Perceived welfare caseworker support and psychological distress among low-income urban women with children.
Hill, Terrence D. ; Cain, Daphne S.
Although some research suggests that the relationship between Child
Protective Services (CPS) workers and their clients may influence client
outcomes, little is known about the function of the relationship between
welfare or Temporary Assistance for Needy Families (TANF) caseworkers
and their clients. This article reviews what is currently know about the
effects of relationship quality between CPS workers and their clients
and extends the knowledge base to include welfare caseworker support and
psychological distress among a sample of predominately minority
low-income urban women with children.
LITERATURE REVIEW
Outcomes of Worker-Client Relationship Quality
The connection between doctor-patient and therapist-client
relationship quality and client outcomes has been convincingly explored.
Factors such as empathy and warmth have been shown to correlate more
highly with client outcomes than do specialized therapeutic treatment
interventions (Lambert & Barley, 2001), and patients who feel they
are listened to by their physicians are less likely to avoid treatment
for both medical and psychological problems (Moore et al., 2004).
However, researchers have only begun to investigate the connection
between CPS worker-client and welfare worker-client relationships and
client outcomes, and virtually nothing is known about worker-client
relationship quality and psychological distress among clients.
Most of the evidence concerning outcomes of CPS worker and client
relationships is qualitative in nature and suggests that relationship
qualities--including cooperative and collaborative problem solving, good
listening skills, empathic understanding, emphasis on solutions and
strengths, and flexibility--may contribute to earlier case closure and
favorable case outcomes (Maiter, Palmer, & Manji, 2006; Richardson,
2008; Trotter, 2002; Tuttle, Knudson-Martin, Levin, Taylor, &
Andrews, 2007).
Trotter (2002) investigated the extent of worker skill and client
outcomes in a qualitative study of 282 Australian child protection
clients (including 50 adolescents who were the subjects of the child
protection intervention, 112 mothers, 69 fathers, and 42 other relatives
or friends) and 50 child protection workers involved in the client
cases. He reported that workers who use a collaborative worker-client
relationship to help clients and their families to understand the role
of the child protection worker, who use problem solving that focuses on
the client's definitions of problems, who reinforce prosocial
expressions and actions, and who make appropriate use of confrontation
have more satisfied clients who achieve better outcomes, including
having their cases closed within a 16-month period.
Using themes that emerged from in-depth interviews with eight
substance-abusing mothers in the child welfare system, Sun (2000)
outlined what she called the "journey of recovery." Mothers in
this study reported that child welfare system intervention was both a
crisis and a turning point for them--an opportunity to break a vicious
cycle and enter the mainstream world. Mothers in the study reported a
desire for a better life, meaningful relationships, and
self-actualization. They reported that having a CPS worker who was
nonjudgmental and nonauthoritative, who cared about and had faith in
their abilities to be successful, who established feasible case plans
that treated both mother and child as one unit, who facilitated and
strengthened the use of social networks (including self-help groups),
and who provided case management and life-skills training were key to
their success in achieving those ends.
Taken together, these studies suggest a growing interest in and
support for the quality of CPS worker-client relationships and improved
client outcomes. Partly due to recent policy shifts and corresponding
job chances for welfare workers, far less is known about the association
between welfare worker-client relationships and client mental health.
TANF
Welfare reform legislation (the Personal Responsibility and Work
Opportunity Reconciliation Act [P.L. 104-193], 1996) established TANF as
a federally funded block grant that replaced the well-known New Deal-era
federal open-ended entitlement welfare programs. The goals of TANF are
wide-ranging and include the following: "assisting needy families
so that children can be cared for in their own homes; reducing the
dependency of needy parents by promoting job preparation, work and
marriage; preventing out-of-wedlock pregnancies; and encouraging the
formation and maintenance of two-parent families" (U.S. Department
of Health and Human Services [HHS], n.d.-a, p. 2). TANF block grants
cover benefits, including cash assistance, administrative costs, and
services for needy families. Although states have great flexibility in
how they administer TANF programs--including eligibility requirements,
methods of assistance, and benefit levels--funding is dependent on
previous expenditures in Aid to Families with Dependent Children, the
Emergency Assistance Program, and the Job Opportunities and Basic Skills
Training Program. Furthermore, all TANF programs are "time-limited
and promote work, responsibility and self-sufficiency" (HHS,
n.d.-a, p. 1).
