Review
Social construction of disability and substance abuse within public disability benefit systems

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Abstract

Federal legislation passed in 1996 in the United States changed the eligibility criteria for public disability benefit programmes. After 1996, persons with a primary diagnosis of substance abuse no longer qualified to receive disability benefits. Using a framework of social construction, a qualitative comparative analysis examines how the national disability systems of eight countries – Australia, Canada, Germany, Japan, the Netherlands, South Africa, Sweden, the United Kingdom, and the US – address issues of substance abuse. The US is the only country among the focal countries that does not currently allow disability benefits to be awarded to those with primary conditions of substance use disorders. International experience in providing disability benefits to persons with substance use disorders can inform US policy makers as to how the current US federal disability benefit system might be expanded to be more inclusive of persons with substance abuse disorders.

Introduction

This paper is based on the premise that the target populations of public policies are based on social constructions, i.e. the cultural characterizations or popular images of the persons or groups whose behaviour and well-being are subject to public policy (Schneider & Ingram, 1993). Social constructions may be positive or negative, reflecting societal views as to which groups either deserve or do not deserve public support. Public programmes face challenges in accommodating to shifting social constructions and in providing services to groups of people for whom there may be decidedly different social constructions. Public disability benefit schemes provide an interesting example: persons with disabilities and persons with substance abuse disorders may be viewed differently as to whether they are deserving of public support, yet both groups intersect potentially within public disability benefit programmes (Lieberman, 1995; Schneider & Ingram, 2005; Stone, 2002, Stone, 2005).

A classification scheme developed by Schneider and Ingram (1993) can be used to understand the complications in justifying the provision (or not) of disability benefits to people with substance abuse disorders. Schneider and Ingram propose a matrix whereby social construction interacts with political power, classifying potential target populations for public programmes into one of four categories. The categories relate type of social construction (positive or negative) to strength of political power (strong or weak). Powerful, positively constructed groups are advantaged; powerful, negatively constructed groups are contenders; weak but positively constructed groups are dependents; and the unfortunate weak and negatively constructed groups are labelled deviants (Lieberman, 1995). Applying this typology to the United States (US), Schneider and Ingram denote people with disabilities as members of the dependents category, whereas persons who abuse substances are labelled members of the deviant category. Persons with disabilities have a more positive social construction and thus are seen as more deserving of public assistance (i.e. disability benefits). Persons with substance abuse disorders have a more negative social construction and are less apt to be viewed as deserving of public assistance.

This article compares and contrasts the current treatment of persons with substance abuse disorders within the US public disability benefit system to the policies and practices used within other national disability benefit systems as a means to furthering understanding of how social constructions intersect with broader policy goals. Eight additional countries were chosen as the focus of this analysis: Australia, Canada, Germany, Japan, The Netherlands, South Africa, Sweden, and the United Kingdom. The disability programmes of these eight countries have been the focus of recent comparative work, providing a basis upon which to build the current analysis. As the federal US disability system only provides benefits to persons who are deemed fully and permanently disabled, the selected countries provide a comparison because each offers similar forms of disability benefits. In addition, each of the countries provides some measure of partial and/or temporary disability benefits so can provide intriguing examples about how these benefit schemes might address issues of substance abuse (Mitra, 2004).

Definitions of disability and substance abuse can differ within countries, across countries, and across data sets (Fujiura & Rutkowski-Kmitta, 2001; Mayer, 1995, Mitra, 2004). Disability can be defined along a number of dimensions, including medical, social and occupational, and programmes that serve persons with disabilities can target their services towards vastly different groups (Mitra, 2006). Uncovering comparable disability prevalence rates between countries is challenging because definitions of disability differ and because disability prevalence is associated with many factors, such as cohort, gender, race, living arrangements and wealth (Heiss, Hurd, & Börsch-Supan, 2003; Lynch, 2003; Von Strauss, Aguero-Torres, Kareholt, Winblad, & Fratiglioni, 2003). Differences in survey design, scope, and reporting may also contribute to observed differences among countries.

