Re-traumatisation? Veterans’ experiences of the Work Capability Assessment

There were significant and complex needs within the sample. The mental health conditions referred to most frequently were PTSD, anxiety and depression. Some had been living with unresolved trauma for many years before reaching a ‘crisis’ point:

Consistent with other studies of veterans both in the UK (Iversen et al., Reference Iversen, Fear, Simonoff, Hull, Horn, Greenberg, Hotopf, Rona and Wessely2007) and elsewhere (Van Voorhees et al., Reference Van Voorhees, Dedert, Calhoun, Branco, Runnels and Beckham2012), in addition to mental ill health attributed to the Armed Forces, some participants had pre-existing trauma often related to adverse childhood experiences. Participants often described the intermittent nature of their mental ill health, referring to ‘good days’ and ‘bad days’:

Mental illness impacted significantly on people’s post-Service labour market experiences. Although many described being able to find employment relatively quickly after leaving the Armed Forces, subsequent difficulties sustaining employment were common and resulted in social security benefit claims. Given that their benefits claims were due to ill health, many participants had therefore been required to undergo a Work Capability Assessment (WCA), which assesses how a person’s health condition/disability affects their ability to complete a range of functional activities. Within ESA, claimants are classified as either ‘fit for work’ (i.e. with the expectation of engagement in a full range of work-related activities); having ‘limited capability for work’ but deemed likely to become capable of work in the future (and placed within the Work Related Activity Group of ESA); or having ‘limited capability for work and limited capability for work-related activity’ (and placed within the Support Group of ESA). Although ESA is being phased out and replaced by UC, the WCA remains the process of determining people’s ability to work. For the veteran participants, the WCA was problematic for two key reasons: the inability to appropriately assess mental health issues that were attributed to service in the Armed Forces; and the potential for re-traumatisation through the assessment process.

The WCA has been widely criticised for the inadequate consideration of mental health (Griffiths and Patterson, Reference Griffiths and Patterson2014; Barr et al., Reference Barr, Taylor-Robinson, Stuckler, Loopstra, Reeves and Whitehead2016; Maclean et al., Reference Maclean, Marks and Cowan2017). Indeed, many veterans reported being assessed as ‘fit for work’ because they felt their WCA had focused primarily on physical capabilities. However, more significant concerns were raised about whether assessors were qualified to assess Service-related mental health impairments. A number of veterans were being treated by specialist mental health practitioners. Consequently, they struggled to understand how the WCA had assessed them as ‘fit for work’ despite these professionals having certified them as unable to work due to the severity of their mental health issues. In some extreme cases, it was alleged that assessors had made inappropriate comments, suggesting that they were ignorant of the psychosocial impacts of trauma, but also revealing a lack of trust in the accounts of veterans:

Like many other benefit claimants (Garthwaite, Reference Garthwaite2014), veterans described the WCA as something to be feared. For some respondents, the WCA created a level of anxiety that undermined the progress made in the management of their on-going mental ill health. One veteran described the devastating consequences of this:

Another respondent described a similar deterioration in mental health following the WCA. He described having PTSD, which had led to an earlier suicide attempt. He was currently being supported by a number of Armed Forces charities, as well as receiving counselling. He had been advised to apply for ESA on the basis of his mental health impairment but had been assessed as ‘fit for work’. He appealed the outcome and at his Wave B interview he reported he had subsequently been placed in the WRAG, where there is still an expectation to prepare for work. Reflecting on his experience of the WCA, he stated:

The harmful effect of the WCA was not just felt by the individual claimant, but also by the wider family. One striking example was described during a joint interview with a veteran and his wife. They explained how he would usually ensure that he was accompanied to his appointments/assessments but had to go alone to his most recent one. His wife described the impact that the ‘stressful environment’ of the WCA had on her husband’s mental health, but also on their family when he had returned home:

Some veterans’ anxiety also manifested as frustration or even, on occasion, anger or aggression towards those involved in the benefits assessment process. For example, some talked about ‘getting into arguments’ during face-to-face appointments or over the phone. One veteran described his reaction to being denied the opportunity to be assessed at home:

Many concerns raised by the veterans were also reiterated by practitioner respondents who had accompanied veterans to assessments and provided support with subsequent appeals. Overall, practitioners felt that assessors often had limited understanding of Service-related conditions (mental or physical) or the impact of trauma. Indeed, some practitioners stated that a significant proportion of their working week was spent in tribunals representing veterans who they felt had been inappropriately assessed as ‘fit for work’.

