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Recent changes in federal and state policy reflect a dramatic shift in the nation's approach to supporting the income of poor Americans and improving their labor force participation. Before the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) was passed, poor families were entitled to cash grants through the Aid to Families with Dependent Children (AFDC) program as long as their income and assets remained below a specified level and they met procedural requirements. In 1996, AFDC was replaced by the newly created Temporary Assistance for Needy Families (TANF) program, which sets a lifetime limit on benefit receipt and emphasizes employment over public assistance as the primary means of support for poor families. In response to time limits and steadily increasing work participation requirements, most state TANF programs encourage participants to find employment as quickly as possible.
Unlike the legislation governing previous welfare employment programs, which were designed to serve a small share of families receiving cash assistance, PRWORA created new expectations and opportunities for nearly all poor families seeking government assistance, including individuals with behavioral or emotional disorders that can create formidable barriers to employment. In the past, such families were rarely required to participate in employment programs. As a result, few states had strategies in place to assist clients with significant barriers to employment. While efforts to address the needs of these individuals are still in their infancy, far more programs are in place today than before the advent of welfare reform.
It is estimated that between one-fourth and one-third of welfare recipients have a serious mental health condition that could affect their ability to find and/or maintain employment (Sweeney 2000). While mental health conditions represent only one of the many personal and family challenges faced by TANF recipients in search of work, the number of recipients affected by mental health conditions is large enough and the identification and treatment of such conditions is specialized enough to have attracted the attention of researchers and policymakers as well as practitioners and program administrators.
In this report, we profile the efforts of four states — Florida, Oregon, Tennessee, Utah — to address the mental health needs of welfare recipients. The report is based on findings from a study conducted by Mathematica Policy Research (MPR) for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. The study was designed with three purposes in mind: (1) to describe in detail the design and structure of mental health services developed by state and local welfare offices(1) to address the mental health needs of welfare recipients, (2) to highlight different service delivery options in designing and implementing these services, and (3) to discuss the key challenges and lessons learned in providing mental health services to welfare recipients.
By highlighting the key choices involved in integrating mental health services into a work-oriented welfare system, this report offers practical guidance to program administrators who are interested in addressing the mental health needs of TANF recipients or other low-income families. It is not intended to prescribe a model for providing mental health services to welfare recipients. As shown in Table I.1, we identified seven key dimensions that define the study states' approaches to the mental health needs of welfare recipients:
| Program Dimensions | Florida | Oregon | Tennessee | Utah |
|---|---|---|---|---|
| Types of mental health services provided | Screening and assessment Linking clients to existing treatment Expansion of existing mental health services Intensive case management | Screening and assessment
Linking clients to existing treatment Short-term mental health counseling (crisis intervention only) Training/consultation for employment case managers Intensive case management Assistance in applying for SSI |
Screening and assessment
Linking clients to existing treatment Short-term mental health counseling Training/consultation for employment case managers Intensive case management Assistance in applying for SSI |
Screening and assessment
Linking clients to existing treatment Short-term mental health counseling Expansion of existing mental health services Training/consultation for employment case managers Intensive case management Assistance in applying for SSI |
| Target population | Low-income families with incomes below 200 percent of poverty | Adults on TANF | Adults and children on and transitioning off TANF | Adults on and transitioning off TANF
|
| Range of service needs addressed | Mental health
Substance abuse |
Mental health
Substance abuse |
Mental health
Substance abuse Domestic violence Learning disabilities Child behavioral problems |
Mental health |
| Strategies for identifying clients with mental health conditions | Formal presentations
Broad screenings Referrals by employment case managers Community outreach |
Formal presentations Broad screenings
Referrals by employment case managers |
Formal presentations Broad screenings Referrals by employment case managers
Automatic referrals to mental health services (sanctions) Community outreach |
Referrals by employment case managers
Automatic referrals to mental health services (sanctions and time limits) |
| Integration of mental health services into employment plans | Up to 5 hours of mental health services per week in work plan | Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services) | Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services) | Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services) |
| Agencies administering and providing mental health services | Mental health & substance abuse program offices
Contracted service providers |
Local employment service providers and welfare offices
Contracted service providers |
University of TN
Contracted service providers |
State welfare agency Contracted mental health service providers (minimal) |
| Funding Approach | $45 million statewide
Designated funding |
Varies by district
No designated funding, included in funding for |
$8 million statewide
Designated funding |
$1.7 million statewide
Designated funding |
Designing programs to address the mental health needs of welfare recipients is a complex endeavor. Program design decisions made in one area may influence the design of other program dimensions. For example, programs that address a variety of barriers such as mental health, substance abuse, learning disabilities, and domestic violence require an administrative structure and staff skills that differ from programs that address mental health conditions exclusively. In weighing potential approaches to address the mental health needs of welfare recipients, careful consideration needs to be given to each key program dimension and how it might influence the overall approach to providing services.
