Ancillary Services to Support Welfare to Work. Mental Health Issues

06/22/1998

INTRODUCTION

Emerging evidence about the obstacles that mental illness poses to productive employment is raising awareness of how prevalent and detrimental these obstacles are. Welfare clients with mental health difficulties are more likely than others to receive public assistance and, unless treated, are likely to continue to need assistance for long periods. These clients, who are the least likely to respond to the pressures of time limits, are in real jeopardy of facing severe and long-term poverty. Welfare-to-work programs will have to determine how best to assess these clients' needs and to design services in ways that will facilitate steps toward employment.

This section provides information on and addresses the following questions related to mental health issues among welfare recipients:

NEED FOR SERVICES:

How are mental health issues defined?

What percentage of the welfare population faces this barrier to employment?

What relationship do mental health issues have to welfare dependency and employment?

Definition

Mental health issues are defined in a variety of ways, which results in different assessments of the severity of mental illness. Narrowly defined, serious mental health issues are psychiatric disabilities that seriously interfere with one or more aspects of a person's daily life (Barker et al. 1992). Such disabilities or illnesses meet diagnostic criteria for affective disorders, including major depressive disorder. More broadly defined, with less rigorous assessment criteria, mental health issues may also include symptomatic problems or indicators of risk for mental illness. Although diagnosable mental illnesses may exist in these cases, these broadly defined mental health issues may actually be merely symptoms of other difficulties in a welfare recipient's life.

Percentage of Welfare Population Facing This Issue

National estimates: 4 to 28 percent

State/local estimates: 13 to 39 percent

Tables 16 and 17 in Appendix A provide estimates of the proportion of the welfare population faced with a mental health issue. The ranges in estimates, presented in the box above, are due primarily to the following factors:

  • Barrier Definition. Mental health issues defined narrowly (as discussed above) tend to have lower prevalence estimates than those defined broadly. When mental illnesses among the welfare population are defined as those meeting diagnostic criteria, estimates range from 6 to 23 percent (Leon and Weissman 1993; and Jayakody and Pollack 1997). When they are defined more broadly, as merely symptomatic of depression, estimates are generally higher, ranging from 13 to 39 percent (Olsen and Pavetti 1996; Quint et al. 1991; Moore et al. 1996; and Iowa Department of Human Rights 1995).
  • Measurement Method. The use of different survey techniques to collect the data explains at least part of the variation in the estimates. For instance, a survey may underestimate prevalence rates when sensitive data are collected in person or when data for an entire family unit are collected from a single household member (Barker et al. 1992).

Relationship to Welfare Receipt

  • Those diagnosed with a mental illness are more likely to receive public assistance and, unless treated, are likely to continue to need assistance for long periods. People meeting the diagnostic criteria for major depressive disorder are 40 percent more likely to receive AFDC than those not meeting these criteria (Leon and Weissman 1993).
  • Having a psychiatric disorder significantly increases (by 38 percentage points) the probability of receiving welfare (Jayakody and Pollack 1997).
  • Welfare recipients are three times as likely as nonrecipients to suffer from regular feelings of depression (Olsen and Pavetti 1996) and are twice as likely as nonrecipients to meet the diagnostic criteria for an affective disorder (Leon and Weissman 1993).

Relationship to Employment Status

  • People with serious mental illnesses (in the form of diagnosed psychiatric disabilities) have rates of unemployment as high as 70 to 90 percent (Anthony et al. 1984). Moreover, nearly half of those with serious mental illness were, as a result, unable to work or limited in their ability to work (Barker et al. 1992).
  • Mental health issues result not only in lower rates of labor force participation, but also in reduced work hours and lower earnings (Bland et al. 1988; Benham and Benham 1982; and Ettner et al. 1996).(1)

Welfare Agency Approaches

  • What can welfare agencies do to assist clients who face mental health issues as a barrier to employment?
  • What does the evidence suggest about the effectiveness of addressing this barrier?
  • What do we know about program costs?
  • What do we know about program implementation?

The two critical program features of an agency's approach to addressing mental health issues as a barrier to employment are (1) identifying which clients have mental health needs, and (2) determining the type of program or service to provide.

Client Identification

Accurate identification and proper diagnosis of clients with mental health needs is the first stage in welfare agencies' effort to help clients move from welfare to work. There are two steps in this process of identification and diagnosis: screening and assessment.