TANF funds can only be spent on families that include a child or an
expectant mother, and there are several restrictions regarding use of
funds. Restrictions for individuals receiving funds include work
requirements, cumulative assistance limits not to exceed 60 months for
any one family, requirements that unmarried teenage parents live in an
adult-supervised setting and stay in school, guidelines that individuals
convicted of a drug-related felony are ineligible for TANF and food
stamp benefits, and requirements that individuals receiving TANF funds
must cooperate with Child Support Enforcement (CSE) requirements or
receive a reduction or loss in benefits (HHS, n.d.-b). States also face
strict requirements and penalties for misuse of TANF funds. For example,
only 15 percent of any state's TANF grant can be used for
administrative costs--including caseworker costs--and states must
enforce the work requirement, enforce the 60-month assistance limit, and
comply with the terms of CSE (HHS, n.d.-b).
Roles of Welfare Workers under TANF
The roles of welfare workers changed as a result of the major
provisions of TANF. Under TANF, frontline welfare workers'
responsibilities shifted from a focus on eligibility determinations and
fiscal accuracy in benefit terminations to a focus on direct services,
including the provision of systematic and individualized assessments,
the dissemination of information, and the interpretation and
implementation of program policies and regulations (Hagen, 1999; Radey,
2008). Unfortunately, the training necessary to provide adequate
assessment, information sharing, and effective program implementation is
often lacking, and, indeed, it is questionable if workers have actually
changed the focus of their work from eligibility determination and
service access in any substantial way (Hagen & Owens-Manley, 2002;
Meyers, Glaser, & MacDonald, 1998). Instead of systematic and
individualized assessments needed to determine service eligibility under
TANF, workers often use highly routinized and scripted application
materials that depersonalize the process and fail to meet individual
needs (Anderson, 2001). Former TANF recipients have reported that the
application process for public assistance can be humiliating, degrading,
and disempowering (Gray, 2005). Moreover, recipients have reported that
workers can be unsympathetic, insensitive, hostile, demeaning,
judgmental, inflexible, and disrespectful toward them (Laakso &
Drevdahl, 2006; McPhee & Bronstein, 2003; Pearlmutter & Bartle,
2000). These types of perceived interactions can make rapport and
relationship building between workers and recipients very difficult.
Moreover, when recipients do not receive comprehensive information
regarding services, service eligibility, and potential sanctions
regarding noncompliance, they may go without services for which they
would qualify or lose services due in part to miscommunication
(Tickamyer, Henderson, White, & Tadlock, 2000).
Ultimately, the interpretation of TANF program policies and
regulations, including the use of sanctions, is left to local
administrators and individual workers. Policies and regulations are
unique to each state and are often complex; criteria for granting
exemptions from TANF requirements are often lacking (Hagen &
Owens-Manley, 2002). A comparison of select welfare policies, benefits,
and requirements for three states included in the subsequent
analyses--Illinois, Massachusetts, and Texas (Rowe & Roberts,
2004)--are presented in Table 1.
Given state-level variations in welfare rules, individual
interpretation of policy and the use of administrative discretion by
frontline workers--including the extension of services for
"good" clients--can produce disparities in access to services
and benefits (Anderson, 2001; Tickamyer et al., 2000). Moreover, threats
of sanctions require less investment of time and energy to obtain
compliance than does the time-consuming process of relationship building
and communication (Hasenfeld, 2010; Hasenfeld & Weaver, 1996).
Indeed, the use of sanctions, or threats of sanctions, to obtain
compliance is not only pervasive, but often a key attribute of
worker-client relationships. Hasenfeld (2010) explained as follows:
At the workers' level, use of sanctions gives
the workers a sense of control over fairly
chaotic and difficult encounters with their
clients. Workers have to contend with recipients
whose lives are fraught with instabilities
and frequent crises that impinge on their
ability to adhere to the "work first" requirements.
To attempt to address these crises
would require the workers to mobilize resources
that are often beyond their capabilities.
They do not have the professional expertise,
and they work under organizational rules and
constraints that discourage individualized responses.
