This paper reports findings of a study of female Temporary Aid to Needy Families (TANF) and non-recipients ages 18-40, receiving behavioral health services in the rural Southwest in 1998-9. TANF recipients (N = 119) were more likely to be seriously mentally ill than non-recipients (N = 370), suggesting that a subgroup of TANF recipients may face significant barriers to employment given the new TANF regulations. The author argues that responsibility for recognizing the needs of TANF recipients for behavioral health services is shared by both the public welfare and behavioral health systems. Suggestions for meeting this challenge in both systems are discussed

Stromwall, Layne K.

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The Journal of Sociology & Social WelfareVolume 28Issue 3 September - Special Issue: Evaluation of TANF Article 8September 2001Mental Health Needs of TANF RecipientsLayne K. StromwallArizona State UniversityFollow this and additional works at: https://scholarworks.wmich.edu/jsswPart of the Clinical and Medical Social Work Commons, Social Welfare Commons, and the SocialWork CommonsThis Article is brought to you for free and open access by the Social Work atScholarWorks at WMU. For more information, please contactmaira.bundza@wmich.edu.Recommended CitationStromwall, Layne K. (2001) "Mental Health Needs of TANF Recipients," The Journal of Sociology & Social Welfare: Vol. 28 : Iss. 3 ,Article 8.Available at: https://scholarworks.wmich.edu/jssw/vol28/iss3/8Mental Health Needs of TANF RecipientsLAYNE K. STROMWALLArizona State UniversitySchool of Social WorkThis paper reports findings of a study of female Temporary Aid to NeedyFamilies (TANF) and non-recipients ages 18-40, receiving behavioralhealth services in the rural Southwest in 1998-9. TANF recipients (N =119) were more likely to be seriously mentally ill than non-recipients(N = 370), suggesting that a subgroup of TANF recipients may facesignificant barriers to employment given the new TANF regulations.The author argues that responsibility for recognizing the needs of TANFrecipients for behavioral health services is shared by both the public welfareand behavioral health systems. Suggestions for meeting this challenge inboth systems are discussed.IntroductionMany low-income, parenting women have historically reliedon public welfare supports as a primary source of income forthemselves and their children. With the 1996 creation of Tempo-rary Aid to Needy Families (TANF), more than four million fami-lies experienced a significant change in the provision of federally-funded public income supports for low income parents and chil-dren (Administration for Children and Families, 2000). Amongthe most significant provisions of the new TANF program weretime limits for financial assistance and stricter work requirements.As a result of these policy changes, many aid recipients mustnow work or attend work training classes. If recipients do notcomply with these requirements, they receive progressive sanc-tions, beginning with a reduction of their monthly benefits. Ifnoncompliance continues, their monthly grant ends.Journal of Sociology and Social Welfare, September, 2001, Volume XXVIII, Number 3129130 Journal of Sociology & Social WelfareWomen with psychiatric disorders receiving TANF must alsocomply with these new regulations. TANF recipients with psychi-atric disorders experience ongoing psychiatric symptoms or psy-chotropic medication side effects that impact their ability to gainor maintain employment. For example, a woman experiencingan episode of major depression or the depressive cycle of bipolardisorder has sleep disturbances, early morning waking and ac-companying sleep deprivation, or difficulty arising. Eating pat-terns change, resulting in significant weight loss or weight gain.The ability to concentrate lessens, and overwhelming feelings ofsadness or anger intrude upon daily activities. If she is receivingtreatment, she must weigh the impact of potential medicationside effects on her ability to function in the workplace and athome. Treatment in the poorly funded public mental health sys-tem may require the use of drug formularies that do not includenewer, more expensive psychotropic medications with fewer sideeffects. Medication side effects can impact the ability to maintainemployment when drug treatment makes early morning risingdifficult.Working parents with psychiatric disorders are not free of theadditional burdens faced by all working parents. Parents mustlocate, secure and pay for quality child care and transportationservices, further complicating the daily lives of women alreadystruggling to manage their psychiatric symptoms while parent-ing. These additional burdens may be viewed as a source oflife stress (Brown & Moran, 1997; Gerdes, 1997) associated withincreased mental health needs of recipients already at risk due totheir socioeconomic status.Poverty itself is associated with increased risk for and preva-lence of psychiatric disorders (Bruce, Takeuchi, & Leaf, 1991).Lower socioeconomic status (SES) has been found to have a neg-ative impact on health generally, including mental health (An-derson & Armstead, 1995; Link & Phelan, 1995) and subsequentmental health outcomes (Saraceno & Barbui, 1997). Poverty isalso associated with other adverse life conditions that influencemental health and parenting (McLoyd & Wilson, 1990). For ex-ample, poverty status increases the risk of stressful life eventsassociated with the development and exacerbation of psychiatricMental Health Needs 131disorders, particularly depression (Steele, 1978; Craft, Johnson &Ortega, 1998). One group at particular risk is low income motherswho receive public welfare assistance. A study that reviewedTANF assessment records in Denver (East, 1999) concluded thatmany TANF recipients had symptoms of severe and persistentpsychiatric disorders that had neither been properly diagnosednor treated.Experiences of parents in the mental health system. TANF recipi-ents' eligibility for mental health services occurs through the pub-lic mental health system. To obtain service, they must negotiatea separate service system from the public welfare system. Unlikethe public welfare system, which focuses on family functioningand needs, the mental health service system treats the individualconsumer's psychiatric disorder, often with insufficient atten-tion to consumers' social environment, including the demandsand supports of family, social network, and other organizationalstructures (Stromwall & Robinson, 1998). For many seriouslymentally ill women, their parent role is identified as a primarysource of life satisfaction (Mowbray, Schwartz, & Bybee, 2000; Ze-mencuk, Rogosch, & Mowbray, 1995; Nicholson & Blanch, 1995;Mowbray, Oyserman, & Zemencuk, 1995.) However, seriouslymentally ill women who are actively parenting report a lack ofsupport from the mental health system for their existing rolesas parents (Zemencuk, Rogosch, & Mowbray, 1995; Mowbray,Oyserman, & Zemencuk, 1995; Apfel & Handel, 1993; Bachrach,1988), including an attention to income supports. Despite a num-ber of recent studies addressing the health and social conditionsof mothers with psychiatric disorders (e.g., Coverdale & Aruffo,1989; Mowbray, Schwartz, & Bybee, 2000), little information isavailable about the added impact of their status as public welfarerecipients, a reality for many parents with serious mental illness.For example, in a Michigan study of mothers with serious mentalillness, 41 % of the mothers studied were recipients of publicwelfare assistance (Mowbray, Schwartz, & Bybee, 2000).The purpose of the current study is to develop a profile offemale TANF recipients receiving behavioral health services. Itcompares the clinical and demographic characteristics of TANFrecipients and non-recipients in a sample of adult women age 40132 Journal of Sociology & Social Welfareand under receiving behavioral health services in an ethnicallydiverse, rural Southwestern catchment area.MethodsThe study used data collected from case records that includeddemographic, clinical, and service use information about mem-bers enrolled in a regional managed behavioral health system in asouthwestern state during 1998-1999. Local programs contractedthrough the managed care organization reported information oneach member served during the year. The sample for this studyincluded all female members ages 18-40 who received treatmentduring the six-month study period (N = 489).The study compared clinical status and demographic char-acteristics of two groups, TANF recipients (N = 119) and non-recipients (N = 370). Demographic characteristics related to pov-erty were obtained by the individual's self-report. The woman'sclinical status as seriously mentally ill was rated by a licensedpsychiatrist.ResultsTable 1 shows selected demographic and clinical characteris-tics of TANF recipients and non-recipients. TANF recipients weremore likely to be women of color (African American, Latina orNative American) than non-recipients, Pearson chi square (1, N =489) = 7.312, p = 005. On other variables, including age, householdincome, household size, and years of education, the groups werevirtually identical.A two-way contingency analysis was conducted to evaluatewhether TANF recipients receiving behavioral health serviceswere more likely to be seriously mentally ill than non-recipients.The two variables were status as a TANF recipient and status asseriously mentally ill. TANF recipient and SMI status were foundto be significantly related, Pearson chi-square (1, N = 489) = 5.017,p = .019.DiscussionThe major finding of this study is that TANF recipients receiv-ing behavioral health services report significantly lower function-Mental Health NeedsTable 1Demographic and clinical characteristics of TANFnon-recipients (N = 489)TANF recipientsrecipients andNon recipientsTotalEthnicityCaucasianAfrican-AmericanLatinaNative AmericanSeriously mentally illYesNoAge (mean)Household income (mean)(in thousands)Household size (mean)Years of education368231.34 (SD 6.56)9.95 (SD 8.72)2.90 (SD 1.98)8.98 (SD 4.07)7729231.03 (SD 6.68)9.35 (SD 7.98)3.06 (SD 1.91)9.05 (SD 4.13)ing and more mental health distress than non-recipients. Desig-nation as seriously mentally ill (SMI) requires an ongoing majormental illness as well as significantly reduced ability to functionacross a variety of life domains. Unlike some of the public's per-ception of welfare recipients, these TANF recipients who receivea designation as SMI are not women who have manufactured amental illness to avoid work. Instead, they are an important sub-groups of TANF recipients-seriously mentally ill women withchildren-whose disability presents a barrier to the employmentrequirements of TANE Before the TANF policy changes, seriouslymentally ill women with children could receive public welfarewithout the need to report or even diagnose their psychiatricdisability. Now, TANF requirements place additional stress onwomen with existing psychiatric disorders that need to be under-stood by the public welfare system.The results of the current study support the benefits of atten-tion to the social environment, particularly that surrounding thereceipt and negotiation of income supports for parenting women134 Journal of Sociology & Social Welfarewith ongoing psychiatric disorders. While clinical diagnosis andtreatment issues remain of prime importance, it may be thatknowledge of the woman's status as a TANF recipient can as-sist in appropriate treatment planning and in more