Screening refers to determining the probability that a mental health need exists, often by identifying symptoms of mental illness or other mental health needs.

Assessment refers to a formal psychiatric diagnosis of the type and severity of mental illness.

Few welfare agencies use formal screening instruments to identify clients with mental health needs. Rather, welfare agency staff generally identify clients in need of mental health services by observing symptoms of mental illness, such as anxiety, behavior problems, and depression, or by incorporating questions into intake and follow-up interviews that are designed to elicit information on symptoms. Questions based on the widely recognized Diagnostics and Statistical Manual of Mental Disorders (DSM) are somewhat more valid and reliable than other questions (American Psychiatric Association 1987). For instance, a four-item scale based on the DSM and adapted from the Center for Epidemiological Studies Depression Scale has been used in research studies to measure risk for clinical depression among clients (Quint et al. 1994; and Moore et al. 1996). Such a scale, or some adaptation of it, may be appropriate for use by welfare agencies. In short, the development of effective mental health screening instruments for use by welfare agencies is much needed and has been recommended by the National Technical Assistance Center for State Mental Health Planning (Emery 1997).

Once clients are screened for mental illness, mental health professionals conduct psychiatric evaluations to arrive at comprehensive assessments. Assessments not only allow diagnosis of a client's mental illness, but also understanding of how it interacts with other possible personal difficulties, such as substance abuse, homelessness, or domestic violence.

Program Strategies

As clients adjust to the new welfare work requirements, welfare agencies are developing and enhancing service delivery strategies to improve treatment for and provide employment support to clients who have mental health needs, particularly clients who are not covered by the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) programs. In addition, mental health agencies are continuing to work with vocational rehabilitation and supported employment providers to help people with mental health needs become successfully employed. Welfare agencies often refer clients with mental health needs to these types of organizations. Lessons from all these program efforts are relevant for welfare agencies as they develop their own approaches to better serve clients with mental health needs.

Our review of programs suggests that there are at least three broad program strategies welfare and other agencies are currently using to address mental health needs. This review is concerned chiefly with examining what welfare agencies can realistically hope to accomplish in response to client needs and does not extend to potential responses beyond the scope of the welfare agency, for example, to address changes in mental health service infrastructure or changes in Medicaid, SSI, or SSDI policy. We categorize these strategies below. The distinctions drawn are not intended to suggest that agencies design programs around a single strategy or that these strategies are necessarily mutually exclusive. They are provided instead to foster thinking about the range of programmatic objectives possible, to help agencies define their own service needs, and to classify the programs described at the end of this section for agencies interested in pursuing further information. The three broad program strategies are as follows:

Enhanced Case Management. Programs with this strategy intend to strengthen treatment services for patients with mental health needs by providing enhanced case management services, for example, through home visits, case staffings, interactive service plans, and the involvement of specialized mental health treatment workers.

Service Coordination. Programs with this strategy strive to institute improved coordination systems and collaborative service efforts between agencies. They include coordinated efforts between welfare agencies and mental health agencies, as well as between mental health agencies, the Vocational Rehabilitation Services (VR) Program, and other supported employment providers. Coordination takes many forms, including structured referral mechanisms and shared funding arrangements.

Employment Integration. Programs with this strategy primarily offer services that are directly linked to preparing clients for employment, usually combining mental health care and counseling with employment-related services such as vocational assessment and training, job preparation and placement, work experience, on-the-job coaching and accommodations, postemployment support, and interpersonal and life skills training. These programs are typically operated not by welfare agencies, but rather by mental health agencies in coordination with the VR program and other supported employment providers. Some of the people served by such programs are on welfare.

Program Outcomes

There is very little empirical evidence about the effectiveness of welfare agency efforts to help clients with mental health issues make the transition from welfare to work. Evaluations of welfare-to-work programs have not isolated the role of mental health strategies in their evaluation designs and analyses. Although little evidence exists about welfare agency efforts, a review of research from the mental health field generally shows that mental health treatment can lead to consistent and significant improvements in client work outcomes over time. Moreover, an examination of programs that integrate mental health treatment with employment-related services shows that this combination of services, when properly implemented, can help clients with mental health needs prepare for and sustain employment. Experience suggests that programs that employ clients quickly and then provide ongoing support and accommodations can help people with mental illness stay employed successfully (National Technical Assistance Center for State Mental Health Planning 1997a).

