Dear Sir/Madam:

The American Psychological Association (APA) is pleased to submit comments on the reauthorization of the Temporary Assistance for Needy Families (TANF) Program Authority in response to the Administration for Children and Families’ (ACF) solicitation that appeared in the October 17, 2001, issue of the Federal Register. APA is the largest scientific and professional organization representing psychology, and includes 155,000 researchers, educators, clinicians, consultants, and students. APA's mission is to advance psychology as a science, as a profession, and as a means of promoting health and human welfare.

APA's commitment to efforts to reduce poverty and increase opportunities for self-sufficiency among the nation’s poor can be seen in the attached policy statement on poverty endorsed by our Council of Representatives in August of 2000 and in many of our association initiatives, including the attached 1998 report, "Making ‘Welfare to Work’ Really Work." Our suggested changes to the TANF program presented here are derived from the social sciences research literature and focus on women who face multiple barriers to self-sufficiency, such as mental health, substance abuse, and domestic violence problems.

The 1996 Personal Responsibility and Work Reconciliation Opportunity Act (PRWORA) established the Temporary Assistance for Needy Families (TANF) block grant, with the primary focus of moving recipients from welfare to work. Strict work requirements, sanctions and lifetime limits have dramatically reduced the number of recipients on the welfare rolls, consequently leaving behind those with serious and multiple barriers to employment. However, the TANF program has failed to adequately address the prevalence of mental health and substance abuse problems among recipients and its impact on their ability to make a successful (and permanent) transition into the workforce. Factors such as stigmatization, lack of appropriate screening mechanisms, underreporting, and lack of reporting by social service agencies have masked the enormity of this problem.

When TANF is considered by Congress for reauthorization in 2002, APA believes that it is imperative to address the need for adequate mental health, substance abuse, and domestic violence screening, assessment and treatment for TANF recipients. Therefore, we present the following issues and recommendations:

• Scientific evidence and clinical experience demonstrate that substance abuse treatment and prevention are effective (American Psychological Association, Task Force on Women, Poverty and Public Assistance, 1998). Of particular significance, the provision of psychological services to high frequency Medicaid users has been associated with a nearly 40% reduction in their Medicaid utilization.
• One of the most prevalent and disabling mental health problems is depression. Women experience depression at roughly twice the rate of men, and the cost of depression is very high. Total costs have been estimated at $43 billion to $53 billion in the United States in 1990 (Greenberg et al., 1996). Employers bear a large part of this cost. Depression among women in the workplace has been estimated to cost $16.8 billion in 1990 (Greenberg et al., 1996). Absenteeism is a major contributor to the cost, especially for depressed women.
• Mental health problems represent significant obstacles to employment. Welfare recipients with mental health problems are more likely to require public assistance, and if they are not identified and treated, they are more likely to continue to require public assistance over a long period of time. A recent U.S. Department of Health and Human Services report (Johnson & Meckstroth, 1998) quotes national estimates of up to 28% of welfare recipients with mental health problems, and state and local estimates of up to 39%.
• Substance abuse problems can severely impair an individual's ability to get and keep a job, and children of substance abusers are more likely to require long term public assistance (Johnson & Meckstroth, 1998). On the other hand, treatment works. For example, in Oregon, calculations of treatment costs indicated that for every dollar spent on treatment, $5.60 was saved on other social services; in California, for every dollar spent on treatment, $2.50 was saved on other social services (cited in Johnson & Meckstroth, 1998).

Mental health problems powerfully affect the productivity and quality of life of millions of Americans. Women with mental health and substance abuse problems are more likely to be poor. At neither federal nor state levels are mental health problems recognized as the serious public health concerns they are.

It is also true that poverty increases women's risk of these problems. According to some researchers (e.g., Eaton & Muntaner, 1999), respondents whose income was less than $17,500 were 16 times as likely to be diagnosed with a major depressive disorder as those whose household income was over $35,000.

• As states contract out Medicaid health coverage to managed care organizations, they need to develop and offer programs to educate both caseworkers and the women on welfare who are their clients about how best to navigate managed care, with the goal of obtaining the best quality care possible (Rice, 1998).
• Federal and state agencies should fund more research on the prevalence, treatment options, and treatment outcomes of mental health and substance abuse problems for women on welfare (Rice, 1998).

