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CHAPTER 1
INTRODUCTION
The Hard to Employ
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) ushered in a new era of welfare reform. Key provisions of PRWORA included time limits and work standards that promoted and even required work for those receiving welfare. In addition, states were given wide latitude to design programs to help families attain self-sufficiency and discourage long-term dependency. The passage of PRWORA and its subsequent implementation reflect a broader societal shift towards expecting all parents to support their children through work, rather than depending on government assistance. Welfare caseloads have declined dramatically since the passage of PRWORA. This reduction reflects changes in federal policy, a strong economy, and state programs that support work.
However, many families have not made the transition to employment. In addition, a significant portion of current welfare recipients experience physical or behavioral health problems that require more intensive services than those provided by traditional "work first" programs. For example, a study conducted by the New Jersey Department of Human Services found that TANF recipients who had received assistance for more than 34 months had, on average, more than two problems that represent barriers to employment (Feldman, Hickson, & Gioglio, 2001). As states face rising federal work participation rates and approaching time limits for long-term recipients, there is an increasing interest in finding effective strategies for the hard-to-employ (HtE). In addition, the broad aim of welfare reform - to require that parents support children through work - can not be successfully implemented unless the needs of HtE populations are addressed. Currently, limited information is available about the nature, prevalence, and impact on employment of these barriers. Even less is known about the types of services that are needed to move HtE families, particularly those with multiple barriers, to stable employment.
Barriers to Employment
A diverse set of factors have been identified as potential barriers to employability. These include situational factors such as transportation; human resource factors like low literacy or low job skills; and personal problems such as domestic violence or substance use disorders. Studies indicate that the presence of these barriers and especially the co-occurrence of multiple barriers, are associated with lower likelihood of employment (Danziger et al., 2000). Prevalence rates for barriers vary based on differing samples and definitions. Nevertheless, several studies concur that the overwhelming majority (70-80%) of welfare recipients experience at least one barrier to employment and about 30-70% experience multiple barriers (Brown, 2001). Traditionally, TANF agencies have addressed some barriers to employment. For example, most TANF agencies assess for some situational and human resource barriers such as childcare, transportation, or lack of educational attainment.
Prior to 1996, TANF agencies did not address behavioral health issues: specifically, substance abuse, mental health, domestic violence, and learning disabilities. However, as evidence mounts that these problems are prevalent in welfare populations and interfere with work, TANF agencies have begun to experiment with a variety of programs to address these needs. Identifying and providing appropriate services to address behavioral health problems present a special challenge to TANF agencies. These barriers are often difficult to detect either because the welfare recipient is unaware of the problem or reticent to self-disclose the problem to welfare workers. In addition, TANF agencies are interested in dealing with these problems only to the extent that they interfere with work, yet it is unclear at what point these problems become barriers to employment, since some individuals who have these problems do work. Finally, developing effective strategies to address these problems is difficult because new models for coordination of services between welfare agencies and community service providers must be developed.
Despite these challenges, recent evidence indicates that these behavioral health problems are highly prevalent in welfare populations. For example, a recent study found that over half of welfare recipients in two California counties had at least one of the above-mentioned problems (CIMH, 2001). In addition, it is increasingly clear that a significant minority of recipients suffer from behavioral health problems, either singly or in combination, that severely impairs their functioning. These findings indicate that, despite inherent difficulties, TANF agencies will need to effectively address the challenge of behavioral health problems as welfare reform takes its next steps.
Substance Abuse
Substance abuse is typically defined based on either consumption patterns or impairment related to drinking or use of other drugs. Excessive alcohol consumption (e.g., drinking more than 5 drinks on one occasion) or use of illegal drugs is often used to define problem consumption patterns. Various indicators of impairment exist. One widely accepted standard is the diagnosis of a substance abuse or dependence disorder as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). According to APA's definition, substance abuse refers to a pattern of recurrent adverse consequences related to substance use. Substance dependence refers to a pattern of substance use where adverse consequences are accompanied by physical or psychological dependence on a substance.
Efforts to understand the issue of substance abuse in the context of HtE populations have focused on three major questions. What is the prevalence of substance abuse among TANF recipients? To what extent is substance abuse a barrier to employability? What types of services do substance abusers need to attain self-sufficiency? Unfortunately, limited information is available to answer these questions. In the following paragraphs, we briefly summarize existing findings.
