Serving the "Hard-to-Serve": The Use of Clinical Knowledge in Welfare Reform

Article excerpt

This critical analysis of recent research and evaluations of welfare reform efforts describes how states have increasingly drawn on clinical knowledge in their efforts to move "hard-to-serve" recipients into the labor force. It argues that a clinical perspective is helpful as it brings attention to the mental health needs of low-income women. At the same time, however, this article suggests that states" use of a clinical framework is problematic in so far as it based on limited knowledge, dampens a broad discussion of the relationship between poverty and mental health, contributes to policy ambiguity, and increases recipient oversight.

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In 1996, the United States federal government passed the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). PRWORA replaced Aid to Families with Dependent Children (AFDC), the federal entitlement program for single mothers and their children, with Temporary Aid to Needy Families (TANF), a time limited welfare-to-work benefits program. In its effort to reduce government "dependency" and promote economic "self-sufficiency," PRWORA gave states extensive flexibility in interpreting and implementing time limits and work participation requirements. Coupled with the unprecedented economic boom of the late 1990s, PRWORA measures contributed to a sweeping caseload decline. Although some states are currently experiencing a caseload rise, between 1996 and March, 2001 the TANF caseload fell 52% nationally (Savner, Strawn & Greenberg, 2002). In the face of this dramatic decline and upcoming TANF reauthorization in 2002, policy makers and researchers have devoted significant attention to recipients who remain on the rolls and have difficulty meeting work requirements. Currently referred to as the "hard-to-serve," many states have progressively looked to individual factors, including mental health problems, to account for recipients' persistent unemployment and welfare use.

This article focuses on the implications of welfare reform for the "hard-to-serve" population. In its critical review of recent research and initial evaluations of welfare reform efforts, this examination finds that two phenomena are occurring in several states. First, states increasingly frame difficulty with or failure to meet work requirements as potential clinical problems that mental health professionals must assess and treat. Secondly, "street level bureaucrats," or state and local administrators and line workers, as well as mental health professionals currently exercise growing discretion and oversight in determining clinical diagnosis and, ultimately, continued welfare eligibility. As we argue, these state-level developments hold mixed implications for women receiving welfare. A clinical lens is helpful as it brings attention to the previously ignored mental health needs of low-income women. Yet states' use of clinical knowledge is problematic in so far as it is based on incomplete information and dampens a broad discussion of the complex relationships among poverty, mental health, work, and welfare. Moreover, mental health diagnoses and interventions are not exact sciences and are subject to variation based on the characteristics of the clinician and the client as well as larger social and political influences. Taken together, worker discretion and a clinical framework reinforce one another and result in ambiguous policies that are inconsistently implemented and applied. Finally, we suggest that states' use of clinical diagnoses and interventions produces greater oversight of recipients. Again, this may benefit women and be welcomed by some, but it also adds an additional investigatory layer in which women must prove themselves worthy of financial assistance.

TANF and PRWORA

The PRWORA of 1996 established TANF, the work-based welfare program for low-income adults with children, that imposes a non-consecutive 60-month lifetime federal time limit on aid receipt. …