Use of sanctions is a way to typify the
clients' problems as failure to comply. It justifies
a fairly standard response, and puts the
onus on the recipients themselves. (p. 161)
Hasenfeld (2010) contended that these power relations between
workers and clients are the primary mechanism through which desired
changes in clients' behaviors are achieved. However, noncompliance
is not always chosen by clients. Noncompliance can be the result of
critical barriers, both perceived and real, at the level of the
individual (for example, domestic violence, child behavior problems,
mental health and substance abuse issues), community (for example, lack
of transportation and child care), and agency (for example,
communication disconnect with agency, lack of primary caseworker, lack
of trust in relationship, poor treatment, unhelpful workers) (Rainford,
2004). Consequently, recipients may experience barriers to compliance as
out of their control, view the circumstances leading up to sanctions as
beyond their ability to overcome, grow less motivated to comply, and
become further alienated from the workers and agencies that are designed
to assist them.
There is no doubt that welfare caseworkers have a powerful
influence on clients. They interpret state-level TANF policies and apply
them to individual cases. They provide services, make referrals, and
assess and monitor client compliance. Furthermore, workers impose
sanctions and terminate services for out-of-compliance clients. These
complicated interactions between workers and clients suggest that the
quality of the relationship between workers and clients may influence
clients' levels of psychological distress. Building on previous
research, this study used data collected from a sample of low-income
urban women with children to investigate the association between the
women's perceptions of welfare caseworker support and their levels
of psychological distress. On the basis of the foregoing discussion, we
expected that higher levels of caseworker support would be associated
with lower levels of psychological distress among clients.
METHOD
Data
The data for this investigation come from the Welfare, Children,
and Families (WCF) project (see http://www.jhu.edu/~welfare/). The WCF
project was a household-based, stratified random sample of 2,402
low-income women living in low-income neighborhoods in Boston, Chicago,
and San Antonio, Texas. The WCF first sampled census blocks (or
neighborhoods) with at least 20 percent of residents below the federal
poverty line on the basis of the 1990 census. Within these
neighborhoods, households under 200 percent of the poverty line were
sampled, with an over sample of households below 100 percent of the
poverty line. Because one of the goals of the WCF project was to assess
the impact of welfare policy and work on children, households were
screened for the presence of children. Households with at least one
infant or child (ages zero to four years) or young adolescent (ages 10
to 14 years) were sampled. The children's caregivers, all women,
were interviewed face-to-face. The data were collected in 1999. The
response rate was 75 percent. Our analysis includes respondents who
reported having welfare caseworkers in 1999 (N = 853).
Measures
Psychological distress was measured with the Brief Symptom
Inventory (BSI-18) (Derogatis, 2000), which contains subscales for
depression, anxiety, and somatization. Psychological distress is
measured as the mean response to 18 items. For example, respondents were
asked to indicate how much in the past seven days they were distressed
or bothered by "feeling no interest in things," "feeling
tense or keyed up," and "nausea or upset stomach."
Responses to all psychological distress items were coded (1) not at all,
(2) a little bit, (3) moderately, (4) quite a bit, or (5) extremely.
Perceived caseworker support was measured as the mean response to
three items. Respondents were asked to indicate how much they agreed or
disagreed with the following statements: "My welfare caseworker is
interested in my well-being"; "My caseworker only wants
what's best for me and [CHILD/my children]"; and "My
caseworker gives me good advice and helps me decide on a plan that suits
my needs." Responses to all caseworker support items were coded (0)
strongly disagree, (1) disagree, (2) neither agree nor disagree, (3)
agree, or (4) strongly agree.
Our multivariate analyses included controls for several background
variables, including age (in years), race/ethnicity (dummy variables for
non-Hispanic white, Mexican, and other Hispanic compared with black),
education (in years), employment status (1 = worked for pay in the past
week, and 0 = otherwise), marital status (1 = married--living with
spouse, and 0 = otherwise), and number of children (one to six or more
[top-coded continuous variable]). We selected these background variables
because they are known correlates of mental health (Mirowsky & Ross,
2003). Clients may also be treated differently by their caseworkers on
the basis of these characteristics. We also controlled for city of
residence (dummy variables for Boston and San Antonio, Texas compared
with Chicago) to account for potential variations in welfare systems and
psychological distress across the three cities.