expeditiousalleviation of these parenting women's perceived distress. Thecurrent study is limited by its focus on women already receivingmental health treatment. Thus, the mental health status of TANFrecipients as a group cannot be determined from this study. Thestudy by East (1999), however, provides evidence that there maybe unmet behavioral health needs in the larger group.Both the public welfare and behavioral health systems mustrecognize the needs of TANF recipients for behavioral health ser-vices. Public welfare workers are in need of extensive educationabout the dynamics of psychiatric disorders. Behavioral healthpersonnel should actively advocate for and provide this infor-mation. The public welfare system should screen applicants fordepression and other mental health conditions and make timelyreferrals to effective behavioral health treatment. Further, publicwelfare workers need to be educated so they can recognize majorsymptoms of psychiatric disorders as such, instead of interpret-ing them as deficits in motivation or attempts to circumvent thesystem. They need to understand the implications of mood andother psychiatric disorders for recipients' ability to comply withcomplex TANF program requirements and to effectively seekemployment. TANF recipients should be assisted in obtainingbehavioral health treatment through active facilitation of the re-ferral process.The public welfare system might also make greater use of re-ferral to disability income supports. Caseload reduction, the pub-lic welfare system outcome goal, can be accomplished throughalternative means than employment for recipients whose psychi-atric disorders prove to be a current barrier. Appropriate diagno-sis and referral for disability income may be an alternative. Whilea TANF recipient may not be eligible for Social Security DisabilityIncome (SSDI) because she has not earned sufficient work credits,she may be eligible for Supplemental Security Income (SSI) basedon her income and diagnosis of psychiatric disorder. When theparent qualifies for disability income, the children may continueMental Health Needs 135to be eligible for TANF payments based on overall family income.Thus, states can meet their goals of caseload reduction at the sametime that families slightly improve their financial circumstancesby combining disability income for the parent with TANF for thechildren.Those referring TANF recipients for disability income must beaware that this application system is complex and can be lengthy(Estroff, Patrick, Zimmer & Lachicotte, 1997). Often applicantsrequire assistance in preparing correct and persuasive applica-tions. They may need assistance in the appeals process if an initialapplication is rejected. The application process itself can result inadditional stress on the applicant and her family.However, the TANF recipient with a psychiatric disorder isalready subject to additional stress resulting from TANF work anddocumentation requirements. Results may include the worseningof psychiatric symptoms or even onset of a secondary depres-sive disorder. In order to be responsive to this source of stress,clinicians need to be aware that it exists. Behavioral healthcareorganizations should, at minimum, collect information about theconsumer's social environment and assure that the information isreadily available to the clinician. Information should include thefinancial supports and family situation of the consumer. Clini-cians should also provide supportive counseling aimed at copingwith the stress of adhering to TANF regulations. These stressesinclude the need to function effectively as trainees or employeesand working parents, at the same time they must manage thesymptoms of their ongoing psychiatric disorder.ConclusionsThis study has demonstrated that female TANF recipientsreceiving behavioral health services are significantly more likelyto be seriously mentally ill than non-recipients. As a response,behavioral health practitioners should be aware of the interplayof an important social system, that of income supports, on thedaily lives of TANF recipients. They must take steps to ascertainunmet behavioral health needs among this group, and educatecolleagues in the public welfare system about needs and charac-teristics of recipients with psychiatric disorders.136 Journal of Sociology & Social WelfareReferencesAdministration for Children and Families: Temporary Assistance for NeedyFamilies (TANF) Program, 2000. First Annual Report to Congress,http://www.acf.dhhs.govlnewslwelfare/congresslindex.htmAnderson, N. 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(1998). Rural-urban women's experienceof symptoms of depression related to economic hardship. Journal of Women& Aging, 10(3): 3-18, 1998.East, J. F. (1999). Hidden barriers to services for women in welfare reform.Families in Society, 80, 295-304.Estroff, S. E., Patrick, D. L., Zimmer, C. R., & Lachicotte, W. S. (1997). Pathwaysto disability income among persons with severe, persistent psychiatricdisorders. Milbank Quarterly, 75, 495-531.Gerdes, K. (1997) Long-term AFDC mothers and posttraumatic stress syndrome:Is there a connection? Affilia, 12,359-367.Link, B.G., & Phelan, J. (1995). Social conditions as fundamental causes ofdisease. Journal of Health and Social Behavior (Extra Issue) 80-94.McLoyd V.C., & Wilson L. (1990). Maternal behavior, social support and eco-nomic conditions as predictors of distress in children. New Directions forChild Development, 46, 49-69.Mowbray, C.T., Oyserman, D, & Zemencuk, J. (1995). 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Mental Health Needs of TANF Recipients

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Mental Health Needs of TANF Recipients

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