Even the most well-designed mental health services are successful only insofar as clients participate in them initally and on an ongoing basis. For program staff, the challenge is therefore to encourage participation. In most of the study sites, participation in mental health services is voluntary, but it becomes mandatory if the client includes it as an activity in his/her employment plan. Family services counselors in Tennessee estimate that the initial no-show rate for clients referred to their agency is about 50 percent but that more clients participate over time. Statewide, two-thirds of clients who have been referred to the program have completed the initial assessment. Other states reported similar participation rates. Client participation rates in mental health services vary by local office and often are influenced by such factors as how quickly clients are linked to services, the accessibility of services, stigma associated with participation in mental health treatment, and the relationships between clients and employment and mental health staff. The following are some of the strategies that successfully increased client participation in mental health services in the study sites:
Addressing the stigma associated with mental health treatment. The stigma associated with mental illness and treatment may deter some employment case managers from talking with clients about mental health services and referring them to the program. The stigma may also make clients less willing to participate in mental health services. To address the stigma and thus encourage greater participation in mental health services, the study sites sought ways to educate clients and case managers about mental health conditions and services.
Mental health staff in some sites talk candidly with clients and employment case managers about mental health conditions. For instance, mental health counselors in the St. John's and Albina welfare offices in Portland, Oregon, talk with clients for typically 90 minutes during orientation about the signs of a mental health condition, how mental health problems may affect their behavior, and ways to treat mental health conditions (such as exercise, medication, mental health therapy, etc.). Social workers in Utah provide in-service training to case managers and discuss mental health treatment with individual managers to make them more knowledgeable about and comfortable with mental health services. Partly to "de-mystify" the treatment process, mental health staff in Florida replaced words such as "treatment" with "life-management help."
Offering flexibility in service location. Tennessee and some welfare offices in Utah are flexible in where they conduct client assessments and provide short-term mental health treatment. Services are provided at the welfare office, in the client's home, at a community-based agency, or at any other location convenient to the client. According to mental health staff in these states, providing services in the welfare office or at locations other than the local mental health agency makes clients less apprehensive about participating and improves access to treatment, especially in rural areas.
Providing supportive services such as transportation and child care while delivering mental health treatment. All of the study states provide child care and transportation assistance for clients participating in mental health services when those services are included as an activity in employment plans. Without supportive services, some clients may not be able to take advantage of the mental health services available to them.
Modifying existing policies or creating new ones to ensure that they support clients participating in mental health services. Flexibility in TANF work requirements (volume and types of activities) appears to encourage both employment counselors to include mental health treatment in an employment plan and clients to participate in mental health services. In Florida, where no more than five hours of mental health services per week can count toward the work requirement, few employment case managers include mental health services in employment plans. The other study states (Oregon, Tennessee, and Utah) do not restrict the number of hours or types of mental health services that count toward the work requirement. Instead, this decision is left to the employment case manager or mental health counselor. These mental health counselors suggested that the modified employment plan encourages clients to participate in mental health services.
Another policy that may influence participation in mental health treatment is extending or temporarily suspending time limits for families in treatment. Utah extends the time limit for families facing severe personal and family challenges who are participating in mental health treatment. In Tennessee, the month of assessment does not count toward the time limit, and families with severe mental health conditions may request an "interruption," or a temporary stop in the "clock" ticking toward the time limit. Currently, about half of the clients participating in mental health treatment have been granted such interruptions.
In most states, clients who include mental health services in their employment plan are subject to grant sanctions if they do not participate in mental health program activities. However, sanctions are not used to force clients to participate in mental health treatment against their will. In general, participation in mental health services is voluntary, and clients may also choose to include treatment in their employment plan.
Providing services that consider and address cultural differences. An ongoing challenge for program managers and mental health staff is to provide mental health services that are sensitive to cultural and language differences. Mental health staff in the study states identified three primary ways in which cultural and language differences may influence mental health service delivery. First, if ethnic and racial differences are not considered by counselors, they may act as a wedge in the relationship between the client and mental health counselor, eroding the trust that is central to this relationship. In the absence of this trust, the effectiveness of mental health services may be reduced. Second, bilingual children are sometimes expected to serve as translators between the mental health counselor and a parent or parents. Children cast in this role are exposed to life stressors and personal details of the parents' lives otherwise "reserved for" adults. The result, according to mental health staff, may be an emotionally unhealthy environment for the children. Third, cultural differences in how mental illness and mental health treatment are perceived can influence the level of comfort in participating in mental health services and therefore the decision to participate at all.
Some of the study sites have attempted to address these cultural and language differences. For example, in Belle Glade, Florida, paraprofessionals from the community are paired with licensed mental health counselors to facilitate the relationship between the client and mental health counselor. For instance, bilingual paraprofessionals may translate in counseling sessions, build relationships with clients in the community, and link clients to mental health services. In Miami, program administrators at contracting agencies have hired mental health outreach workers and counselors who are racially and ethnically similar to communities in which they work.
Protecting client confidentiality. According to mental health staff, protecting the confidentiality of clients creates a trusting relationship, which encourages client to participate in mental health services. Mental health counselors take several precautions to protect the confidentiality of clients. In general, mental health counselors begin the process of working with clients by clearly explaining the steps they take to protect the confidentiality of clients' information. Counselors then ask clients to sign release-of-information forms allowing the exchange of information between mental health counselors and other agencies. In some areas, mental health counselors store all client records in a locked filing cabinet.