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. Author manuscript; available in PMC: 2016 Feb 6.
Published in final edited form as: Addict Behav. 2013 Sep 11;39(2):445–448. doi: 10.1016/j.addbeh.2013.09.005

Veterans’ Attitudes toward Work and Disability Compensation: Associations with Substance Abuse

Sarah Meshberg-Cohen a,b, Kathryn Reid-Quiñones c, Anne C Black a,b, Marc I Rosen a,b
PMCID: PMC4744469  NIHMSID: NIHMS749258  PMID: 24090622

Abstract

Introduction

Veterans deemed disabled for conditions resulting from, or aggravated by, their service in the military are eligible for service-connected disability payments. Despite many positive effects of disability payments, one concern is that Veterans with psychiatric conditions who receive disability payments are less likely to be employed compared to those who are denied benefits. Little is known about the attitudes of substance using Veterans, for whom work is a particularly important part of recovery, toward work and disability compensation.

Methods

This study compared the responses of Veterans with (n=33) and without substance use problems (n=51) to questions about work's significance and its relationship to disability payments. T- and chi-square tests were conducted to determine if Veterans with substance use problems differed from the others on work-related attitudes and perceptions of the relation between work and Veterans' benefits.

Results

Veterans endorsed high levels of agreement with statements that working would lead to loss of benefits. Veterans with substance use agreed more strongly that they would rather turn down a job offer than lose financial benefits.

Conclusions

The greater preference for disability payments among substance-using Veterans may reflect a realistic concern that they are particularly likely to have difficulty maintaining employment. The widespread concern among Veterans that work will lead to loss of VA disability payments is striking given the ambiguity about how likely loss of benefits actually is, and should be addressed during the service-connection application process.

Keywords: Service-Connected Disability, Substance Use, Substance Abuse, Veterans, Employment, VA Disability, Benefits, Work, Military, Service-Connection, Psychiatric Disability

1. Introduction

Each year, about 200,000 US service members transition to Veteran status (James, 2006), and many have difficulty finding work. Complicating efforts to work, recently discharged Veterans exhibit high rates of psychiatric problems, including Posttraumatic Stress Disorder, depression, and substance use (Hoge, Auchterlonie, & Milliken, 2006; Milliken, Auchterlonie, & Hoge, 2007; Sayer, Nooebaloochi, Carlson, Gravely, & Murdoch, 2010). These psychiatric illnesses have been strongly associated with impairment in social and occupational settings (Dewa & Lin, 2000; Goetzel et al., 2004; Hoge et al., 2002).

Job re-entry is particularly challenging for Veterans with psychiatric diagnoses (VanTil et al., 2012), particularly for those who also have substance use problems (Burnett-Zeigler et al., 2012). In response to difficulties finding or holding a job, a Veteran with a psychiatric condition may apply for service-connection disability.

Veterans who are judged to be disabled for conditions resulting from, or aggravated by, their service in the military, are eligible for service-connected disability (Sayer, Spoont, & Nelson, 2004). Substance abuse cannot be a stated reason for a disability claim, but it is highly prevalent among Veterans presenting for disability evaluations (Sayer et al., 2010; Rosenheck, Dauset, Frisman, & Kasprow, 2000), as it is a frequent co-occurring problem that exists with psychiatric disorders that confer eligibility for service connection including: PTSD, depression, anxiety disorders and psychosis.

Despite many positive effects of disability payments (e.g., Rosenheck et al., 2000), one concern is that Veterans with psychiatric disabilities who receive disability payments are less likely to be employed compared to those who are denied benefits (Rosenheck, Frisman, & Gallup, 1995; Drew et al., 2001). The reasons for this underemployment are complicated, but one cause appears to be the perception that Veterans who work may be deemed psychologically well enough to not merit benefit payments (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003). This perception is widespread (Sayer et al., 2004; Drew et al., 2001; Tremblay, Smith, Xie, & Drake, 2006), yet not completely accurate in that, unlike Social Security disability recipients whose benefits are gradually terminated if they exceed minimal earnings from work, Veterans who engage in paid employment may still continue to receive service-connection benefits (IOM, 2007), and the Code of Federal Regulations states that VA disability ratings are primarily based upon “the economic or industrial handicap which must be overcome and not from individual success in overcoming it” (Department of Veterans Affairs, 2012, 38 CFR 4.15).