As noted earlier, poor women experience depression, anxiety disorders, panic disorders, post-traumatic stress disorder, and other mental health problems at higher rates than women in the general population, and these problems can interfere with their ability to hold onto a job. However, because neither the women themselves nor the caseworkers or other service providers may recognize their symptoms as symptoms of mental health disorders, these women may function at low levels for years without being identified as in need of mental health treatment.

According to a recent report (U.S. General Accounting Office, 2001), some states and localities relied primarily on feedback from the job market to identify recipients who had barriers to employment, such as mental health problems. Most counties (77%) reported that they relied on self-disclosure by the recipients. The report concluded that relying on self-disclosure would not uncover all impairments, for example, problems of which the recipients are unaware.

• It is not reasonable to expect caseworkers to serve as mental health care providers. However, rudimentary training in recognizing some basic signs and symptoms, along with the resources to refer individuals for more complete assessment and/or treatment, will more effectively identify women who with some treatment may be better able to live a healthier, more productive life, including moving from welfare into the workplace.
• States and localities should adopt approved screening tools that identify mental health and substance abuse problems that interfere with success in the workplace, and ensure that appropriately trained professionals, preferably as part of a multidisciplinary team, administer them.
• In welfare offices, job training offices, child support offices, housing offices, primary health care provider’s offices, and hospital emergency departments, make available to all clients and patients printed information identifying the signs and symptoms of depression, post-traumatic stress, panic disorder, anxiety disorder, and other mental health problems, and ways to get help, so individuals are able to self-identify and perhaps seek treatment.
• In addition to screening tools, better integration of services, comprehensive case management, and procedures to allow immediate assessment and treatment will help identify these women with mental health and substance abuse problems and make treatment available to them (Kaplan, 1998).

Women who have experienced intimate violence, either as children or in their adult lives, frequently suffer from low self-esteem, post-traumatic stress, substance abuse, and homelessness, and they are more likely to be unemployed and have high rates of job turnover. Failure to identify and address issues of violence leave victims at greater risk both for more violence and for long term poverty (Johnson & Meckstroth, 1998). Because disclosing violence in their lives is risky for low income women, accurate assessments of the prevalence of violence are difficult to get. Johnson and Meckstroth's report for the U.S. Department of Health and Human Services provides estimates that up to 50% to 65% of welfare recipients have experienced intimate violence in their lives.

The Family Violence Option (FVO) is intended to help domestic violence victims and survivors move from welfare to work. States have the option of implementing the FVO as part of the 20% caseload exemption for welfare recipients experiencing personal and family challenges. The FVO allows states to screen welfare participants for domestic violence victimization, provide referrals to specialized services, and provide good cause waivers from the five-year lifetime limit on TANF assistance and mandatory work requirements. Only 36 states and the District of Columbia have adopted all or part of it, and two states have made it an option at the county level (Family Violence Prevention Fund, 2001). In addition, indications are that the FVO as currently implemented is not effectively in identifying and helping the women for whom it was intended.

• States adopt the Family Violence Option, and provide exemptions to and extensions of time limits to all women identified as victims of past, recent and/or current abuse.
• The recommendations related to screening and identification of TANF recipients for mental health problems and substance abuse (outlined above) apply as well to screening for histories of violence and abuse, that is, caseworkers, primary care physicians, providers in family planning clinics, providers in pediatrician's offices, emergency room personnel, child care providers, child support enforcement staff, housing office staff, employment office staff, and police officers should receive additional education and training to recognize signs of abuse. Information on the prevalence of violence among women and the connection between the experience of violence and current mental health and substance abuse problems, as well as how to get help, should be made available to women in all these settings, so they are able to self-identify.
• Better integration of services and comprehensive case management are needed to better coordinate care and connect women with the services they need.

Women identified as needing mental health and/or treatment for substance abuse face intimidating obstacles. The majority of these women have numerous financial, legal and social problems. They suffer from issues of poor housing, child care, transportation, and medical assistance. Only after these critical needs are met can these women focus on their mental health and substance abuse problem. Providing them with information about treatment is not enough. Getting poor women into treatment requires extensive outreach. In addition, for women in abusive situations, an abusive partner may feel threatened by a woman's help seeking, proving dangerous for the woman herself.

• Establish mental health treatment centers in locations that are convenient to and frequented by poor women, including family planning clinics and welfare offices.
• Provide vouchers for transportation and childcare to enable mothers to participate in the treatment programs.
• Integrate mental health and substance treatment resources and services into employment efforts.