Data from a number of programs that integrate mental health treatment with employment-related services are presented below. Most of these programs are not administered by welfare agencies, nor do they target welfare recipients exclusively. However, they are relevant for welfare agencies, since they suggest types of strategies that welfare agencies might consider as they improve their own efforts to serve clients with mental health needs better. Additional information on referenced programs is provided in the section entitled Program Models.

Program Effect on EMPLOYMENT(2)

  • Descriptive program data from Nevada County's intensive GAIN program for clients with mental health and substance abuse needs show that, after six months of participation, over 70 percent of welfare recipients moved from the intensive program into either employment or the regular GAIN program (Pavetti et al. 1996).
  • Descriptive program data from Wisconsin's Transition Services for Persons with Severe Mental Illness show that, after the first year of implementation, 50 percent of clients had been placed in competitive employment.(3)
  • Descriptive program data from New Jersey's Supported Employment Program show that, of the 2,000 people served by the supported employment providers over the past 10 years, 65 percent were placed in full- or part-time employment.(4)
  • A quasi-experimental evaluation of the VR program in Virginia compared participants (both successful and unsuccessful rehabilitants) with program dropouts and found that female participants with mental and emotional disabilities had significantly greater earnings at one-year followup than did dropouts (Dean and Dolan 1991).

Program Costs

The literature contains little data on the costs to welfare agencies and other organizations of operating programs that address employment barriers related to mental health. Costs will vary according to differences in program approach. For instance, the cost to welfare agencies of using screening instruments to identify mental health needs among clients is minimal. Once a client is identified as having mental health needs, welfare agencies can then often make referrals to other organizations for specialized assistance. If a referral is made, for instance, to a mental health center, a supported employment program, or the VR program, the costs can be assumed by the other program. According to program data from 1984 to 1988, VR programs spent an average of $985 on services to help employ people with mental health needs (Rutman et al. 1994). The cost of welfare agency efforts to provide enhanced case management services to clients, for example, by including a mental health professional on staff, will be much higher, since it must be assumed directly by the welfare agencies.

Although little data is available on program costs or on the cost-effectiveness of different program approaches, a good deal is known about the high costs associated with mental illness. One study estimated that costs related to lost productivity, treatment, and other needs associated with people with mental illness equaled nearly $148 billion in 1990 (Rice and Miller 1992). Because of these high costs, programs that provide treatment and employment-related services are potentially very cost-effective, since clients with mental health needs can be productively employed if those needs are identified and treated and if appropriate employment-related assistance is provided.

Program Implementation

Welfare agencies are continuing to develop and enhance strategies to identify, serve, and refer clients with mental health needs. These agencies have not traditionally provided extensive supportive services to clients with these needs but instead have made referrals to other service providers, most often mental health agencies. Mental health agencies, in turn, often coordinate efforts with vocational rehabilitation and supported employment providers to meet both the mental health and employment needs of their clients, some of whom receive welfare. Through the experiences of both welfare and mental health agencies, many lessons have been learned about how to better serve people with mental health needs, lessons relevant for welfare agencies as they help these clients make a successful transition from welfare to work.

Our synthesis of various program strategies leads to a discussion of implementation issues that welfare agencies and other organizations face in four key areas: (1) client identification, (2) program staff, (3) coordinated delivery of services, and (4) service capacity. Along with the discussion, we recommend steps that welfare agencies should take to serve clients with mental health needs better.

Client Identification

If program implementation is to be successful, welfare agencies must develop screening and assessment tools that staff can use to identify clients with mental health needs. Only a very small number of state welfare agencies use formal screening tools or questions to identify mental health needs among their clients. Instead, welfare staff are more likely to rely on enhanced case management techniques, such as case staffings or interdisciplinary service teams. Reliance on these methods, however, will not ensure that clients' needs are identified in a timely manner. To ensure that these clients are accurately identified at intake and then provided with appropriate services, welfare agencies need effective screening instruments (Emery 1997). In developing such instruments, agencies would likely benefit from coordination and technical assistance at the national level.

Program Staff

If program implementation is to be successful, welfare agencies must make a substantial commitment to training staff on mental health issues, particularly on how to screen for mental illness and make appropriate service referrals. Welfare clients with mental health needs require various supportive services to help them get and maintain a job, so sensitizing staff to their unique counseling, rehabilitative, and on-the-job needs is a critical first step. After initial training to sensitize staff on mental health issues, training must also be provided to help them recognize symptoms of mental illness, use screening instruments to identify it, provide support and services to clients, and make appropriate referrals to specialized welfare agency staff and outside professionals. Developing staff capacity to perform these roles is likely to require both initial and ongoing training.