Substance-using Veterans who cannot find or hold jobs are harmed because they are not participating in a goal-directed activity—work—that reduces the free time to use substances and increases the social costs of using drugs and alcohol (Drake, Wallach, & McGovern, 2005; Siegal et al., 1996). However, very little, if any, research has been done to examine how substance-using Veterans who are seeking service-connected disability benefits view work. To try to better understand factors impacting how potentially disabled Veterans with substance use problems view working, we compared the reported attitudes towards work of Veterans with and without substance use problems.

2. Methods

2.1 Procedure

Data were selected from pre-intervention assessments collected from Veterans who had agreed to participate in a randomized clinical trial of an intervention designed to test the efficacy of an employment-focused intervention. Eligible Veterans were those who were scheduled for a service-connection evaluation by a psychologist or psychiatrist, were not already receiving Veterans Benefits Administration benefits for a psychological condition, and were receiving no more than 30% of the full benefit for a medical condition. Veterans were recruited by posted advertisements and/or by clinic staff to meet with a research assistant for study screening. Veterans were enrolled who provided written informed consent and answered “yes” to any part of the SF-36 question about emotional problems interfering with work in the last 28 days (Ware & Sherborurne, 1992).

Attitudes were elicited by questionnaires that addressed the importance of work relative to other priorities, the meaning of work in various domains, beliefs about whether working precluded receiving service-connected benefits, and beliefs about the relative importance of working versus receiving disability benefits.

2.2 Measures

2.2.1 Sociodemographic characteristics

Veterans completed a questionnaire that covered the following domains: demographics, veteran status, psychiatric history, and employment (Morrissey et al., 2002).

2.2.2 Psychiatric diagnoses and substance use problems

Veterans’ current psychiatric diagnoses were obtained from their medical record. Substance abuse severity was characterized by questions from the Addiction Severity Index (ASI; McLellan, Kushner et al., 1992) that assessed illicit drug use and alcohol use.

Veterans were classified as having a substance use problem if they met any of the following criteria: a) Review of the medical record indicated a substance use problem; b) Problematic alcohol use calculated by ASI responses (≥12 days drinking to intoxication in the last 28 days for males and ≥8 days drinking to intoxication in the last 28 days for females based on Saitz's guidelines (Saitz, 2005); c) Use of an illicit drug in the last 28 days on pre-treatment ASI.

2.2.3 Attitudes about work and disability compensation

Veterans completed the 12-item Meaning of Work Scale (Mor-Barak, 1995) which assesses the importance of various aspects of work to the respondent. Items are rated on a Likert-scale (Strongly Disagree = 0 to Strongly Agree = 4), and responses were summed to create a total score reflecting the overall importance of various aspects of work, yielding a summed score (range 0–48). The three aspects of work include: 1) The Social Contact factor, 2) The Personal factor, 3) The Financial factor, which show high internal consistency (Alpha = .92 for total scale), and high internal consistency for each sub-scale: Social Contact (Alpha = .81), Personal (Alpha = .87), Financial (Alpha = .70). On a separate item, Veterans were instructed to rank-order the importance of the following areas in their lives: leisure, community, work, religion, and family, from most important (1) to second most important (2), and so on, until they completed all 5 areas.

Veterans also rated their agreement with three statements concerning the relationship between work and receipt of disability payments (Rosenheck & Mares, 2007) on a four-point Likert-scale (Strongly Disagree = 1 to Strongly Agree = 4).

2.3 Statistical analyses

T- and chi-square tests were conducted to determine if substance using Veterans differed from non-substance users on ratings of work-related attitudes and perceptions of the relation between disability payments and work. Findings that had less than a .05 likelihood of occurring by chance (two-tailed) were considered significant, alpha = .05.

3. Results

3.1 Characteristics of participants

The sample included 84 veterans who were included in the main analysis of the parent clinical trial. Their mean age was 38.7 years (SD=14.3), and they averaged 13.5 (SD = 1.8) years of education. Eighty-three percent were male; 63% identified as White, 16% as Hispanic, 13% as African-American, and 8% reported another race/ethnicity. There were no significant differences on demographic variables between those who were identified as having a substance use problem and those without a substance use problem (Table 1).

Table 1.

