This review of programs designed to address the mental health needs of welfare recipients was intended to be exploratory in nature. We identified the types of mental health services provided to welfare recipients and how these services are administered and delivered by state and local welfare offices. We outlined the key decisions involved in designing and providing mental health services as well as the types of service delivery options associated with each decision. We also documented many of the primary implementation issues. Our overall goal was to create a guide for program administrators in other states and communities interested in delivering mental health services to welfare clients. This guide is also intended to assist researchers who are interested in evaluating mental health service programs for welfare recipients. Through our investigation, we have arrived at several conclusions about what is involved in providing mental health services to welfare recipients and about the relationship between these services and the work-related thrust of welfare reform.
- Mental health services can be a valuable resource for employment case managers seeking to move hard-to-employ individuals from welfare to work.
Employment case managers said that mental health services help them to address the personal and family challenges faced by hard-to-employ welfare recipients. Mental health staff offer specialized services that employment case managers are not trained to provide. Mental health staff also help employment staff understand mental health conditions and how these conditions may affect the clients' ability to find and keep a job.
- There are a variety of ways to address mental health needs of welfare recipients; there is no evidence to suggest that one model for providing services is better than any other.
In each local community, Medicaid-funded mental health services are available to welfare recipients. However, some recipients may not be aware that they have a mental health condition that affects their employability. And even those aware of their condition may not know how to access treatment. In the study states, TANF and Welfare-to-Work funds have been used to link clients to existing mental health treatment or to expand treatment options or create new ones. The experience of the four states suggests that the mental health needs of welfare recipients may be addressed in a variety of ways.
Florida. In Florida, TANF funds have been used to purchase mental health treatment for welfare recipients and those at risk for TANF involvement. These funds have also been used to hire outreach staff who link individuals to these services. Mental health services are administered and coordinated by mental health and substance abuse agencies, which operate outside the welfare office and workforce development system. Operating mental health services out of an agency outside of the TANF eligibility and TANF employment services system has made integration difficult.
Oregon. In Oregon, the focus is on assessing clients and linking them to Medicaid-funded mental health treatment providers. Oregon has integrated mental health services into the welfare system by co-locating mental health staff in most local welfare offices and allowing each district office to develop an administrative structure that reflects the mental health resources available in the community.
Tennessee. The Family Services Counseling program in Tennessee provides assessment and short-term, solution-focused mental health treatment for welfare recipients using an approach that is uniform statewide. Through this statewide model, Tennessee is striving for maximum integration of mental health services into the welfare office by co-locating program administrators in the state welfare office. Family services counselors and district coordinators are co-located in the local welfare offices. Individuals with more intensive mental health needs are linked to a Medicaid-funded mental health treatment provider.
Utah. Social workers in Utah conduct clinical assessments and some short-term therapy. They also link clients to Medicaid-funded mental health treatment and to some contracted mental health treatment providers. Hiring mental health staff members as employees of the welfare agency has more solidly integrated mental health services into the workforce system that serves TANF recipients.
- Regardless of program design and administrative structure, it is a challenge to integrate mental health and employment services.
Mental health services are delivered most effectively when they are integrated into employment services. Connecting the two influences not only the process for identifying and linking clients to services but also the monitoring and tracking of client participation in mental health services. In addition, integrating services fosters strong collaborative relationships between mental health and employment staff, improving the exchange of information between agencies about mental health services and welfare requirements and ultimately benefiting clients by serving a broader range of their needs.
Regardless of the administrative structure through which mental health services are provided, however, it is a challenge to fully integrate these services into a welfare employment program. Some employment service staff are skeptical of any service that appears to detract from the immediate goal of getting clients employed. Others are simply too busy to identify and refer clients who might benefit from mental health services. The single most effective strategy for fostering integration appears to be co-locating employment services and mental health services staff. When it is not possible to do this, extra efforts are necessary to build trusting relationships between mental health and employment services staff.