Coordinated Delivery of Services

To serve clients with mental health needs successfully, welfare agencies should develop partnerships with other organizations for the provision of mental health counseling and treatment, vocational rehabilitation, and other employment-related services. Welfare clients with mental health needs require a broad range of supportive services to help them get and then maintain a job. These services include mental health counseling and treatment, employment-related assistance, and, to the extent that clients face multiple barriers to employment, services that address other areas, such as domestic violence, substance abuse, or housing. This broad range of needed services makes coordinating service delivery with other organizations an important challenge. To meet this challenge, welfare agencies must devote the time necessary to develop and strengthen collaborative partnerships with other organizations, the most important being mental health service providers, vocational rehabilitation programs, and other employment-related service providers.

Mental health service providers offer counseling and treatment, as well as an established referral link to vocational rehabilitation and other employment-related programs. In addition, mental health providers can act as a source of technical assistance to welfare agencies as they improve their staff training and client identification methods. Welfare agencies should also develop and strengthen direct referral linkages with employment-related programs that serve people with mental health needs, including the VR and supported employment programs. All states offer VR programs, and most states offer some type of supported employment program that serves individuals with mental health needs (Emery 1997). Finally, as necessary and with the consent of clients, welfare agencies should consider communicating with the employers of clients with mental health needs to negotiate individualized on-the-job accommodations. With appropriate accommodations--many of which are very simple and cost-effective--clients with mental health needs are more likely to stay employed; without them, their chances of losing jobs and returning to welfare increases.

To link services provided directly by welfare agencies with those provided through referrals to other organizations, welfare agencies should consider hiring or contracting with a professional mental health and vocational counselor who could offer specialized support to both case managers and clients. This strategy is consistent with research and practice from the mental health field, which shows that service delivery is facilitated by a multidisciplinary approach that combines case managers with other staff who specialize in mental health and vocational rehabilitation counseling (National Technical Assistance Center for State Mental Health Planning 1997a). A mental health and vocational counselor could perform a number of functions, including offering on-site counseling and employment-related services to clients, fostering collaborative partnerships with other organizations, facilitating appropriate referrals, and communicating as necessary with clients' employers.

Service Capacity

To serve clients with mental health needs successfully, welfare agencies must assess the extent to which current local service capacity helps to treat, rehabilitate, and employ clients with mental health needs and, where gaps exist, address shortages. Program resources to provide mental health treatment, vocational rehabilitation, and employment-related services to welfare clients with mental health needs may be limited in many communities. That is, the service infrastructure may not offer programs with which welfare agencies can develop collaborative partnerships to serve clients with mental health needs. For instance, referrals for specialized mental health care are often difficult to obtain in some communities (Pavetti et al. 1996). This is particularly true in rural areas where relatively few resources are available. In terms of employment-related programs, existing resources may also not be adequate in some communities. For instance, the VR program typically serves only an estimated five to seven percent of all potentially eligible people (GAO 1993). In addition, the VR program is required to give priority in participant selection to people with the most severe disabling conditions. These factors, while not providing evidence of a service gap, do suggest that the VR program may be limited in its capacity to serve welfare recipients with mental health needs.

Service capacity related to the VR program may also be somewhat more problematic in those states that do not fully access available federal matching funds for the VR program. In some states, welfare, mental health, and other agencies have already coordinated efforts with the state VR program by contributing funds to help the VR program access additional federal matching funds. When agencies contribute such "third-party payments" to access additional funds, they essentially ensure that the VR program will provide services to their clients. This is one strategy that welfare agencies may wish to consider in order to increase service capacity in their communities. When welfare agencies cannot make referrals to or otherwise coordinate with other organizations to meet the mental health needs of their clients, there will be greater pressure on them to develop and enhance their own programs to provide treatment, counseling and employment-related support.

Program Models(5)

  • What are welfare agencies doing to address this issue?
  • Whom can I contact?

The following programs are presented alphabetically by state. The reader can determine the relevance of a program by noting its primary program strategy and geographic location and then refer to the brief descriptions and contact information on the subsequent pages. We have used primary objective(s) to assign program strategies, though a program may have many objectives.