Baseline Characteristics

Characteristics Substance Use (N = 33) No Substance Use (N = 51) Mean Total (N = 84)
Age (M ± SD years) 37.30 (14.11) 39.61 (14.41) 38.70 (14.25)
Male (n, %) 30 (90.9%) 40 (78.4%) 70 (83.3%)
Female (n, %) 3 (9.1%) 11 (21.6%) 14 (16.7%)
Race-ethnicity a (n, %)
 White 19 (57.6%) 33 (64.7%) 52 (61.9%)
 African-American 4 (12.1%) 7 (13.7%) 11 (13.1%)
 Hispanic 7 (21.2%) 6 (11.8%) 13 (15.5%)
 Other 3 (9.1%) 4 (7.8%) 7 (8.3%)
Years of Schooling (M ± SD years) 13.28 (1.46) 13.66 (2.03) 13.51 (1.83)
Employment Pattern b (n, %)
 Working Full- or Part-time 14 (42.4%) 23 (45.1%) 37 (44.0%)
 Student 1 (3.0%) 1 (2.0%) 2 (2.4%)
 Military Service 10 (30.3%) 16 (31.4%) 26 (31.0%)
 Retired 0 (0.0%) 2 (3.9%) 2 (2.4%)
 Unemployed 8 (24.2%) 8 (15.7%) 16 (19.0%)
Longest duration of
Employment (Mean years ± SD) 7.68 (7.30) 11.14 (10.34) 9.77 (9.36)
Income last 28 days (Mean ± SD) 854.18 (1310.76) 1167.98 (2132.27) 1044.70 (1850.69)
Psychiatric Diagnosesc (n, %)
 Major Depression 9 ( 28.1%) 16 ( 32.0%) 25 (230.5%)
 PTSD 14 (43.8%) 13 (26.0%) 27 (32.9%)
 Adjustment Disorder 1 (3.1%) 13(26.0%) 14 (17.1%)*
 TBI 1 (3.1%) 5(10.0%) 6 (7.3%)
 Schizophrenia spectrum or 5 (15.6%) 2 (4.0%) 7 (8.5%)
Bipolar
 Other Psychotic Disorder 2 (6.3%) 2 (4.0%) 4 (4.9%)
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*

p < .05

a, b

N = 83

c

N=82 (Substance Use n = 32; No Substance Use n = 50)

3.2 Significance of work

Mean rankings of work’s importance among five choices (leisure, community, work, religion, family) did not differ between Veterans with substance use problems versus those without substance use problems. Notably, work was on average the second most important domain (mean ranked importance of substance users = 2.76 [SD = 0.83] vs mean non-users = 2.98 [SD = 1.10]), immediately behind family (mean ranked importance substance users = 1.24 [SD = 0.44] vs mean non-users = 1.31 [SD = 0.62]), and was followed by leisure (mean ranked importance substance users = 3.21 [SD = 1.05] vs mean non-users = 3.16 [SD = 1.14]), religion (mean ranked importance substance users = 3.52 [SD = 1.60] vs mean non-users = 3.47[SD = 1.46]), and community (mean ranked importance substance users = 4.27 [SD = 0.72] vs mean non-users = 4.08 [SD = 0.91]), p > .05. Summed scale scores on the Meaning of Work Scale also did not differ between Veterans with and without substance use problems (33.97 [SD = 7.91] vs 33.75 [SD = 6.43]), p > .05 (Table 2). Veterans' ratings of the importance and significance of work in their life were relatively high in both substance users and non-users.

Table 2.

Work Related Attitudes & Significance of Work

Substance Use (N = 33) No Substance Use (N = 51) p-Value
(Mean ± SD) (Mean ± SD)
Work Related Attitudes a,b
“If a person receiving VA benefits starts working for pay, income benefits will be reduced or stopped” 3.61 (1.23) 3.35 (1.34) .38
“If person receiving VA benefits starts working for pay, medical benefits will remain the same” 2.68 (1.30) 3.06 (1.39) .22
“I would rather turn down a job offer than lose monthly financial benefits” 3.68 (0.98) 3.22 (0.94) *.04
Significance Meaning of Work Scale
Summed Scale Score c 33.97 (7.91) 33.75 (6.43) .89
Open in a new tab
*

p < .05

a

Rating on 1–4 Likert scale anchored by 1 “strongly disagree” and 4 “strongly agree”

b

Substance Use N= 31, No Substance Use N = 49

c

Summed Score of 12 items from Significance Meaning of Work Scale (Rating on 0–4 Likert Scale anchored by 0 “strongly disagree” and 4 “strongly agree”); range 0–48