Trauma-blind? Conditionality, the Claimant Commitment and interactions with Jobcentre staff

So far, we have described the difficulties faced by veterans in navigating the assessment process that determines the type and level of benefit they will receive. Now we focus on their experiences as they navigate the rules and responsibilities associated with their benefit claims. Although a significant proportion of the sample were ESA claimants, there were some veterans who were claiming UC or JSA and were subject to varying degrees of conditionality, despite their on-going mental ill health. As highlighted earlier, much has been written about the ineffectiveness of conditionality for people with disabilities or health conditions (Patrick, Reference Patrick2011; Weston, Reference Weston2012; Lindsay and Houston, Reference Lindsay and Houston2013; Pickles et al., Reference Pickles, Holmes, Titley and Dobson2016; Dwyer, Reference Dwyer, Horsfall and Hudson2017), with suggestions that it can actually trigger, or exacerbate, mental ill health (Dwyer et al., Reference Dwyer, Scullion, Jones, McNeill and Stewart2020).

It was evident that many veterans experienced difficulties meeting the conditions of their claim. When discussing what was expected of them, people referred to their Claimant Commitment, which sets out their obligations and what will happen if they fail to comply (i.e. the possibility of being sanctioned). The Claimant Commitment is produced during the initial interview with the Jobcentre Plus (JCP) Work Coach, with work-related requirements supposedly tailored to an individual’s circumstances (DWP, 2016). However, it has been described as a ‘paternalist tool’ that forms one of the ‘strategies of surveillance’ of claimants (Fletcher and Wright, Reference Fletcher and Wright2018: 323). Many participants felt they had no control over the content of their Claimant Commitment; rather, they viewed it as something that they had to agree to, or they would lose financial support. Frustration over this lack of control sometimes led to disagreements with Work Coaches during JCP appointments. For example, one veteran described a dispute that required the advocacy of a third sector organisation:

Similar to the distrust of the WCA process above, such interactions demonstrated limited understanding or consideration of the impact of trauma, and for veterans elicited a lack of trust in those tasked with administering social security benefits. This mistrust was particularly acute where people had experienced inconsistency in their interactions. The interviews were carried out in different locations across England and it was evident that there was significant variation both across and within JCP, in how staff responded to the disclosure of Armed Forces attributed mental health issues. For example, one veteran’s initial positive experience with his UC Work Coach (at Wave A) contrasted with his experience of being allocated a new Work Coach (at Wave B):

Veteran: The fella I was dealing with is really good actually (Wave A)

Veteran: it was quite brutal actually … we were talking about ex-Forces … and then that’s where she said, ‘Well, surely to God you know what you signed up for?’ She went, ‘This is what I don’t understand, you lads all know what you’re signing up for.’ (Wave B)

These interactions were also narrated as displaying a lack of respect towards their Armed Forces background, with perceptions that some staff lacked empathy in relation to their Service-attributed mental ill health and how this can impact on their ability to navigate the benefits system:

Although the majority of veterans did not want, or expect, a separate system to be in place for them, it was evident that a ‘one size fits all’ approach was not appropriate to address their needs:

However, it is unfair to suggest that all interactions with the benefits system were negative, and there was evidence of significant good practice, often in geographical areas where staff were more regularly engaging with Service/ex-Service personnel. For example, one participant described the flexible approach of his Work Coach, where telephone appointments were offered to those experiencing periods of mental ill health:

Another example of good practice related to a DWP Armed Forces Champion who acted as the first point of contact for veterans within their district and had taken on the responsibility of bringing together the other relevant statutory and specialist organisations:

However, such examples appeared to relate to the approaches and discretion of individual workers, and consultation with staff did not suggest that trauma-informed care principles were a motivating factor.