Integrating mental health and employment services is especially difficult when the mental health service delivery structure is completely separate from the TANF employment structure. In Florida, for instance, mental health treatment providers rely on outreach workers to link clients to services, and they rely on district coordinators at the local level to coordinate mental health and employment services. The state has developed an expansive set of mental health services for TANF recipients and those at risk for TANF involvement. However, except in a few communities, integration of mental health and employment services is limited. Program administrators attribute the lack of integration to the fact that the workforce development system, the agency that provides employment services to welfare recipients, was not included in the initial planning stages for the mental health services. Efforts at the local level (such as co-locating mental health workers in the one-stop centers) have improved the coordination of services in some communities.
- Identifying clients in need of mental health services is more art than science.
Florida is the only study state that has developed a standardized screening tool used by outreach staff to identify clients who may need mental health services. Most of the study states rely on employment case managers to identify clients in need. Once clients are referred for services, highly skilled licensed mental health professional conduct in-depth psychosocial or clinical assessments with clients. The purpose of the assessment is to identify those for whom mental health treatment may be appropriate and to recommend the types and volume of services to include in the client's employment plan. Tennessee is the only study state that uses a standardized tool to conduct the in-depth assessment. The assessment format and process in the other study states varies by mental health counselor. When hiring mental health counselors, many program coordinators or managers place a very high value on experienced mental health workers with very strong assessment skills.
- As in many welfare-related programs, it is a challenge to get clients to participate in mental health services, although this challenge varies by site.
The initial no-show rate is estimated to be around half in most of the study states, although this varies some by site. There is no evidence to suggest that certain groups of clients are more likely than others to miss appointments. However, mental health staff suggest that no-show rates tend to be lower when the mental health counselor is co-located in the welfare office. In addition, clients who are identified through broad screenings may be less inclined to show up for the initial assessment because broad screenings may incorrectly identify clients as needing services. Mental health staff indicate that even though the initial no-show rate is high, many clients referred to mental health services over time complete the in-depth assessment with the mental health counselor.
- Use of TANF funds to pay for mental health treatment increases the flexibility in the types of nonmedical mental health services provided and allows program administrators to purchase or provide mental health treatment that focuses on employment.
In most areas and with the help of mental health staff, clients are able to access mental health treatment through the local Medicaid-funded mental health service provider. However, in some areas, there is a delay in accessing treatment and/or some limitations on the types of services provided (e.g., therapy is provided in groups rather than in individual sessions). Using TANF funds to pay for mental health therapy increases the flexibility in the types of nonmedical mental health services that can be provided. It also allows program administrators either to purchase therapy that is structured around the goal of moving welfare recipients into work and/or to create new services that work toward this goal.
- More research is needed on the effectiveness of mental health services in improving the employability and general well-being of welfare recipients.
In general, most of the study sites have not heavily emphasized evaluating the overall success of mental health services. Program administrators typically track the number of referrals and types of services used. However, few have examined how mental health services affect clients' employability or general level of well-being. Some sites have shared success stories about how clients who participated in mental health services have found and kept a job, but this evidence is anecdotal. Only Tennessee has an extensive evaluation study underway.
Evaluation of Tennessees Family Services Counseling Program
The College of Social Work at UT is evaluating the Family Services Counseling program. The evaluation has several components, including (1) an analysis of administrative data collected from the case files of mental health counselors; (2) focus groups with district coordinators; (3) mail surveys to local service providers, district coordinators, and Department of Human Services case managers; and (4) phone interviews with 400 welfare recipients who participated in mental health services.
For more information, contact: Deborah Goodwin Perkins, Ph.D., Evaluation Research Specialist, University of Tennessee; Phone: (865)974-4636; E-mail: firstname.lastname@example.org.
In the absence of evaluation research and outcome data, it is difficult to determine the success of these programs in improving the employability of welfare recipients. However, even with an evaluation, the outcomes of mental health services are not always easy to measure. Relying strictly on employment outcomes does not capture other benefits of mental health services, such as general family functioning and individual and family well-being. Still, it is important to evaluate mental health programs for welfare recipients to determine the effectiveness of these services in moving welfare recipients to work. In addition, evaluation research can reveal ways to improve the quality of mental health services in terms of addressing mental health needs that may be specific to welfare recipients.