Discussions occurring during the initial phase of welfare reform often suggested that substance abuse was quite prevalent and a major problem among welfare recipients. For example, 25 state AFDC offices found substance abuse to be the most frequently cited problem preventing recipients from successfully transitioning into employment (U.S. Department of Health and Human Services, 1992). National survey data indicate that a minority of female welfare recipients report having substance abuse problems. For example, 21% used illegal drugs in the prior year, 5% used crack or cocaine, and 9% were diagnosed as dependent on alcohol (Jayakody, Danziger & Pollack, 2000). Prevalence rates of more specialized studies conducted on welfare recipients at a county or state level have varied, but generally confirm the finding that a minority of recipients have substance abuse problems. For example, a study conducted in an urban Michigan county found that 2.7% were diagnosed with alcohol dependence and 3.3% were diagnosed with drug dependence (Danziger et al., 2000). By contrast, studies conducted in California (CIMH, 2001) and New Jersey found higher rates (Klein et al., 1998). For example, prevalence rates for alcohol or drug dependence in one California county were 10.1%.
One serious limitation of these findings is exclusive reliance on self-report. Findings from two studies comparing self-report and biological measures of substance use among welfare recipients suggest substantial underreporting may occur. Klein et al. (1998) surveyed substance use among a representative sample of welfare recipients in New Jersey. They found that 12% self-reported recent cocaine use, but 25% were positive for cocaine use based on hair sample analyses. Based on an analysis of self-report and biological measures, Klein et al. found that 20% of TANF recipients in New Jersey required substance abuse treatment. Schottenfeld et al., (2001) surveyed substance use among welfare recipients in Connecticut and reported similar results regarding the discrepancy between self-report and biological measures. Self-reported rates of cocaine use were 6.1%, but hair analyses indicated rates of 18.8%.
Regardless of prevalence rates, substance use is of interest in welfare settings because it is hypothesized to be a barrier to employment. Experts would agree that functional impairment is related to the severity of substance abuse. At lower levels of problem use individuals may be able to work, but as problem levels rise the ability to work becomes impaired. However, data are not available to establish thresholds at which substance use impairs ability to work. Moreover, the issue is complicated because if employers screen for illicit drug use, even occasional marijuana use will be a barrier to employment. In addition, impairment in work ability caused by substance use almost certainly varies based on other individual characteristics such as level of stress, emotional well-being, or physical health problems. Currently, many states rely on a clinical determination of need for substance abuse treatment to trigger diversion from welfare-to-work programs to substance abuse treatment.
Studies have generally supported the effectiveness of community substance abuse treatment (Hubbard et al., 1997). In addition, studies have shown that welfare recipients receiving substance abuse treatment were more likely to become employed than those who dropped out of treatment or did not receive care (Wickizer et al., 2000). However, the literature is consistent in suggesting that the current structure of substance abuse treatment is poorly matched to the needs of disadvantaged, parenting women (e.g. Brindis et al., 1997; Gustavson & Rycraft, 1993). Thus, it may not be sufficient to provide substance-abusing women with traditional substance abuse treatment alone, without considering their need for other services. A primary concern has focused on issues of treatment engagement. Parenting women experience tangible (e.g., lack of child care) and psychological (e.g. denial of problems) barriers to entering treatment. In addition, parenting women present with an array of problems not addressed by substance abuse treatment programs. Recommendations for improving outcomes have focused on lowering treatment barriers and providing more comprehensive and coordinated care. Studies have suggested that augmenting existing substance abuse treatment with intensive case management services might improve treatment engagement and outcome (Laken & Ager, 1996). In addition, contingency management such as providing incentives to reinforce treatment tasks has improved outcomes compared to substance abuse treatment alone (Iguchi et al., 1997).
Overall, the literature on treating substance abusing parenting women suggests that simply providing substance abuse treatment may not be sufficient to effectively address substance abuse among women on welfare and that a more comprehensive, intensive, and integrated set of services may be needed. Preliminary findings indicated that an integrated service model yielded significant reductions in substance abuse and welfare dependency, and increases in employment and earnings (McLellan et al., 2001) While promising, no studies have rigorously tested whether integrated, intensive care will improve outcomes as compared to simply providing substance abuse treatment.
In summary, substance abuse has been identified as an important barrier to employability in welfare populations. Prevalence data indicate that a significant minority of women on welfare have a substance abuse problem. However, prevalence rates have varied considerably depending on the location of the study, criteria used to define substance abuse, and whether studies relied solely on self-report data. Prevalence rates based on self-report have ranged from about 3% to 10%, whereas those based on biological measures have yielded substantially higher rates varying from 19% to 25%. Substance abuse clearly impairs one's ability to work, but little data are available to indicate threshold levels that would clearly impair job performance. Most states have adopted clinical standards as a means of identifying those who should receive treatment prior to work training. Substance abuse treatment has been shown to be effective and related to improved employment. However, the structure of the current system of care may be insufficient for substance abusing TANF women and more intensive, integrative treatments may be needed.