3.3 Work-related attitudes

Veterans’ endorsed high levels of agreement with statements that working would lead to loss of benefits (Table 2) and most agreed they would decline a job if it meant loss of disability benefits. However, Veterans with substance use problems agreed more strongly that they would rather turn down a job than risk losing benefits, t (78) = −2.06, p < .05. The standardized mean difference effect size was δ=0.48. According to Cohen’s guidelines, this is a medium effect size; the mean score for the substance use group was approximately ½ standard deviation higher than that of the non-substance use group.

4. Discussion

Most Veterans believed that working would result in loss of benefits, and the majority agreed they would turn down a job if it entailed loss of disability payments. Veterans with substance use problems agreed more strongly than non-users that they would rather turn down a job offer than lose financial benefits. Mean rated preference for turning down a job among substance using Veterans was approximately one-half standard deviation higher than among non- users.

Despite the importance of retaining disability payments, Veterans' ratings of the significance of work in their lives were relatively high. While there is a well-documented association between drug and alcohol abuse and employment-related difficulties (Siegal et al., 1996; Comerford, 1999), ratings of the significance of work did not differ between Veterans with substance use problems and non- users. One interpretation of these results is supported by research showing that unsatisfactory terminations were associated with substance abuse (Becker et al., 1998). That is, although they value working, substance users may be especially leery about giving up the stability of disability benefits for jobs which they are at higher than average risk of losing. This is unfortunate because employment success has been related to decreases in substance use as well as improvements in medical, legal, family, social, and psychiatric functioning among individuals seeking substance abuse treatment (Siegal et al., 1996).

Veterans' concern that a Veteran who works will lose VA disability payments may reflect heuristics in which decision-making reflects a tendency to avoid possible losses (loss aversion) rather than a profit-maximizing calculation of the odds of loss vis-á-vis offsetting gains (Kahneman & Tversky, 1979; Kahneman, 2011). Indirect evidence suggests that the likelihood of having service-connection benefits reduced appears to be low but the odds are in fact unknown (Sayer, Spoont, & Nelson, 2004). Employment is an important component in the rehabilitation of drug users (e.g., Platt, 1995; Comerford, 1999) and, thus, unemployment and underemployment pose a barrier to recovery for Veterans with substance use problems.

An important limitation of this study is that we enrolled a small convenience sample of participants in a parent clinical trial, and therefore, the results should be interpreted with caution. The single question assessing relative preference for employment vis à vis disability payments was rated significantly different by substance users and non-users, but whether this was because this item assessed a unique construct or because it was an artifact of multiple t-tests cannot be determined with certainty. Another limitation is that there was no uniform chemical testing for substance use. However, substance use information was gained from a variety of sources including the evaluation of the disability claim, chart review, and an ASI completed with assured confidentiality. In prior research, substance use detected by one of several assessments has usually reflected true positives (Kosten & Rounsaville, 1992).

Despite these limitations, our findings suggest that Veterans with substance use problems may be particularly worried about trusting their financial security to paid employment when service-connection payments are an alternative. Nonetheless, the high value that both substance-using and non-substance using Veterans place on work suggests an opportunity to engage them in work-promoting activities.

Highlights.

  • Compares views toward work and disability in substance using and non-using Veterans

  • Veterans' ratings of the significance of work in their lives were relatively high

  • Widespread concern among Veterans that work will lead to loss of VA benefits

  • Greater preference for disability payments over job among substance-using Veterans

Acknowledgments

Role of Funding Sources

This research was supported by the VISN 1 Mental Illness Research Education and Clinical Care Center (MIRECC) and a grant from the VA Rehabilitation Research & Development Office (D6432R).

The authors would like to thank the clinic staff.

Footnotes

Contributors

Sarah Meshberg-Cohen, PhD, conducted literature searches and provided summaries of previous research studies. Sarah Meshberg-Cohen, PhD, and Kathy Reid-Quinones, PhD, wrote the first drafts of the manuscript and all authors contributed to and have approved the final manuscript. Anne Black, PhD, conducted the statistical analysis. Marc Rosen, MD, wrote the study protocol.

Conflict of Interest

All authors declare they have no conflict of interest.

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