The vast majority of recipients of public assistance are poor women, including women of color, and their children. Treatment models and facilities need to take into account the special needs of women. Women, who frequently bear the burden of child and elder care must have these critical issues addressed prior to entering treatment.

National Institute on Drug Abuse (NIDA) research indicates that drug abuse progresses differently, has different consequences, and therefore, requires different preventive and treatment approaches for women and men (Wetherington & Roman, 1998). For instance, numerous studies have documented a "telescoping" phenomenon in which female substance abusers experience a more rapid progression of illness and a more rapid onset of substance-related physical and social consequences than their male counterparts.

• Effective mental health and substance abuse treatment for women needs to accommodate differences in patterns of substance abuse by women, the impact of violent assault and sexual abuse on the mental health of women, issues of employment and other discrimination based on such factors as gender, race, disability, and sexual orientation.
• Most substance abuse facilities are inpatient treatment facilities. Inpatient or residential treatment programs for women must be structured to meet the needs of the women and their dependant children, including childcare and other on-site childcare.

Mental health and substance abuse problems often occur together. Up to half of those individuals with serious mental illness also have substance abuse problems, as noted in the Surgeon General's Report on Mental Health (U.S. Department of Health and Human Services, 1999). If these co-occurring problems are treated together, treatment is more effective, consistency and continuity of care is better assured, hospitalization is reduced, and social functioning is improved.

• Treatment programs for mental health and substance abuse need to be better coordinated. Poor women need a single point of entry into the service delivery system, and more comprehensive information on accessing these programs.
• Caseworkers need training to refer to these programs and information on all options available.

Past performance expectations for caseworkers are based on experience with a very different population of clients. As women move off TANF and into the workplace, the remaining population, those still receiving TANF, changes fundamentally and inexorably. States are experiencing these changes now which will likely result in overwhelmed caseworkers and poorer services will be provided to needier people.

• Caseload expectations must decrease to ensure that minimal standards are met in the provision of services to clients with serious and multiple barriers to employment. Caseload expectations must be at appropriate levels, which allow caseworkers to adequately assess needs, refer clients for appropriate help, including treatment, and coordinate services and other actions as needed.

Combining work and family responsibilities is one of the number one stressors for working women (Swanson, Piotrkowski, Keita, & Becker, 1997). This problem is of particular magnitude for women on welfare who often have fewer resources. Flexible work hours and flexible employers are critical. Women on welfare with mental health problems and substance abuse problems must be able to make treatment appointments -- sometimes during working hours -- and to meet welfare program activity requirements.

• Flexible employers and flexible hours will increase productivity and eradicate the need for missed days and hours at work. Potential employers should be apprised of the importance of flexible hours, and welfare recipients should not be required to take jobs with nonflexible hours. It would also be helpful for time spent receiving mental health and substance abuse treatment to be counted towards hours at work.
• Transportation and quality child care will also help in reducing the number of stressors.

Women with felony convictions of any kind are ineligible for TANF provisions. From an employer's point of view, a felony conviction of any sort automatically makes a potential employee ineligible for hire, leaving them with fewer options for better paying jobs, health insurance coverage, mental health coverage, and flexible hours. As substance abuse co-occurs with other problems, such as depression, this automatic prohibition severely disadvantages poor women.

• Through treatment, women with mental health and substance abuse problems can recover and function successfully in the workplace. Employer education is needed, to emphasize the distinction between a felony conviction related to a mental health or substance abuse problem and other felony convictions.
• Drug-related felony convictions should not automatically prohibit individuals from receiving assistance under TANF. Women with substance abuse problems, including those who have drug-related felony convictions, should be identified and referred for treatment, as well as be eligible for TANF assistance.

SSBG has the following five broad goals: 1) achieving or maintaining economic self-support to prevent, reduce or eliminate dependency; 2) achieving or maintaining self-sufficiency, including reduction or prevention of dependency; 3) preventing or remedying neglect, abuse, or exploitation of children and adults unable to protect their own interests; or preserving, rehabilitating, or reuniting families; 4) preventing or reducing inappropriate institutional care by providing for community-based care, home-based care, or other forms of less intensive care; and 5) securing referral or admission for institutional care when other form of care are not appropriate or providing services to individuals in institutions. SSBG-supported services include counseling, child care, case management, mental health, substance abuse, housing, transportation, and legal services. Services are targeted at families, seniors, and people with disabilities.