Nevada County Department of Public Social Services

Greater Avenues for Independence (GAIN) Employment Services Program

Nevada County, CA

Program strategy: Enhanced case management

Location: One rural county


New Jersey Division of Mental Health Services

Supported Employment Program

Trenton, New Jersey

Program strategy: Service coordination

Employment integration

Location: Statewide


Ohio Department of Mental Health

Employment and Training Projects

Columbus, Ohio

Program strategy: Service coordination

Employment integration

Location: Most counties statewide, urban/suburban/rural


Oregon Adult and Family Services

JOBS Program

Salem, Oregon

Program strategy: Enhanced case management

Service coordination

Location: Statewide


Utah Departments of Workforce Services and Human Services

Family Employment Program (Single Parent Employment Demonstration)

Salt Lake City, UT

Program strategy: Enhanced case management

Location: Statewide


Wisconsin Bureau of Community Mental Health

Transition Services for Persons with Severe Mental Illness

Madison, Wisconsin

Program strategy: Service coordination

Employment integration

Location: Ten (mostly) rural counties


Program Name/Contact

Nevada County Public Social Services

Greater Avenues for Independence (GAIN) Employment Services Program(6)

Nevada County, California

*Note: This program model is also relevant for the substance abuse service area.

Suzanne Nobles, 916-265-7171

Terri Fransen, 916-265-1760

Program strategy: Enhanced case management

Location: One rural county

Brief Program Description

California's GAIN program, a welfare-to-work initiative started under the JOBS program, operated in all California counties. Its efforts continue in the form of the CalWORKS TANF program, which seeks to expedite job search and job placement while providing a range of supportive services. In addition to core services, the Nevada County program provides intensive and specialized case management to clients exempt from program requirements because of mental illness, mental health problems, family crises, or legal difficulties. Clients are identified and referred for intensive, specialized services through a one-on-one interview with an employment and training counselor, primarily to cover employability and job readiness issues. Clients referred for intensive GAIN services faced financial penalties for failure to participate.

At the Nevada County GAIN office, a social worker with an advanced degree provides intensive and specialized case management services to referred clients, including the following types of services: assessment of mental health and other problems, crisis counseling, support dealing with stressful situations, regular home visits, and referrals to specialized community resources. The social worker and the client together develop an individualized, interactive service plan that includes setting short-term client goals. Clients identified as having severe and diagnosed mental health illnesses are referred to appropriate providers in the community. Once such a referral is made, the social worker communicates with the service provider and offers ongoing support to the client.

Evaluation

There has been no impact evaluation of Nevada County's GAIN program. However, a case study analysis of the program was conducted by the Urban Institute (Pavetti et al. 1996).

Findings

Program data for Nevada County's intensive case management program show that, after six months of participation, more than 70 percent of participants moved from the intensive program into either employment or the regular GAIN program (Pavetti et al. 1996).

Program Name/Contact

New Jersey Division of Mental Health Services

Supported Employment Program

Trenton, New Jersey

Steve Fishbein

New Jersey Division of Mental Health Services

609-777-0708

Program strategy: Service coordination

Employment integration

Location: Statewide

Brief Program Description

New Jersey's Supported Employment Program, an ongoing 10-year collaborative effort between the Department of Labor's Division of Vocational Rehabilitation (VR) and the Department of Human Services' Division of Mental Health Services, provides individualized job placement and supported employment services to people with severe and persistent diagnosed mental illnesses. About two-thirds of clients receive SSI or SSDI; the rest are mostly people receiving public assistance, many of whom are subject to the TANF work requirements. Services are provided through contracts with 21 nonprofit supported employment providers--one provider for each of New Jersey's 21 counties. Referrals are typically made by VR or by community mental health services providers. Welfare recipients are usually referred to the program through one of these organizations.

The supported employment providers offer the following individualized services to clients: mental health counseling, vocational and skill assessments, development of client work profiles, identification of necessary job supports and accommodations, interpersonal and life skills training, job preparation, job coaching, work experience internships, and individualized job placement. All but two of the supported employment providers are also community mental health providers; the remaining two work with community mental health centers to obtain the necessary psychiatric services. In facilitating job placement, the supported employment providers have had contact with more than 520 businesses statewide. Clients are usually placed in jobs 1 to 6 months after beginning the program, and postemployment support is provided as long as necessary. The statewide program operates at an annual cost of $2.4 million. The Division of Mental Health Services provides money to help VR access additional federal VR matching funds.