Statistical Procedures
We begin with the presentation of descriptive statistics for all
study variables. Minimum and maximum values, means, percentages,
standard deviations, and alpha reliability estimates are included in
Table 2. Ordinary least squares estimates from our regression of
psychological distress are presented in Table 3. This analysis tests
whether current levels of perceived caseworker support are associated
with current levels of psychological distress, controlling for
background variables.
RESULTS
The average respondent exhibited low levels of psychological
distress and moderate levels of perceived caseworker support (see Table
2). Higher levels of perceived caseworker support were associated with
lower levels of psychological distress, net of a host of relevant
background variables (see Table 3). This pattern suggests that women who
perceive their welfare caseworker to be interested, caring, and helpful
also tend to exhibit lower levels of psychological distress. Our results
also reveal that older respondents, other Hispanics (compared with
non-Hispanic blacks), and San Antonio, Texas residents (compared with
Chicago residents) tended to report higher levels of psychological
distress.
DISCUSSION
Although some evidence suggests that relationships between CPS
workers and their clients may influence client outcomes, very little is
known about the effects of relationship quality between welfare or TANF
caseworkers and their clients. This article reviewed what we currently
know about the effects of relationship quality between CPS workers and
their clients and extends that knowledge base to include welfare
caseworker support and psychological distress among clients. Building on
previous research, we used data collected from a sample of low-income
urban women with children to investigate the association between
perceived welfare caseworker support and levels of psychological
distress. We expected that higher levels of caseworker support would be
associated with lower levels of psychological distress among clients.
Consistent with this hypothesis, we found that women who perceived their
welfare caseworker to be interested, caring, and helpful also tended to
exhibit lower levels of psychological distress.
Under TANF, welfare caseworkers are responsible for interpreting
complex policies and regulations, providing comprehensive information to
recipients regarding eligibility and noncompliance regulations, and
providing individualized assessments to maximize utilization
effectiveness. However, inadequate training and structural and
organizational barriers to service delivery make the jobs of welfare
caseworkers difficult (Meyers et al., 1998). To improve these
conditions, Radey (2008) recommended that social work education and
training be prioritized for welfare caseworkers. Currently, there is
modest job-related preparation and little in the way of on-site training
or ancillary support for welfare caseworkers (Annie E. Casey Foundation,
2003). Whereas the BSW curriculum is designed, in part, to train
frontline social workers to perform jobs analogous to frontline welfare
caseworkers (Council on Social Work Education, 2008), our results may
extend beyond welfare caseworkers to all frontline social workers, who
could benefit from professional social work skill building, including
active-listening, rapport-building, and problem-solving skills
development.
Former welfare recipients have reported that they want validation
and recognition for their strengths and their efforts to leave TANF for
employment (Gray, 2005). These former recipients reported that they want
their workers to focus less on compliance issues and more on
encouragement to help woman become wage reliant. These are activities
taught in strengths-based social work models. However, for change to be
enacted at the frontline-worker level, administrative and policy changes
must be enacted that promote a strengths-based and empowerment model
that will enable caseworkers to develop more positive and supportive
relationships with recipients (Anderson, 2001).
The present study has several limitations. First and foremost, the
cross-sectional nature of our data makes it impossible to establish the
causal order of any observed associations. Although we propose that
perceived caseworker support might protect against psychological
distress, we acknowledge that psychological distress could also shape
perceptions of caseworker support in the first place. Women could rate
their caseworker relations more favorably simply because they are
healthier and happier. Another limitation of the data is our measurement
of caseworker support, which is based on general self-reports.
We were also unable to explore some of our ancillary findings. We
found that older respondents, other Hispanics, and San Antonio residents
exhibited elevated levels of psychological distress. These patterns
could be explained by unobserved cultural or regional-level variations
in administrative structure and policies that may have influenced these
results (for example, caseload variations, record keeping policies and
procedures, individual intake and assessment scripts with varying levels
of intrusive questioning).
Despite the limitations of our study, our results emphasize the
importance of the nature of the caseworker-client relationship. When
caseworker-client relationships are supportive, they tend to favor the
psychological well-being of clients. When caseworker-client
relationships are characterized by a lack of support, they are
associated with greater psychological distress. Welfare caseworkers must
appreciate these outcomes and pay special attention to relationship
quality because increased symptoms of psychological distress-including
depression, anxiety, and somatic symptoms--can only serve to undermine
the obvious goal of helping clients through difficult periods of
socioeconomic instability.