The Substance Abuse Research Demonstration Project (SARD)
The SARD is a welfare demonstration project designed to compare the outcomes and costs of two competing approaches to providing services to substance abusing women on TANF. One approach is similar to the standard of care provided in states that are attempting to address this issue. TANF recipients are screened for substance abuse in the welfare office as a routine part of benefit determination. Those who respond positively to the substance abuse screening measure are assessed to determine their need for substance abuse treatment. Those requiring care are referred to a treatment program. Level of care is based on the American Society of Addiction Medicine Patient Placement Criteria (ASAM, 1996). Thus, women are eligible to receive short-stay inpatient and varying levels of outpatient care.
The alternative treatment approach is based on a comprehensive, integrated care model. TANF recipients screening positive for substance abuse are assessed and referred for substance abuse treatment. In addition, intensive case management and contingency management are provided. The goal of the case management is to provide comprehensive, coordinated care as well as to enhance continuity of care. Case managers provide outreach services to engage women in treatment, assess and broker services for basic needs (e.g., child care, housing), and arrange for needed professional services such as medical and mental health services. In addition, case managers monitor progress in substance abuse treatment and assist in the transition between levels of treatment as well as between treatment and work activities. Case managers continue to have regular contact with women for up to one year following engagement in work activities to enhance continuity and assist in preventing relapse. Women also receive modest incentives in the form of product vouchers as a reward for initial engagement in substance abuse treatment.
The SARD is a collaborative project involving the New Jersey Department of Human Services (NJDHS), the New Jersey Department of Health and Senior Services - Division of Addiction Services, The National Center on Addiction and Substance Abuse at Columbia University (CASA), and the Center of Alcohol Studies at Rutgers University. The study is being conducted in two New Jersey Counties: Essex and Atlantic Counties. Women are recruited at the local welfare and employment services offices in each county. Assessment and case management services are provided by the National Council on Alcohol and Drug Dependence - New Jersey (NCADD-NJ). The SARD is in its third year of operation. Funding for assessment and services is provided by the NJDHS. Funding for the evaluation has been provided to CASA by the National Institute on Drug Abuse, the Administration for Children and Families, the Assistant Secretary for Planning and Evaluation, and the Annie E. Casey Foundation.
The Current Study
Similar to other welfare systems, New Jersey screens welfare applicants for substance abuse problems at the time of benefit eligibility determination. Those who respond positively on the screen are referred for a comprehensive assessment. The broad aim of this study was to determine the types of barriers to employability and need for services among TANF women assessed as having a substance abuse problem. This information is needed to determine what types of services are required to assist these women in achieving self-sufficiency. Little is known about this issue because substance abuse has not been assessed nor considered a service need by welfare departments prior to welfare reform. The study focused on two primary areas. First, it examined the nature, severity, course, and treatment needs for substance abuse problems. Gaining a better understanding of this issue is important in order to determine whether screening practices identify those women for whom substance abuse is likely to be a barrier to employment and to guide planning for treatment services.
Second, the study examined other hypothesized barriers to employment. Many studies have suggested that substance abusing women on welfare experience substantial problems in other areas and need comprehensive and intensive services beyond those typically provided in substance abuse treatment. Indeed, a central assumption of the SARD was that women would require and benefit from intensive services. However, little data are available examining this issue among substance abusers identified in a welfare setting. The current study examined problems in domains often mentioned as potential barriers to employment: mental health, stress, domestic violence, family, social, physical health, legal, housing, childcare, transportation, education, and employment history. The existence of problems or deficits in these areas would suggest that additional services may be required as well as have prognostic implications for the ability of this group to achieve self-sufficiency. Because little is known about the prevalence of these additional barriers among welfare recipients in general, the study also assessed the existence of these barriers in a group of non-substance abusing women on TANF. The study compared prevalence rates of barriers between substance abusing and non-substance abusing groups. This information expands our understanding of how substance abusers might differ from other welfare recipients on factors thought to be critical to successful transition from dependency to employment.
Third, the study briefly examined indices of child well being as reported by mothers. Children's physical health, mental health, and learning disability problems can create a barrier to employability for women. The impact of welfare reform on children has been a subject of great concern for policy makers. Although it does not appear that welfare reform policies have caused harm to children, more needs to be understood about the well being of poor children ( Devaney et al., 1997; Brooks-Gunn & Duncan, 1997). Children of substance abusing parents are at risk for adverse social and academic outcomes (Bauman & Dougherty,1983; Black et al., 1994; Famularo et al., 1992). The current study compared the children of the substance abusing versus non-substance abuse group on indices of physical and mental health, academic engagement, and risk behaviors.
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