In this introductory chapter, we discuss the context for this study, the prevalence and types of mental health conditions among welfare recipients, and how mental health conditions affect employment. We also describe the study, including our general approach to the work, the selection of the study sites, and the data collection procedures. Chapter II covers key program design issues, including how to define the types of services to be addressed and how to identify clients with mental health conditions. Chapter III discusses the key decisions involved in building an infrastructure to provide services, that is, deciding who will provide and administer services and how the services will be funded. Chapter IV highlights the issues involved in implementing mental health services for welfare recipients, and Chapter V summarizes the lessons learned from this early look at programs designed to address the mental health needs of TANF recipients. Appendix A includes a detailed description of each study site, and Appendix B provides contact information for obtaining copies of the program forms, including the screening and assessment tools used in the study states.(2)
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PRWORA gave states considerable flexibility in deciding how to spend their TANF block grant funds. States may use TANF funds to provide nonmedical mental health treatment services for welfare recipients and other low-income families at risk for TANF involvement. Such services might include specialized short- or long-term counseling services, or outreach, assessment, and case management intended to link clients to existing mental health services. In addition, TANF funds can be used to expand the capacity of treatment providers as long as the expansion covers only nonmedical services and is targeted to families who are eligible for TANF-funded services. States can also use funds from the Welfare-to-Work grants program to provide mental health services, although there are more constraints on who can be served with these funds.
Most welfare recipients qualify for Medicaid, so they can access mental health treatment through Medicaid-funded providers. While some TANF recipients may be receiving services through these providers, others may not know how to access such services, while still others may not be aware that they have a mental health condition. The flexibility of TANF allows states to fund efforts designed to identify clients in need of services and link them to existing Medicaid-funded mental health services. It is also possible that TANF recipients need services not easily accessed or offered by a Medicaid provider. Program administrators could address these needs by using TANF funds to expand existing services or to provide services not currently offered by Medicaid providers. The drawback is that TANF funds now available for mental health services may shrink as a result of either the outcome of the reauthorization debate or a downturn in the economy. (The latter would force states to use the funds to provide cash assistance and employment services to the families moving onto welfare because of the downturn.)
The states profiled in this report are leading the development of innovative approaches to providing mental health services to TANF recipients. In all of the approaches, existing services have been augmented, not replaced. In addition, all of the states have used TANF funds to identify recipients in need of mental health services and to link them with these services. Two of the states have created specialized mental health services that are delivered within the welfare system, and two have expanded the capacity of existing providers to serve TANF recipients or TANF-eligible families.
Medicaid-Funded Mental Health Treatment ProvidersIn most states, Medicaid covers a basic range of services for treating mental health conditions, such as individual or group therapy, crisis intervention, psychiatric evaluations, medications, day treatment, and inpatient care. States decide not only the type of Medicaid-funded mental health benefits, but also the amount, scope, and duration of benefits. In general, the type and amount of treatment for those accessing Medicaid often are more restricted than for those with private health insurance. Within each community are Medicaid-funded mental health treatment providers, which are any mental health agency where welfare recipients can access mental health treatment using Medicaid assistance. Access to treatment through Medicaid-funded service providers tends to vary within and between states. For example, in some areas, frequent staff turnover and a limited number of staff have created difficulties in accessing treatment at the Medicaid service provider. For TANF recipients referred to the Medicaid treatment providers, the treatment typically has a short-term orientation and tends to be provided in groups rather than individual therapy. Clients who are seen individually may be scheduled for treatment every other week. In addition, therapy may be geared toward those with diagnosable mental disorders, which may not include all TANF recipients referred to mental health services. The advantage to using the Medicaid managed care providers for treatment is that state Medicaid funds can be used to draw down federal matching funds to help share the cost of treatment. This allows TANF funds to be used for other purposes. The drawback to using Medicaid treatment providers is that the types and amount of treatment are often restricted and, in some areas, clients have difficulty accessing treatment. |
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Although most states have made significant progress in moving families off welfare and into the labor force, many families continue to receive cash assistance. While some of these families are new to the TANF system, many have been receiving assistance for some time and may therefore be at risk of losing cash assistance due to approaching time limits. As legislators and TANF administrators assess the progress that has been made since the passage of welfare reform, it is becoming apparent that some individuals, especially those with mental health conditions, may need more job-related assistance than most welfare employment programs are designed to provide. Because mental health conditions are more common among low-income families in general and welfare recipients in particular than they are among the general population, addressing the mental health needs of welfare recipients is a priority for many program administrators. The goal of providing services to these individuals is to increase the likelihood that they will be able to make the transition from welfare to work and remain employed.
