Mental illness, substance abuse and domestic violence problems are major, sometimes insurmountable obstacles for individuals transiting from welfare to employment. When Congress enacted welfare reform in 1997, establishing Temporary Assistance to Needy Families (TANF) to replace the Aid to Families with Dependent Children (AFDC), adequate means and methods for identifying and providing necessary services and treatment to improve employment success for these individuals were not included.
In enacting this legislation, the federal government designated responsibility to each State to provide the resources and changes necessary to improve the employment rates of these "hard to serve" populations. In California, the California Work Opportunities and Responsibility for Kids Act (CalWorks) was instituted with provisions that specifically address the treatment needs of those welfare recipients facing multiple barriers to employment.
CalWORKS participants from any of the CalWORKs welfare-to-work sites in San Diego County identified as having a probable mental disorder and needing mental health, substance abuse, and or domestic violence (MH/SA/DV) services are referred to one of seven MH/SA/DV programs. These programs were implemented during fiscal years 1999-2000 and 2000-2001in various locations across San Diego County. They were funded by CalWORKs through contracts to three non-profit community-based organizations: Community Research Foundation, Mental Health Systems, Inc., and Union of Pan Asian Communities.
As programs attempt to address the major barriers to employability of mental disorders, substance abuse, and domestic violence among CalWORKs participants, measuring the outcome of these efforts is of central importance in establishing evidence-based best practices. This study was the first to compare measures of symptoms, functioning, work-related activity, and competitive employment before and after receiving MH/SA/DV services specifically designed for CalWORKs participants.
To evaluate MH/SA/DV program services in San Diego County, an investigation team was established to examine the population and conduct a preliminary outcome study. The team was comprised of research faculty from UCSD Department of Psychiatry and SDSU School of Social Work, AMHS staff, and representatives from the two organizations providing MH/SA/DV services.
The study employed a repeated measures design in which each participant serves as his or her own control. Data were collected on the six-month period before program admission and the six-month period following program admission. Participants were interviewed and completed standardized measures every two months during the six-month period following program admission.
The study had four aims:
- 1. Analyze available information and describe the population.
- 2. Assess whether measurable improvements occurred after receiving MH/SA/DV services compared to before receiving services.
- 3. Assess participant satisfaction with MH/SA/DV services received and their perception of the treatment environment.
- 4. Examine whether participant characteristics, including ethnocultural factors and service use were associated with outcome.
Six of the 7 programs participated in this study. The MH/SA/DV program operated by Union of Pan Asian Communities provides services to people of Asian decent who either do not speak English or have difficulty speaking English. As study instruments in appropriate languages were not available the UPAC program was not included in the study. A list of participating sites is included as Appendix I in the main Report.
One hundred seventy-seven people agreed to participate in the study. These 177 study participants represented 41% of eligible CalWORKs participants referred for MH/SA/DV services during the subject recruitment period. As there were only eight males (4.5%) among the 177 study participants, they were eliminated from the analyses to reduce variance and cell-size problems. The remaining 169 women in this study tended to be unmarried, disproportionately non-white compared to the general population, and depressed, with responsibility for an average of 2.2 children each. While most participants were depressed (32% Major Depression and 10% other depression), all had significant mental health-related problems. Eighty-two percent (138) also had problems related to substance abuse (44, 26%), domestic violence (39, 23%), or both (55, 32%). Their average age was 34 years (SD=9) with a range from 19 to 54. Most of them (139, 82%) completed the six-month study period.
We found improvements in a number of domains across the 6-month study period. When comparing measures before receiving services with after receiving services, findings included:
- Significant improvements in symptoms and functioning across the four assessment periods
- Significant improvements in quality of life
- African-Americans showed significant improvements in alcohol severity, while Euro-Americans and Latinas did not
- Drug severity scores improved for Euro-Americans and African-Americans, but not for Latinas
- There was a 59% reduction in the number of physical assaults among the 53 subjects reporting physical assaults at the time of admission
- Although not significant, there was a 62% reduction in the number of reported assault-related injuries among the 26 subjects reporting injuries at the time of admission
- Latinas reported the greatest reduction in physical assaults (63%)
- We found a 25% increase in the number of subjects reporting competitive employment hours
- The number of subjects reporting competitive employment hours in the highest category (greater than 229 in 60 days) more than doubled (111%) by the six month follow-up
Study participants reported generally favorable perceptions of the treatment environment and satisfaction with services received. Nearly half of the study participants (71, 49%) reported an unfavorable living situation. Eighty-six percent of study participants (126) reported they would recommend the services to a friend or family member. Eighty-four percent of participants reported getting a timely appointment. However, we found ethnic/racial group difference in perception of timely appointments (Pearson Chi Sq.=7.27, p=.03). Fewer African Americans (23, 70%) than Euro-Americans (42, 89%) and Latinas (43, 90%) agreed that they were able to get an appointment as soon as needed. Similarly, fewer African Americans (26, 77%) than Euro-Americans (51, 96%) and Latinas (48, 94%) reported that clinicians explained things in a way they understood (Pearson Chi Sq.=10.66, p=.005). African Americans more frequently reported not getting their needs met (9, 26%) compared to Euro-Americans (4, 8%) and Latinas (4, 8%).
African Americans appeared to have improved outcomes when assessed by alcohol and drug abuse severity, overall functioning, competitive employment, decrease in reliance on TANF, and lower rates of physical injury among persons reporting domestic abuse prior to their enrollment in the program. However, at 6-month follow-up, the African American women reported fewer overall hours in work activity and no improvement in quality of life. At the 60-day follow-up assessment there were more reports of dissatisfaction with timeliness of appointments with clinicians, more reports of clinicians not explaining things clearly, and fewer reports of participation in more than one type of service among the African Americans clients. Generally, the outcomes for Latinas tended to parallel those of the Euro-American women. This may reflect a high acculturation level for Latinas as eligibility criteria for this study required English speaking fluency and legal immigration status.
This study has a number of limitations that should be kept in mind when interpreting results. The study was observational and as such involved no random assignment to treatment or control group. As a result we cannot conclude that improvements were caused by the services. Also, while these findings reflect the outcomes for these participants, they may not apply to all CalWORKs participants.
We also relied on self-report information in a number of important areas such as work-related activity, competitive employment, domestic violence, and substance abuse.
The actual number of hours reported in the areas of work-related activity and competitive employment tended to be low. For example," baby or child sitting" fits the definition for competitive employment but yields low pay and usually does not result in self-sufficiency. On the other hand, childcare is important as all study participants had children (mean of 2.2 children each) and could not work without someone to take care of them.
This study was implemented during the first year of the implementation of the six countywide CalWORKs MH/SA/DV service programs. This was not optimal timing and both clinical and research staff reported difficulties including failure to inform and refer eligible CalWORKs participants to research staff to explain the study and invite participation.
Despite the limitations, this preliminary study suggests an association may exist between the MH/SU/DV services provided and improvements in symptoms, functioning, quality of life, and employment. However, as these results are not conclusive, follow-up studies in multiple counties are needed to ascertain whether these findings can be replicated and to add to the literature on best practices for helping CalWORKs participants with special needs make a successful transition from welfare to work.