As part of the 1996 welfare reform package, an agreement was made to fund SSBG at $2.38 billion dollars per year, with states given the authority to transfer up to 10 percent of their TANF funds into SSBG to provide support to TANF- eligible families. Unfortunately, the transportation law the following year cut the SSBG authorization to $1.7 billion. Not only has funding decreased from $2.38 to $1.7 billion (almost 30%) in the past four years, but the amount of funds that can be transferred from TANF has also been reduced from 10% to 4.5%.

• For TANF to continue to succeed in meeting the needs of our most vulnerable citizens, the SSBG authorization needs to be restored to a minimum of $2.38 billion and the maximum transfer must be restored to 10%.

One of the primary uses of SSBG funds in several states is for child care. Through the Child Care Development Block Grant, the federal government will have spent $4.567 billion on child care in 2001. Of this amount, $2.567 billion is mandatory funding established by the PRWORA and the remainder is discretionary funding allocated through the appropriations process. Despite this investment, the funds are inadequate to meet the needs of low-income families. No state serves all the families who are eligible for assistance under federal guidelines. Nationally, only 12% of eligible children who need help are getting any assistance (U.S. Department of Health and Human Services, 2000).

• As TANF reauthorization is debated, it is critical that additional funding be provided to ensure available, accessible, quality child care for TANF recipients.

In closing, the American Psychological Association greatly appreciates the opportunity to suggest programmatic changes to the Administration on Children and Families regarding the upcoming reauthorization of the TANF program. We look forward to continuing to work with the Administration in this process. If you have any questions or need more information, please contact Lori Valencia Greene, Senior Legislative and Federal Affairs Officer, in our Public Policy Office at (202) 336-5931.

Sincerely,

Henry Tomes, Ph.D.
Executive Director for Public Interest

     American Psychological Association, Task Force on Women, Poverty, and Public Assistance. (1998). Making ‘welfare to work’ really work. Washington, DC: Author.

     Eaton, W. W., & Muntaner, C. (1999). Socioeconomic stratification and mental disorder. In A. V. Howitz & T. L. Scheid (Eds.), A Handbook for the Study of Mental Health: Social Contexts, Theories, and Systems (pp. 259-283). New York: Cambridge University Press.

     Family Violence Prevention Fund. (2001). Fact Sheet: The Family Violence Option [On-line]. Available: http://endabuse.org/programs/display.php3?DocID=175.

     Greenberg, P. E., Kessler, R. C., Nells, T. L., Finkelstein, S. N., & Berndt, E. R. (1996). Depression in the workplace: An economic perspective. In J.P. Feighner & W. F. Boyer (Eds.), Selective Serotonin Re-uptake Inhibitors: Advances in Basic Research and Clinical Practice (pp. 327-363; 2nd ed.). New York: Wiley.

     Johnson, A., & Meckstroth, A. (1998, June 22). Ancillary services to support welfare to work. Washington, DC: Mathematica Policy Research, Inc. (for U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation).

     Kaplan, A. (1998). Domestic violence and welfare reform [on-line]. Washington, DC: The Welfare Information Network. Available: http://www.welfareinfo.org/aprildomestic.htm.

     Rice, J. K. (1998). Interventions with populations at risk: Women, public assistance and psychological health. Proceedings of the 1998 Psychology of Women Mid-Winter Conference, American Psychological Association, Lexington, Kentucky, 1998.

     Stocker, S. (1998). Men and women in drug abuse treatment relapse at different rates and for different reasons. NIDA Notes, 13 (4). Rockville, MD: National Institute of Drug Abuse.

     Swanson, G. S., Piotrkowski, C. S., Keita, G. P., & Becker, A. B. (1997). Occupational stress and women’s health. In S. J. Gallant, G. P. Keita, & R. Royak-Schaler (Eds.), Health Care for Women: Psychological, Social, and Behavioral Influences (pp. 147-159). Washington, DC: American Psychological Association.

     U.S. Department of Health and Human Services. (1999). Mental health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

     U.S. Department of Health and Human Services (2000). New Statistics Show Only Small Percentage of Eligible Families Receive Child Care Help. U.S. Department of Health and Human Services Press Release, December 6, 2000. Available: http://www.acf.dhhs.gov/news/press/2000/ccstudy2.htm .

     U.S. General Accounting Office. (October 2001). Welfare reform: More coordinated federal effort could help states and localities move TANF recipients with impairments toward employment (Publication No. GAO-02-37). Washington, DC: Author.

     Wetherington, C.L., & Roman, A. B. (Eds.). (April 1998). Drug addition research and the health of women. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse.

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