According to a report by the U.S. Surgeon General (1999), low-income families and certain minority groups have higher-than-average rates of mental disorders. Those in the lowest socioeconomic group are about two-and-a-half times more likely to have a mental disorder than those in the highest socioeconomic group (Holzer et al. 1986, Regier et al. 1993). In a study of mental health conditions among single mothers, Jayakody and Stauffer (2001) found that single mothers have significantly higher rates of psychiatric disorders than do married mothers, and that low-income single mothers and those receiving cash assistance have even higher rates of psychiatric disorders than do single mothers who earn more than $20,000 a year. In a review of depression and low-income women, Lennon et al. (2001) reported that the rates of depression among low-income families are approximately twice those in higher-income families. Poor women — particularly those who have been exposed to traumatic experiences such as childhood abuse, domestic violence, rape, and other criminal behaviors — are at even greater risk for mental health problems (Bassuk, Browne, and Buckner 1996; Bassuk et al. 1996; Brooks and Buckner 1996; Miranda and Green 1999).
African Americans and Native Americans also have higher rates of mental health conditions compared to whites. However, some researchers argue that most of these differences can be attributed to disparities in socioeconomic status (U.S. Department of Health and Human Services 1999). There are fewer differences in the rates of mental disorders between whites and other ethnic groups.
Though there are few differences in the overall rates of mental illness between men and women, women are more prone to certain mental health conditions such as depression, post-traumatic stress disorder (PTSD), and anxiety disorders (Ulbrich et al. 1989, McLeod and Kessler 1990, Turner et al. 1995, Miranda and Green 1999). It is estimated that the rate of depression among women is 1.5 to 3 times the rate among men (Lennon et al. 2001).
Compared to the general population, welfare recipients have higher-than-average rates of mental health conditions (see Table I.2). Approximately 6.5 percent of the general population is diagnosed with major depression in a given year. Fewer individuals are diagnosed with PTSD (3.6 percent) or generalized anxiety disorder (3.4 percent) (U.S. Department of Health and Human Services 1999).
| Disorder | U.S. General Adult Population | Female Welfare Recipients in Michigan | Long-Term Welfare Recipients in Utah |
|---|---|---|---|
| Major Depression | 6.5% | 26.7% | 42.3% |
| Post-Traumatic Stress Disorder | 3.6% | 14.6% | 15.1% |
| Generalized Anxiety | 3.4% | 7.3% | 6.7% |
| Sources: U.S. Department of Health and Human Services (1999), Danziger et al. (1999), Barusch et al. (1999). | |||
There is wide variation in the reported rates of mental health conditions among welfare recipients. Estimates differ depending on how mental health conditions are defined and measured, and by the population studied. In the National Survey of America's Families, 35 percent of low-income families reported having poor mental health using scales measuring anxiety, depression, loss of emotional control, and psychological well-being (Zedlewski 1999). Researchers in Michigan found similar rates of mental health conditions (36 percent) among welfare recipients (Danziger et al. 1999). In a look at the prevalence of mental health, substance abuse, and domestic violence issues among California's CalWORKs participants, Chandler and Meisel (2000) found that more than one-third of these individuals had at least one diagnosable mental disorder in the previous 12 months, and about 20 percent had two or more. Of those with a mental disorder, more than one-fourth indicated their disorder interfered "a lot" with life or daily activities.
Major depression is the most common mental disorder among welfare recipients, followed by PTSD and generalized anxiety disorder. The prevalence of depression is startlingly high. In a Michigan study of barriers to employment faced by female welfare recipients, 27 percent of the study sample screened positive for clinical depression (Danziger et al. 1999). Researchers in Utah, using the measure for depression used in the Michigan study, found that 42 percent of long-term welfare recipients in Utah had clinical depression in the year before the interview (Barusch et al. 1999). This rate is nearly seven times that of the general adult population. Barusch et al. also found that 57 percent of these long-term welfare recipients were currently at risk for depression. Other researchers have found sizable differences in the rates of depression between welfare recipients and nonrecipients (Olson and Pavetti 1996, Leon and Weissman 1993).
