Mental Health Services and the Welfare System

The United States cash aid welfare system underwent a major overhaul in 1995, when Congress and Clinton famously “ended welfare as we know it.” There were a whole lot of important changes made to the system then, but the most significant was the imposition of 5 year lifetime limits on welfare receipt. Under the previous system, people could receive welfare as long as they were eligible by having a child under 18 and being economically eligible. Now, even if a person has minor children as is poor enough to qualify for welfare, if that person has already received 60 months of aid, she cannot receive any more. (I use female pronouns when referring to people who are on welfare because the caseload is predominantly female, but men do receive it also.)

Even the federal government realized that if we were going to cut people off at the end of 5 years, we had to offer them some tools to move towards economic self-sufficiency and to remove any existing barriers, such as mental health problems, substance abuse issues, or domestic violence.  So, in theory, a person can use her 60 months of aid to receive treatment, medication, and therapy for a mental health problem so she is more able to work when her time limits kick in and her case aid is cut off. In theory, the group of people who are very poor and have disabilities so severe that they cannot engage in work activity are not in the welfare population because they are already on the Supplemental Security Income (SSI) program through the Social Security Administration, so welfare administrators assume that everyone on welfare will eventually be able to work and support themselves once the “barrier” has been removed.

To be clear, the concept and terminology of “barrier removal” is the welfare program’s and not mine. I don’t find it a particularly helpful or accurate framework. I do not think that a mental health problem is something like a brick wall standing between me and the workplace and if I could just dismantle the wall, I could go right into work without any problems. I think it’s unproductive to frame it as a temporary condition that can be permanently eradicated, rather than a life long disability that can be managed to various extents but will continue to need attention, treatment, and management over time. I also think framing it like this gives the welfare system tacit permission to blame people who have undergone treatment while on welfare but who are not economically self-sufficient at the end of the 5 years, whether that be because their ongoing mental health issues need ongoing management, the failure of workplaces to provide meaningful accommodations, or even the lack of jobs that provide living income wages.

Even presuming the framework in which the welfare system thinks about mental health care were a meaningful one, their administration and implementation of that framework is … problematic. To phrase it generously. I’ll primarily focus on the Los Angeles County implementation, as that’s what I’m most familiar with, but problems like this exist to some degree in most welfare programs. Keep in mind that California is considered to be very generous with our welfare benefits and progressive in our “barrier removal” methods, so this may be the best case scenario.

For this discussion, I’m also assuming that participation in the mental health system is a good and beneficial thing, which is also far from a foregone conclusion, especially given the language and cultural diversity present in the welfare population and the, um, lack of such diversity in the mental health providers. (For example, good luck finding a therapist who can talk to you in Khmer! And good luck benefiting from therapy that has to go through a translator!)

The welfare system aims to identify people would would benefit from mental health treatment and connect them with providers. And right there is where there’s a major breakdown in the system. How do we identify people who would benefit from treatment? The welfare system relies primarily on what they call “self-identification,” where a person meeting with her caseworker would be asked if she has any mental illnesses. If she discloses, she will be routed into mental health services. If not, she would not.

Obviously, self-identification is a very problematic method. First, there are significant barriers that would prevent a woman from disclosing an existing mental illness to a welfare caseworker. Among those barriers: fear that disclosure will result in a referral to child services and could result in the children being taken from the home; fear that disclosure will result in involuntary treatment and/or institutionalization and/or medication; fear that disclosing will result in losing welfare and/or food stamp and/or Medicaid benefits; fear that any personal information disclosed to a caseworker will lead to discrimination, etc. And those are just the fears specific to the welfare context – there’s also general stigma issues and everything else that makes it difficult for anyone to disclose a mental health issue, even if they’re not financially dependent on the person to whom they’re disclosing.

And that long list of problems only applies to the people who already know that what they are experiencing is considered a mental health issue, usually people who have already had some access to the mental health system and gotten a previous diagnosis. If I don’t know that the anxiety and panic I sometimes feel culd be considered a panic attack, I’m not going to disclose anything. If I don’t realize that the depression and hopelessness I feel is not how everyone feels and might be related to a mental health issue rather than my abject poverty, I’m not going to disclose anything. The relationship between welfare recipients and caseworkers is notoriously fraught with mutual distrust, so I’m certainly not going to start discussing my symptoms with the worker, and even if I did, a caseworker with no mental health training isn’t going to recognize my symptoms as a potential mental health problem.

I know very well what happens to people who have mental health issues who are unable or unwilling to self-identify to a caseworker — they’re required to comply with work requirements (in CA, 30 or 35 hours a week, it varies by state) and if they’re unable to comply because of untreated mental health problems, they’re sanctioned for failing to work and their cash grant is cut significantly. If they continue to be unable to comply, they will eventually be cut off the grant entirely and cash aid will go only to the minor children (again, in CA. In other states, the entire cash grant, including that for the kids, will be terminated.).

This doesn’t even deal with the problems with the mental health care that is offered to those identified as needing it, just illustrates how a significant number of people with mental health disabilities will not even make it that far and are likely to be penalized financially for their disability status. And in some cases, their children will be significantly penalized also – simply because the welfare system cannot figure out how to meaningfully identify and accommodate people with mental illness in the welfare system.