Evaluation

There has been no formal evaluation of this program. However, a three-state implementation study that included the New Jersey program was recently conducted on reasonable work accommodations for people with psychiatric illnesses (MacDonald-Wilson 1997).

Findings

There is no information on program impacts. Descriptive data show that, of the 2,000 people served by the supported employment providers over the past 10 years, 65 percent were placed in full- or part-time employment. Program staff generally find that emotional encouragement, problem-solving support, and mental health counseling are useful postemployment services.

Program Name/Contact

Ohio Department of Mental Health

Job Training and Rehabilitation Services Project

Columbus, Ohio

Roy Pierson

Ohio Department of Mental Health

614-466-7347

Program strategy: Service coordination

Employment integration

Location: Most counties statewide, urban/suburban/rural

Brief Program Description

The Ohio Department of Mental Health (ODMH) offers job training and rehabilitation services to people with serious mental illness. Independent local programs are operated through county mental health boards. Most clients suffer from serious mental illness. About 14 percent are welfare recipients, many of whom are not exempt from the TANF work requirements. Welfare recipients are usually referred to the local programs by a local welfare office.

The county mental health boards, through contracts with local mental health centers and collaborative arrangements with the Department of Rehabilitation Services and other local service providers, offer a full range of mental health services, along with extensive job training and vocational rehabilitation services. Local programs operate in about two-thirds of Ohio's counties. The ODMH provides incentive payments to the county mental health boards to collaborate more closely with local service providers and to make successful job placements for clients. This program has operated in its current form for two years.

Case managers from the mental health centers work with participants to develop a service plan for both mental health and vocational rehabilitation services. A supported employment model of service delivery is used. To assist the case managers, vocational counselors are co-located in mental health centers in some counties. The following types of individualized services are typically offered, either on site at the mental health center or through a referral to another service provider: mental health counseling, vocational and skill assessments, identification of necessary job supports and accommodations, job coaching, individualized job placement, and postemployment support.

Evaluation

This program has not been formally evaluated.

Program Name/Contact

Oregon Adult and Family Services

JOBS Program(7)

Salem, Oregon

*Note: This program model is also relevant for the substance abuse service area.

April Lackey

Adult and Family Services/Office of Alcohol and Drug Abuse Programs

503-945-6197

 

Christa Sprinkle

Mount Hood Community College

Steps to Success Program

Portland, Oregon

503-256-0432

Program strategy: Enhanced case management

Service coordination

Location: Statewide

Brief Program Description

Since the early 1990s, Oregon has included mental health screening, counseling, and treatment services in its Job Opportunities and Basic Skills Training (JOBS) program. Mental health problems among welfare participants are identified by case managers through ongoing interactions with clients, home visits, and observations of clients during Life Skills sessions and other JOBS-related classes. Case managers are supported by mental health professionals, some of whom are also located in the welfare offices. Clients may be referred for mental health assessment if they exhibit problems with attendance, behavior, or attention; appear to be anxious, depressed, or isolated; or show signs of drug or alcohol use or domestic violence.

Mental health counseling and treatment is coordinated among case managers, mental health therapists or counselors, and, in some cases, district mental health coordinators. Individual districts determine how to provide the services. In several districts, for example, strong partnerships have been formed with local mental health providers. In these cases, counties in the district contract with a local mental health service organization for the provision of services. A professional therapist from the service organization provides assessment, counseling, and treatment services to referred clients. In many cases, these therapists are also located in the welfare office, which facilitates easy access to services and allows them to provide both education and counseling to clients more easily. When therapists are not co-located in the welfare office, case managers refer the client to a mental health service provider. Funding for mental health services is included in the Oregon state health plan.

Clients in treatment receive regular mental health counseling services for an average of three months. Counseling services, however, can last as long as a year. Although individual counseling is standard, some group counseling may be used. Oregon has a waiver to mandate participation in mental health services, although it does so only in cases when staff believe participation to be in the best interests of the client.

Evaluation

MDRC is conducting an ongoing evaluation of the JOBS program, including the Portland site. This experimental design evaluation includes an impact, cost-benefit, and implementation study (MDRC 1994). The effect of the mental health services program, however, will not be isolated, and mental health outcomes will not be assessed.