Discussion: Towards a trauma-informed social security system

Internationally the experiences of combat veterans have been crucial to the development of effective approaches to supporting trauma survivors (Herman, Reference Herman2015), with trauma-informed care employed as a framework for improving veteran’s access to healthcare in the US (Kelly et al., Reference Kelly, Boyd, Valente and Czekanski2014; Currier et al., Reference Currier, Stefurak, Carroll and Shatto2017; Gerber, Reference Gerber and Gerber2019). The issues that veterans with mental ill health experienced in accessing social security in the UK are similar to those described in the US literature on trauma-informed healthcare for veterans (Kelly et al., Reference Kelly, Boyd, Valente and Czekanski2014; Currier et al., Reference Currier, Stefurak, Carroll and Shatto2017; Gerber, Reference Gerber and Gerber2019), and on trauma-informed human services more broadly (Harris and Fallot, Reference Harris and Fallot2001; Bloom and Farragher, Reference Bloom and Farragher2013a, Reference Bloom and Farragher2013b). Indeed, as highlighted previously, trauma-informed approaches are being effectively adopted by a range of human services (Ko et al., Reference Ko, Ford, Kassam-Adams, Berkowitz, Wilson, Wong and Layne2008; Hopper et al., Reference Hopper, Bassuk and Olivet2010; Muskett, Reference Muskett2014; Quadara and Hunter, Reference Quadara and Hunter2016; Levenson, Reference Levenson2017; Sweeney et al., Reference Sweeney, Filson, Kennedy, Collinson and Gillard2018), but the social security system appears to be absent from this movement. In this section we propose that the five key principles of trauma-informed care - safety, trustworthiness, choice, collaboration and respect - provide a useful framework for identifying opportunities for improving interactions with the social security system. We will provide a brief overview of each principle, with reflections on how they relate to the experiences of veterans outlined in the previous findings sections.

The principle of safety is relevant to our discussion and involves ensuring that clients are physically and emotionally safe. From the perspective of trauma-informed care, it is the clients’ perception of safety that matters, and this is promoted through awareness of clients’ triggers, and by respecting privacy and personal boundaries (Kelly et al, Reference Kelly, Boyd, Valente and Czekanski2014). This is important because people who have experienced trauma can be acutely sensitive to threats in their environment; consequently, small acts of disrespect can sometimes be met with violent outbursts (Bloom and Farragher, Reference Bloom and Farragher2013b: 158). As such, the first step in recovering from trauma is regaining a sense of safety and the approach of trauma-informed services is to try to create predictable environments for clients that are absent environmental stresses such as loud noises and crowding (Gerber, Reference Gerber and Gerber2019). The impact of the physical environment of JCP offices/WCA centres was referred to by participants, some of whom expressed feelings of significant anxiety when faced with busy waiting rooms/offices or when having to wait for extended periods of time at these venues. Additionally, the fluctuating nature of people’s mental ill health (described by some as ‘bad days’ and ‘good days’) meant that people’s capabilities varied over time. Although some staff did appear to provide flexibility – for example, offering telephone appointments rather than an expectation of coming into the office – this appeared to be the exception rather that the rule.

It was also evident that many veterans experienced difficulties with emotional safety when navigating other aspects of their claim. For example, the potential of having their benefits stopped – either as a result of ‘failing’ a WCA or through a benefit sanction – was another source of anxiety that could undermine their feelings of safety. The experiences presented in the findings sections demonstrate that some people were intensely fearful, and this appeared to be a key trigger for both self-harm but also aggression towards staff. However, it is not surprising that these potential threats to their means of subsistence created high levels of anxiety. Indeed, the provision of an effective social safety net has been identified in the trauma-informed literature as a way of increasing people’s sense of safety, and thereby their opportunity for recovery (Bowen and Murshid, Reference Bowen and Murshid2016: 224–5).