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Terrence D. Hill, PhD, is assistant professor, Department of
Sociology, Florida State University, 526 Bellamy Building, P.O. Box
3062270, Tallahassee, FL 32306-2270; e-mail: thill@fsu.edu. Daphne S.
Cain, PhD, LCSW, is associate professor, School of Social Work,
Louisiana State University, Baton Rouge.
Original manuscript received December 17, 2010
Final revision received July 15, 2011
Accepted August 19, 2011
Advance Access Publication November 9, 2012
Table 1: Comparison of Welfare Rules, by State (July 2000)
Welfare Policies, Benefits, Chicago Boston
and Requirements
Maximum monthly income for 467 708
initial eligibility for a
family of three ($)
Asset limits ($) 2,000 2,500
Maximum monthly benefit for 377 618
a family of three ($)
Benefit determination Payment standard Need standard
policies minus net income minus net income
Mandatory job search at No No
application
Minor parents must live with
their parent(s) or in Yes Yes
state-approved setting
School requirement Yes Yes
(dependent children)
Health screening requirement No No
(dependent children)
Work exemptions for Caring for child No exemption
single-parent households under age of 12
months
Timing of work requirements After TANF Within 60 days of
for single-parent assessment TANF assessment
recipients over 21 years
of age
Minimum work hour
requirement for single- 30 hours 20 hours (for
parent recipients over 21 recipients with
years of age children age six
or older)
Work requirement Entire benefit Entire benefit
noncompliance sanction for 3 months until in
(most severe sanction) compliance for
two weeks
TANF lifetime time limit 60 months None
Welfare Policies, Benefits, San Antonio, Texas
and Requirements
Maximum monthly income for 401
initial eligibility for a
family of three ($)
Asset limits ($) 2,000
Maximum monthly benefit for 201
a family of three ($)
Benefit determination Maximum grant
policies minus net income
Mandatory job search at No
application
Minor parents must live with
their parent(s) or in Yes
state-approved setting
School requirement Yes
(dependent children)
Health screening requirement Yes
(dependent children)
Work exemptions for Caring for child
single-parent households under age of 36
months
Timing of work requirements After work
for single-parent orientation
recipients over 21 years
of age
Minimum work hour
requirement for single- 30 hours
parent recipients over 21
years of age
Work requirement Adult portion of
noncompliance sanction benefit for 6
(most severe sanction) months
TANF lifetime time limit 60 months
Notes: All data come from Rowe and Roberts (2004). TANF = Temporary
Assistance for Needy Families.
Table 2: Descriptive Statistics (Welfare, Children, and Families, 1999)
Variable Range % M SD [alpha]
Psychological distress 1-4.61 1.49 0.61 0.94
Caseworker support 0-4 2.13 1.25 0.91
Age (in years) 18-74 32.40 10.72
Non-Hispanic white 0-1 9.00
Black 0-1 49.00
Mexican 0-1 19.00
Other Hispanic 0-1 23.00
Education (in years) 0-14 10.32 2.22
Currently employed 0-1 19.00
Married, spouse in house 0-1 5.00
Number of children 1-6 2.80 1.42
Boston 0-1 34.00
Chicago 0-1 42.00
San Antonio, TX 0-1 24.00
Note: N = 853.
Table 3: OLS Regression of Psychological
Distress (Welfare, Children, and Families,
1999)
Age b SE [beta]
Caseworker support -0.058 ** 0.017 -0.118
Age 0.004 * 0.002 0.077
Non-Hispanic white 0.060 0.078 0.028
Mexican 0.112 0.065 0.072
Other Hispanic 0.204 ** 0.059 0.141
Education 0.012 0.010 0.042
Currently employed -0.099 0.054 -0.064
Married, spouse in house 0.015 0.094 0.006
Number of children 0.014 0.015 0.032
Boston 0.027 0.053 0.021
San Antonio 0.143 * 0.058 0.101
Model F 3.556 ***
[R.sup.2] 0.044
Sample size 853
Note: OLS=ordinary least squares.
* p < .05. ** p < .01. *** p < .001 (two-tailed tests).