Program Name/Contact

Utah Departments of Workforce Services and Human Services

Family Employment Program (Single Parent Employment Demonstration)(8)

Salt Lake City, Utah

*Note: This program model is also relevant for the substance abuse service area.

Helen Thatcher

Family Employment Program

801-468-0177

Program strategy: Enhanced case management

Location: Statewide

Brief Program Description

Utah's original welfare reform program--the Single Parent Employment Demonstration--began in 1993 with the requirement that all participants work or take part in work-related activities. As part of this program and currently under Utah's Family Employment Program (FEP), participants who are unable to work or to participate in work-related activities receive a variety of supportive services, including mental health counseling and mental health treatment. The identification of needs and delivery of services is facilitated by the involvement of case staffing teams and treatment workers. In addition, participants are responsible for taking part in program activities, with financial penalties for choosing not to participate and financial incentives for full-time participation.

Caseworkers, called employment counselors, negotiate individualized plans for all participant families to achieve self-sufficiency. Utah's FEP is currently finalizing the development of a standardized screening tool to identify, at the initial intake interview, clients with mental health and substance abuse needs. The screening tool is currently being pilot-tested in one FEP office and will ultimately be used statewide. Participants with identifiable barriers to employment are referred to a case-staffing team, which includes staff who have expertise and experience in different service areas and who work together to assess participant needs and determine the best service strategies. A participant with mental health problems, for instance, is referred to a specialized treatment worker, who is often co-located in the local FEP offices.

The treatment staff in some offices may manage caseloads about half the size of those of regular self-sufficiency employment counselors. They provide a variety of services to participants with mental health needs, including one-on-one counseling, home visits, referrals to specialized mental health resources in the community, and, in some areas, group counseling sessions. In providing one-on-one counseling, a "brief therapy" model is typically used, usually involving 8 to 10 counseling sessions aimed at overcoming one single issue that makes employment more difficult.

Evaluation

The Social Research Institute at the University of Utah is conducting a descriptive study of the program, based on participant survey data. Preliminary results are expected in late 1998. In addition, a case study analysis of the program was conducted by the Urban Institute (Pavetti et al. 1996).

Program Name/Contact

Wisconsin Bureau of Community Mental Health

Transition Services for Persons with Severe Mental Illness

Madison, Wisconsin

Patricia Rutkowski

Wisconsin Bureau of Community Mental Health

608-266-9331

Program strategy: Service coordination

Employment integration

Location: 10 (mostly) rural counties

Brief Program Description

The Wisconsin Bureau of Community Mental Health (BCMH), in partnership with the Division of Vocational Rehabilitation (VR), initiated, in 10 mainly rural counties in 1996, pilot programs intended to promote employment for people with serious mental illnesses. The pilot programs use the Program for Assertive Community Treatment (PACT) model of service delivery, an individualized and comprehensive approach to providing employment and support to people with psychiatric disabilities. They focus on transitioning clients into work while providing a comprehensive mix of ongoing supportive services, such as psychiatric care and counseling, vocational assessment and training, assistance with life skills (for example, housing, mental health, and social skills), and postemployment training (for example, counseling, assistance with transportation and work clothing, and off-site job coaching).

Participating clients are those with functional difficulties and a clinical diagnosis of a serious psychiatric disability. Referrals to the pilot programs are made jointly by the mental health agency and VR. Most clients are low-income people who have received public assistance; a little over half are men. Each pilot program actively serves 15 clients at any given time. The staff:client ratio is typically 1:10.

To support the programs, CMH contributed $100,000 in matching funds to obtain an additional $370,0000 in federal funds from the Wisconsin VR. The money pays for additional vocational rehabilitation staff, monthly consultation visits between VR and CMH staff, and quarterly training sessions for VR staff.

Evaluation

This program has not been formally evaluated.

Findings

There is no information on program impacts. However, program data show that after the first year of implementation, 50 percent of clients had been placed in competitive employment.

Further Information

Further information on issues related to mental health is available from the following

Organizations

Center for Psychiatric Rehabilitation

617-353-3549

Website: http://web.bu.edu/SARPSYCH

The Center for Psychiatric Rehabilitation conducts research, trains treatment staff, helps organize coordinated service delivery systems, and develops rehabilitation programs that, among other things, seek to employ people with psychiatric disabilities.