Available information on disability prevalence within countries provides a sense that rates of disability are relatively similar among assorted countries, as shown in Table 1, ranging from 11% to 21% for similarly measured rates of disability (Government of Canada, 2006, Mitra, 2004). For countries other than Japan and South Africa, information was obtained from general household surveys or census estimates, sources that measured persons having a severe or moderate disability in relation to activities of daily living or work. Information available for Japan and South Africa, drawn from data in which disability is defined in relation to the presence of medical impairments, find that only five percent of adults in Japan (excluding those with mental illness) and five percent of adults in South Africa reported impairments (Mitra, 2004).

The primary purpose of disability benefit programmes is to replace wages lost due to an inability to work. The employment rates shown in Table 1 depict the proportion of the population aged 16–64 who are participating in the labour force. Employment rates for persons with disabilities are substantially lower than employment rates for persons who are not disabled: reasons include the limitations inherent in certain disabling conditions, a lack of employer interest in either hiring or accommodating persons with disabilities, or the disincentive effects of disability benefit systems on decisions to pursue employment. Most disability benefit programmes attempt to redress some of this gap between the employment rates of persons with and without disabilities by providing some combination of income, access to health care, and access to employment services. How countries address persons with substance use disorders within these disability benefit systems is the focus of the current analysis. The prevalence of use and abuse differs by type of substance and among countries. Table 2, as an example, presents past year alcohol dependence rates and select illicit drug use prevalence rates for each of the focal countries. South Africa has the highest rate of past year alcohol dependence, Canada has the highest rate of past year cannabis use, and the US has the highest rate of past year cocaine use.

While nations typically employ many approaches to address issues of substance use and abuse, certain practices are often favoured over other methods. Countries can choose among punishment versus therapy, both, or neither (Gerevich, 2005). Supply-side approaches favour a criminal justice orientation to reducing the production, distribution and sale of substances. Demand-side policies favour a public health approach to reducing individual-level demand for substances by implementing prevention, intervention and treatment programmes.

The belief underlying supply-side approaches is that use and abuse of substances can be best controlled through the deterrent and educational functions of punishment (Bollinger, 2004). The US government is a strong believer in the benefit of such approaches. The US has a decidedly punitive view of drug use and has continued to try to encourage other nations to adopt a similar view. Embracing such a supply-side approach seems to reflect the idea that persons involved with substance use are deserving of punishment, not social assistance. Other countries have more strongly embraced demand-side approaches to addressing issues of substance use and abuse. Such policies are designed to minimize the individual and societal harms associated with problematic use by providing prevention, education and treatment within the health care system (Bullington, 2004).

Recently, countries such as Australia, Canada, the Netherlands, Germany, Sweden, and the UK have begun to challenge the US-supported supply-side approach in favor of public health approaches (Bullington, 2004, Goldberg, 2004). Some have opted to decriminalize certain substances, replacing criminal penalties with fines, diversion, warnings, or no action at all. Some have informal practices that reduce or eliminate punishments for obtaining and possessing small amounts of illicit drugs (Bullington, 2004, Bollinger, 2004, Dorn, 2004). The Dutch system supports the idea that drug use first needs to be addressed as a public health question and only secondarily as a criminal justice one (Bullington, 2004, Uitermark, 2004). The Dutch have very liberal policies, allowing for the sale of cannabis from coffee shops and for the implementation of a monitoring system so that ecstasy users can have the purity of their pills tested (Uitermark, 2004). Germany has a monitoring system as well (Bollinger, 2004). Canada has allowed drug injection rooms, heroin or prescription, and the provision of medical cannabis to patients suffering from a variety of diseases (Bullington, 2004).

Australia has developed public health strategies within a strong law enforcement regime (Bammer, Hall, Hamilton, & Adi, 2002). Sweden has been noted to be both tough on addiction but also relatively compassionate in the services provided to those with substance use disorders (Mooney, 2005). While aggressive enforcement measures are tempered with income support and access to drug treatment and health care services, critics have suggested that further harm reduction measures should be implemented (Goldberg, 2004; Ministry of Foreign Affairs, 2006; Stimson, G., personal communication, 2008).

The types of substance use policies favored within countries are reflective of normative views about substance use and may impact on how disability is framed within public disability programmes.