While it is clear that depression is the most widespread mental health condition among the welfare population, what is not clear is the extent to which the depression precedes unemployment and receipt of cash assistance or vice versa, the depression being a product of the stress and frustration associated with those experiences. Regardless of which comes first, the symptoms of depression — sleeplessness, loss of self-esteem, social withdrawal, apathy, and fatigue — often interfere with the ability to find and keep a job and to support a family.
In addition to depression, generalized anxiety disorder and PTSD are prevalent among the welfare population and are often a result of childhood maltreatment, domestic violence, and other traumatic experiences. Welfare recipients experience generalized anxiety disorder and PTSD at rates substantially higher than the general population (see Table I.2). In-person interviews of women on welfare in Michigan revealed that the incidence of PTSD is four times that of the general population (Danziger et al. 1999). And the rate of generalized anxiety disorder among these women is twice as high as in the general population. Using the same measures as the researchers in Michigan, researchers in Utah found similar results among long-term welfare recipients (Barusch et al. 1999).
Overall, there is a strong relationship between mental health and employment. Those with mental health conditions are more likely to have poor and sporadic work histories, to be unemployed, and to be receiving cash assistance. Nationally, between 70 and 90 percent of working-age adults with serious mental illnesses are unemployed (Baron et al. 1996, National Institute on Disability and Rehabilitation Research 1993). Other studies focusing more broadly on mental disorders have also found that the presence of a mental disorder is associated with a decreased likelihood of working. Mintz et al. (1992), who looked at the relationship between depression and the general capacity to work, found that about half (52 percent) of depressed patients said that they had some level of functional work impairment. Lennon et al. (2001) concluded that depression may interfere with an individual's capacity to retain employment. In a review of research, Johnson and Meckstroth (1998) reported that mental health conditions not only result in lower rates of labor force participation but also in reduced work hours and lower earnings among those who are working.
Examining the link between mental health conditions and employment in welfare recipients, Danziger et al. (1999) found that major depression significantly decreased the likelihood that a woman on welfare would work, although other conditions such as generalized anxiety disorder and PTSD had no noticeable effect on employment. Focusing on the relationship between mental health conditions and welfare receipt, Jayakody et al. (1999) found that the presence of one or more of four psychiatric disorders increased the likelihood of receiving cash assistance by 32 percent.(3) In a related study, researchers reported that those who were diagnosed with major depression were 40 percent more likely to receive cash assistance than those not so diagnosed (Leon and Weissman 1993). Finally, Olson and Pavetti (1996) found that welfare recipients without a mental health condition were almost twice as likely to be employed throughout the year compared to those with a mental health condition.
Mental health conditions may affect employment in various ways, creating, for example, an inability to concentrate, fatigue, poor interpersonal skills, and difficulty sustaining a job. The stigma associated with mental health conditions may prevent a person from requesting workplace accommodations such as a flexible work schedule to manage a mental disorder.
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This study was designed to be exploratory in nature. Our primary goal was to gather as much information as possible on mental health services for welfare recipients in selected states and to identify the key decisions involved in providing these services and the options for delivering them. We were also interested in documenting the challenges faced, and lessons learned, by state and local welfare administrators and program staff in implementing and providing these services. This study is based on in-depth site visits to eight communities, including a rural and an urban location in each of four study states — Florida, Oregon, Tennessee, and Utah. Here we explain how we identified candidate programs for the study, our approach to site selection, and our data collection methods.
To begin this study, we gathered information on a broad range of programs and agencies that provide mental health services to welfare recipients or other low-income populations. To identify these programs, we reviewed several recently published reports on programs for the hard-to-employ, searched the Internet for such programs, and consulted with other researchers and program administrators who we knew were knowledgeable about and/or were providing mental health services to welfare recipients. In addition, the National Governor's Association sent an announcement to key state contacts notifying them that we were looking for programs designed to address the mental health needs of welfare recipients. From these sources combined, we identified 23 programs that were providing mental health services to welfare recipients and other low-income families; 16 of these programs were operating state- or countywide.(4)
After we developed a list of programs, we held brief telephone conversations with each of the program administrators providing mental health services at the state or local level. Calls typically lasted 30 minutes and covered a range of topics, including client characteristics, program staffing, number of clients served, types of services provided, ways clients are informed about services, length of time the state or community had been offering services, and general experience in delivering these types of services.
