Providing Mental Health Services to TANF Recipients: Program Design Choices and Implementation Challenges in Four States. Linking Clients to Existing Community Mental Health Treatment Services


In Florida and Oregon, the primary purpose of mental health services is to identify clients with mental health conditions through an assessment and link them to mental health treatment providers within the community. In Utah and Tennessee, mental health counselors provide short-term therapy to some clients and link others to mental health treatment agencies. However, mental health counselors who have high caseloads or are working with clients with extensive mental health needs typically link clients to other treatment providers. The complexity of the process for linking clients to mental health services depends on the availability and structure of mental health services in the local community; the process is often streamlined when the mental health counselor is an employee of the agency to which the client is referred.

One of the primary challenges faced by mental health counselors in linking clients to services is obtaining access to treatment in a timely manner. The wait time for treatment is particularly problematic under managed care arrangements. In some sites, clients are required to wait up to a month before they see a mental health counselor, and sometimes even longer to see a psychiatrist. The ability to access treatment in a timely manner appears to be worse in the urban than in the rural areas. According to mental health professionals, as the wait for treatment increases, so does the likelihood that the client will no longer participate in treatment. Mental health counselors often provide short-term mental health treatment until a mental health treatment provider can see the client.

Screening and Assessment Tools or Techniques
Used to Identify TANF Recipients in Need of Mental Health Services

Mental health staff use a variety of tools and techniques to screen and/or assess clients. The study sites use three such tools to screen and assess welfare recipients for mental health conditions:

Standardized instrument. Standardized screening and assessment tools are used statewide in Florida and Tennessee. Although these tools vary in length, they cover a wide variety of mental health and other conditions. Florida outreach workers use a 32-item screening tool that focuses exclusively on substance abuse and mental health. Tennessee is the only study state that has created a standardized, general assessment tool for use by licensed mental health professionals. It covers a range of topics such as source of stress, current functioning, health, and history of counseling. Mental health counselors in Tennessee also use the following, more specific tools to assess mental health needs and related needs: a Learning Needs Screening, Drug and Alcohol Referral Screening, Family Violence Screening, and a Functional Assessment screening tool. The advantage of using a standardized assessment tool is that it creates uniformity in the program and levels out the variation among workers in screening and assessment skills. The drawback is that it is difficult to adjust or tailor the instrument to client needs; as a result, some key information may be overlooked.

Clinical inventories. Many mental health counselors who do not use a standardized assessment tool use some type of clinical inventory in combination with their own clinical skills to conduct client assessments. Clinical inventories detect clinical depression, generalized anxiety, personality disorders, and suicide risk, among other disorders. Clinical inventories can be administered differently depending on the mental health counselor. Some mental health counselors use specific inventories depending on what mental health conditions they sense may be an issue for clients. For example, if a social worker suspects that a client may be depressed, he/she would use a depression scale to explore this possibility in greater depth, but the depression scale would not be administered to every client. Other mental health professionals use the same inventories for all clients. The advantage of clinical inventories is that they are a valid, reliable way to identify specific mental health conditions. The drawback is that they tend to be long, and staff may need additional training to score and interpret results.

Clinical expertise. Many of the mental health professionals we interviewed rely on their experience to guide the types of questions they ask a client during an assessment. They may or may not include clinical inventories to augment this expertise. The advantage of clinical expertise is that it allows the mental health counselor to individualize the assessment. The challenge is that it may be costly or difficult to hire licensed mental health staff with this expertise.

Overall, there are two primary advantages to having mental health counselors link clients to services: clients have someone to guide them through the process of accessing mental health treatment, and according to some workers, counselors can actually help clients access treatment more quickly, especially when it is provided through Medicaid providers. One of the challenges for mental health counselors is that their role requires them to be aware of different treatment options in the community.

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