In the US, two of the largest public programmes that target persons with disabilities, Social Security Disability Insurance (DI) and Supplemental Security Income (SSI), adhere to a work-based definition of disability when determining working-age adult eligibility for benefits. Administered by the federal Social Security Administration (SSA), the programmes provide monthly cash stipends and access to health insurance to eligible persons. For working-age adults, the programmes aim to replace income and supports that are lost because of an inability to fully participate in the labour force. A guiding assumption of these programmes is that adult beneficiaries would have been willing participants in the labour force were it not for the presence of a disabling condition.

In the US, prior to 1996, a claimant could be awarded benefits based upon the presence of a substance abuse disorder. Persons with a primary diagnosis of substance abuse were treated differently from persons awarded benefits for other conditions, however. If a substance abuse disorder was deemed “material” to the disability determination, the claimant was required to assign a person or organisation to manage the financial aspects of his or her benefits and to have a 3-year limit on eligibility (Camp, 2008). Prior to 1996, SSA also required SSI recipients who were receiving benefits on the basis of substance abuse to receive treatment, although SSA did not itself provide payment for this treatment. Instead, recipients were instructed to access existing state substance abuse treatment systems (GAO, 1994, Nibali, 2000). In addition to the limitations inherent in existing state treatment systems, the actual monitoring of this treatment requirement for SSI recipients by SSA was quite lax and few recipients complied. Furthermore, no records of outcomes for persons who did participate in treatment were kept. DI beneficiaries were not required to attend treatment (GAO, 1994).

During the early 1990s, a number of studies and news reports linked receipt of disability benefits to the purchase and use of drugs (Cohen, 1994, Satel, 1995; Sennot & Murphy, 1994; Shaner, Eckmand, & Roberts, 1995). When SSA began to face considerable public pressure to stop providing disability benefits to such an “undeserving” population of substance abusers, legislators took action to codify a new policy which would remove substance abuse as an acceptable form of disability (Hunt & Baumohl, 2003). With the passage of the Contract with America Advancement Act of 1996, SSA was no longer allowed to grant disability benefits to persons whose primary diagnosis was one of substance abuse or dependence (Watkins & Podus, 2000). Contrary to the flurry of reports that were released in the 1990s, however, more recent studies have not confirmed the existence of a link between benefit receipt and level of substance use (Rosen, McMahon, Lin, & Rosenheck, 2006; Swartz, Hsiech, & Baumohl, 2003; Watkins & Podus, 2000). Many of the studies that attributed a relationship between disability income and ongoing substance abuse examined outcomes for persons with co-occurring mental illness so their results may not apply to individuals without co-morbid mental illness (Frisman & Rosenheck, 1997; Shaner et al., 1995).

After the passage of the Contract with America Act, benefits were terminated for the approximately 210,000 SSI and DI beneficiaries whose primary disability was substance abuse. Most (64%) of these beneficiaries attempted to be reclassified under another type of disabling condition but only 35% had conditions other than substance abuse that were severe enough to warrant the award of benefits (Watkins & Podus, 2000).

Section snippets

Data and methods

The eight countries were selected to provide meaningful comparison with the US disability system. Although these countries have diverse institutional structures, each has some form of public disability benefit system that provides benefits to persons who are fully and permanently disabled. The countries provide a relatively diverse mix of programmes and experiences.

A multiple-case study design was used to organize the collection and analysis of information about the public disability programmes

Results

Each of the eight focal countries in this comparative study provides disability benefits to persons with substance abuse disorders if certain eligibility criteria are met. The countries can be broadly categorized into two groups: those where substance use disorders are immaterial to eligibility for disability benefits and those where substance abuse is explicitly defined as a disabling condition that would meet eligibility criteria. Within this latter group, countries may or may not place

Discussion

Disability programmes may reflect and reinforce societal views of persons who have substance use disorders. With the exception of the US, each of the focal countries currently allows disability benefits for persons with primary disorders of substance abuse. In general, the results of this analysis support the view that negative social constructions of substance abuse within states coincide with narrower definitions of disability within national disability schemes.

The US has the strongest

Conflict of interest

None.

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