With regards to the principle of trustworthiness, people who have experienced trauma have difficulty trusting, so services need to help them to learn to trust again by being trustworthy themselves; for example, through consistency and transparency. Unfortunately, the accounts of the veterans often demonstrated a lack of trust in a benefits system they found, at times, inconsistent, confusing and hard to navigate. For example, the disparity between the outcomes of the WCA and the judgements made by specialist mental health practitioners were a concern, with participants articulating a significant lack of trust in the skills and qualifications of the benefits assessors. A further source of mistrust was the imposition, via the Claimant Commitment, of expectations that didn’t fit their needs and priorities (Currier et al., Reference Currier, Stefurak, Carroll and Shatto2017: 55), which made some veterans sceptical about the motivations of Work Coaches. This mistrust was particularly acute where people had experienced inconsistency in the approaches of different Work Coaches.

This also links to the principle of collaboration – services can help trauma survivors rebuild their sense of self-efficacy by doing things with their clients rather than to them. In practice, this means working with clients towards goals they value and believe are achievable (Harris and Fallot, Reference Harris and Fallot2001). Feelings of helplessness and powerlessness are central to traumatic experiences so recovery entails learning to exercise agency again (Hopper et al, Reference Hopper, Bassuk and Olivet2010; Levenson, Reference Levenson2017). As such, trauma-informed services aim to give clients a sense of control and choice over what happens to them. Here, interactions with staff, particularly in relation to the Claimant Commitment and on-going expectations of the claim, were often perceived as perfunctory and disempowering, and veterans described a lack of control over the requirements that were enshrined within their benefit claim. Moving away from a ‘one size fits all’ approach and allowing claimants to have more input into the Claimant Commitment, but also a greater say over the pace of JCP meetings or the WCA process, as well as the opportunity to take breaks if they felt overwhelmed, would enable people to feel more in control.

Shame is also a powerful part of the experience of trauma, so trauma-informed services work to discourage shame and stigma (Harris and Fallot, Reference Harris and Fallot2001; Levenson, Reference Levenson2017). Existing research shows that such feelings are common amongst benefit claimants (Shildrick et al., Reference Shildrick, MacDonald, Webster and Garthwaite2012; Patrick, Reference Patrick2017) and it was evident that veterans were grappling with an intense sense of shame at moving from a position of respect in the Armed Forces to having to ask for financial support. This was amplified when staff appeared to demonstrate a lack of respect towards people’s experiences. Treating clients with respect and empathy is a central part of trauma-informed care because people recover from trauma through connection with others (Herman, Reference Herman2015). The interviews suggested that some JCP staff and benefits assessors failed to see a connection between veterans’ traumatic life histories and their current difficulties in seeking and sustaining employment. Better understanding of the symptoms of psychological trauma would therefore enable staff to understand veterans’ difficulties in taking steps towards employment not as moral failure but as a predictable effect of overwhelming, life-threatening experiences (van der Kolk, Reference van der Kolk2014).

Referral to appropriate services (e.g. therapeutic treatment) is also a key component of trauma-informed care (Harris and Fallot, Reference Harris and Fallot2001). The interviews revealed that some staff are successfully providing support that meets the needs of veterans by working collaboratively with statutory and third sector organisations (even though they may not be familiar with the terminology of trauma-informed care). A key challenge was the inconsistency in this support. There is a need to build capacity of all staff who are interacting with veterans to ensure that those delivering social security are aware of the relevant services and are referring people appropriately. One approach would be to emulate the good practice of those Jobcentres that appeared to be effectively supporting veterans. However, a vital step in making social security interactions more trauma informed – even in those areas where good practice was evident – is through the provision of appropriate staff training on how traumatic experiences can affect individual functioning. This appears to be particularly urgent for those responsible for conducting benefits assessments.