National Mental Health Services Knowledge Exchange Network

Center for Mental Health Services

800-789-CMHS (2647)

Website: www.mentalhealth.org

The National Mental Health Services Knowledge Exchange Network (KEN) is a one-stop source of free information and resources on prevention, treatment, and rehabilitation services for mental illness. KEN offers information in various forms on mental health issues and programs, makes referrals to state and community resources, and provides an on-line forum for public discussions and networking.

National Association of State and Mental Health Program Directors (NASMHPD) and the National Technical Assistance Center for State Mental Health Planning

703-739-9333

Website: www.nasmhpd.org

NASMHPD conducts research and advocacy for the collective interests of state mental health authorities. It analyzes trends in the delivery and financing of mental health services, disseminates knowledge about the integration of public mental health programs into health care systems, identifies public mental health policy issues, provides information on best practices in the delivery of mental health services, and provides consultation and technical assistance.

The National Technical Assistance Center for State Mental Health Planning (NTAC) provides focused technical assistance and consultation to state mental health agencies, state mental health planning and advisory councils, and clients and families.

Further information on issues related to mental health is available in the following

Documents

Center for Mental Health Services, R. Manderscheid and M. Sonnenschein (editors). "Mental Health, United States." U.S. Department of Health and Human Services, Publication Nos. SMA 94-3000 and SMA 96-3098. Washington, DC, 1994 and 1996 (and five other editions).

This series of reports on mental health issues in the United States provides descriptive discussions of statistical information on mental health policy and program issues. Recent editions have focused on the following types of issues: mental health care reform, mental health coverage under health insurance, mental health epidemiological data for adults and children, capacity of and service delivery by mental health organizations, status of the state mental health service delivery system, vocational rehabilitation for people with mental disabilities, and managed care issues for mental health services.

Emery, B. "Welfare Reform Briefing Paper on the Personal Responsibility and Work Opportunity Reconciliation Act of 1996." Alexandria, VA: National Technical Assistance Center for State Mental Health Planning (NTAC), December 1997.

This paper summarizes issues related to the impact of welfare reform on adults with psychiatric disabilities, children with serious emotional disturbances, and people with substance abuse disorders. It identifies strategies for ensuring that welfare recipients with these difficulties continue to receive effective services and supports that enable them to move from welfare to work. The paper is based largely on issues discussed at a conference on welfare reform that was jointly sponsored by the National Technical Assistance Center for State Mental Health Planning and the Center for Mental Health Services.

Leon, Andrew C., and Myrna M. Weissman. "Analysis of NIMH's Existing Epidemiologic Catchment Area (ECA) Data on Depression and Other Affective Disorders in Welfare and Disabled Populations." Washington, DC: U.S. Department of Health and Human Services, Office of Assistant Secretary for Planning and Evaluation, June 1993.

Using data from the National Institute for Mental Health's Epidemiologic Catchment Area Program, this paper evaluates the relationship between different types of public assistance (including AFDC) and affective mental health disorders. Rates of public assistance are evaluated for different types of affective disorders. Health care utilization for emotional problems is also examined.

Rouse, B. (editor). Substance Abuse and Mental Health Statistics Sourcebook. U.S. Department of Health and Human Services Publication No. (SMA) 95-3064. Washington, DC: Superintendent of Documents, U.S. Government Printing Office, 1995.

This statistical document provides a wide range of descriptive data on mental health and substance abuse in the United States, including costs and effects of mental illness and substance abuse, the prevalence of mental illness and substance abuse, specialized mental health and substance abuse treatment utilization and staffing, and funding sources and expenditures for the prevention and treatment of mental illness and substance abuse.

 

1. Most of these studies examine men with mental health problems, not women receiving welfare.

2. Reported impacts are not always impacts that have occurred exclusively for welfare recipients.

3. Data are based on a personal communication with Patricia Rutkowski of the Wisconsin Bureau of Community Mental Health, February 1988.

4. Data are based on a personal communication with Steve Fishbein of the New Jersey Division of Mental Health Services, February 1998.

5. For an explanation of how programs were selected, please refer to the discussion included in the Introduction under the paragraph heading "Program Models."

6. This program summary benefited from a previously published description of the program (Pavetti et al. 1996).

7. This program summary benefited from a previously published description of the program (Pavetti et al. 1996).

8. This program summary benefited from a previously published description of the program (Pavetti et al. 1996).