Our goal in selecting the sites was to include a range of programs that were operating at the state or county level, had sufficient experience in serving welfare recipients, and that varied in how they structured and provided services. We also wanted to include a mix of rural and urban sites. Specific site-selection criteria included the following:
Provision of Mental Health Services to Welfare Recipients Statewide or Countywide. Programs designed to address the mental health needs of welfare recipients vary in scale. Some operate at the state or county level and are integrated into the full range of services provided to welfare recipients. Others are individual programs run through one agency that serve a narrowly defined group of clients. We selected only programs operating on a state or county level, but they could be run out of the welfare, workforce development, or mental health systems.
Operating Before or Since the Implementation of PRWORA in 1996. Most of the programs we identified were implemented in response to state and federal welfare reform efforts. However, several programs were designed before the passage of federal welfare reform. Our goal was to include programs that, together, would represent a range of experience. For instance, from the programs that have been in operation for a longer period of time, we hoped to gather more information about how they have evolved. From the more recently established programs, we hoped to gather information on program design in the context of a work-based assistance system and a block grant funding arrangement.
Service Provision to a Relatively Large Number of Clients. We wanted to include programs that have substantial experience in providing mental health services to welfare recipients, as defined by the number of clients served. We selected statewide programs that had served at least 500 clients and countywide programs that had served at least 200 clients since inception.
Variation in the Structure and Delivery of Services. States and localities can structure and deliver mental health services to welfare recipients in a variety of ways. For example, some programs provide all of the services in-house, others use contracted service providers, and still others use a combination of the two. We attempted to include programs that would represent this variation in service type, structure, and delivery. In addition to the administrative framework for providing mental health services, we also considered the administrative structure for providing employment services, staffing for mental health services, the approach to identifying clients with mental health conditions, and the location at which mental health services are provided.
Rural/Urban Mix of Study Sites in Each State. We wanted to include an urban and a rural site for each state to learn how location, community demographics and infrastructure may influence the way mental health services are structured and delivered. In choosing the urban sites, we wanted to include at least one site with a very large and demographically diverse TANF population. In general, we let program administrators recommend sites. We were also looking for urban and rural sites in close proximity to one another or sites that may have implemented an innovative approach to providing services.(5)
Based on these criteria, we selected eight study sites — a rural and an urban site in each of four states (Table I.3). A detailed description of each state's approach to providing mental health services to welfare recipients appears in Appendix A.
| State | Urban Sites | Rural Sites | ||
|---|---|---|---|---|
| Site | TANF Cases | Site | TANF Cases | |
| Florida | Miami (Dade County) |
16,615 | Belle Glade (Palm Beach County) |
222 |
| Oregon | Portland (Multnomah County) |
3,500 | Astoria (Clatsop County) |
125 |
| Tennessee | Chattanooga (Hamilton County) |
2,450 | Clarksville (Montgomery County) |
571 |
| Utah | Salt Lake City (Salt Lake County) |
2,165 | St. George (Washington County) |
800 |
We collected data for this study primarily through two- to three-day site visits. In addition to collecting information on service delivery, types of services provided, and implementation challenges and lessons, we gathered information about the environment in which these services are provided, including the state welfare system (e.g., policies and administrative structure) and the mental health service delivery system for low-income families.
During each site visit, a two-person team conducted 60- to 90-minute semi-structured interviews with a wide range of welfare and mental health program staff, including staff from the welfare office, mental health treatment providers, and other key players involved in identifying and treating mental health conditions. In addition, we collected organizational materials (e.g., program descriptions, organization charts, service delivery pathways, etc.), screening and assessment tools, reporting and tracking forms, outcome and evaluation reports, and other types of materials at each site. We synthesized all of this information in in-depth descriptive program summaries for each state.
1. For the purpose of this report, welfare office is used as a generic term to describe a place that serves welfare recipients, which, in some areas, may be a combined welfare/workforce development system.
2. Appendix B is available at http://aspe.hhs.gov/hsp/TANF-MH01/forms/appb.htm. [All forms are in PDF format.]
3. Psychiatric disorders included in the study: (1) major depression, (2) generalized anxiety disorder, (3) agoraphobia, and (4) panic attack.
4. Ten of the programs were operating statewide. Programs varied in the extensiveness of the services they provide.
5. For example, in Utah, St. George (Washington County) was selected because the program uses a Welfare-to-Work competitive grant to expand the capacity of existing mental health services.
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Updated: 10/03/01