Providing Mental Health Services to TANF Recipients: Program Design Choices and Implementation Challenges in Four States. Referrals by Employment Case Managers


Most programs rely heavily on employment case managers to identify clients in need of assistance and to refer them to mental health services. Employment case managers may be trained to identify mental health conditions as part of their own orientation when they are hired, during in-service meetings or case staffings, or individually by mental health counselors.

According to employment case managers, clients vary in how and when they disclose a mental health condition, but whether they even do so depends on the level of trust between the case manager and the client. This principle of trust is also critical to getting a client into treatment insofar as it also operates in the relationship between the employment case manager and the mental health counselor. Case managers report that they are more likely to make a referral if they trust the mental health counselors and believe the services they provide will benefit the client. In some local offices, a few case managers referred a large proportion of clients to mental health services. In other offices, the number of referrals was more evenly represented across case managers.

To find out more about how clients needing assistance are identified, we asked employment case managers about which behaviors or characteristics acted as a red flag for a mental health condition. Employment case managers cited extreme displays of emotion (such as anger or crying), no emotion at all (flat demeanor), lack of concentration or focus, unkempt appearance, children with behavioral problems, lack of participation or reluctance to participate in program activities, recent eviction from public housing, and making decisions not based on current conditions or with an eye toward the future. In general, most of the employment case managers we interviewed were able to describe some client behaviors and characteristics that signaled a mental health condition.

The advantage of relying on employment case managers to make the referral is that they have the most contact with clients and can therefore more accurately identify those who may have mental health needs. The drawback is that some employment case managers may be uncomfortable talking about mental health issues with clients and so may not refer clients to mental health services. For this reason, it is important to use a variety of approaches to link clients to mental health services.

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