & Miller, 2009). Using this measure of “on-the-books” jobs, they found that a higher percentage of clients (37%) obtained employment within six months of participating in the UBA CSM program.

9 Editor's note: The reader is referred to Hill's criteria for causation, which were developed in order to help assist researchers and clinicians determine if factors were causes of a particular disease or outcomes or were merely associated with it (Hill, 1965).

10 There were multiple steps in the infraction process before a client's case was closed, including the opportunity to request a fair hearing. Since the “fair hearing” process was adjudicated by administrative law judges, practically speaking, punishments tended to be rendered many months after an infraction occurred.