A consumer view of teen living programs: Teen parents' satisfaction with program components and services

Abstract

This paper reports on the program satisfaction of teen parents who resided in residential programs developed as part of welfare reform in Massachusetts. These teen living programs (TLPs) provide an alternative living situation for teen-parent welfare recipients who cannot live with a parent or guardian, but who must live in an approved setting to receive assistance. One hundred and ninety-nine interviews were conducted with teen parents, 72 with those who were currently living in the program and 727 with those who had left the program. Both quantitative and qualitative data were collected to assess global satisfaction with services, satisfaction with specific program componer>ts, and other open-ended feedback about the program. The measurement of program satisfaction is particularly important for programs serving young people, as they typically have few opportunities to voice their views. Consequently, implications for further program practice are identified.

IF PROGRAMS ARE DESIGNED to be dynamic, adaptive, and responsive, the measurement of client satisfaction with services is a necessary component of program evaluation. In two circumstances, the measurement of satisfaction is particularly crucial. First, new program models can benefit from the collection of data on client satisfaction because they are typically in a developmental stage and most able to incorporate client feedback into program change. Second, measurement of satisfaction is also particularly appropriate when the consumers of services are those with limited power, such as youth in residential programs. For these populations, collection of data about consumer satisfaction provides a voice to program clients.

In Massachusetts, a new program model has been developed to serve teen mothers and their children affected by welfare reform. In response to legislation that requires teen parents receiving welfare to live with their parent, adult relative, or guardian, the Massachusetts legislature has funded teen living programs (TLPs), which provide an alternative setting for those unable to meet the living requirement (due to abuse, neglect, or other family circumstances). As a new program, the State of Massachusetts Department of Transitional Assistance (DTA) supported an evaluation to assess the extent to which key outcomes of the program were attained. Earlier reports have described clients' attainment of outcomes (Collins, Stevens, & Lane, 2000) and the key issues in service delivery (Collins, Lane, & Stevens, 1999). The current study examines data collected from the teen parents regarding their satisfaction with program components, satisfaction with other program elements (e.g., staff relationships), and suggestions for further program development.

Background

Several authors have noted the importance of measuring satisfaction. Speaking primarily about client satisfaction with treatment services, Heflinger, Sonnichsen, and Brannan (1996) write that satisfaction provides a viewpoint that is necessary for evaluation concerned with multiple stakeholders, that it is a primary domain necessary for examining program effectiveness, that it furnishes administrators and policy makers with the feedback needed to improve service delivery, and that it offers a measure of "acceptability" of treatment that may be related to compliance and success. Corrigan (1990), in discussing satisfaction with mental-health settings, suggests that in addition to overall satisfaction, the identification of the elements that consumers find satisfying is necessary for developing user-friendly services. Moreover, LaSala (1997) has suggested that client satisfaction is an appealing outcome measure because it has strong face validity, is consistent with social-work values, and can be an inexpensive method of data collection.

Program satisfaction is particularly important in youth services because young people typically lack the power to express dissatisfaction in meaningful ways and generally cannot display dissatisfaction by terminating services. Specifically, in residentially based programs, young people typically must follow many program rules but have little input into program structure. Despite its importance, the measurement of satisfaction has been particularly lacking in services for children and youth (Stuntzner-Gibson, Koren, & DeChillo, 1995; Shapiro, Walker, & Jacobson, 1997).

Stuntzner-Gibson, Koren, and DeChillo (1995) reviewed several studies aimed at measuring children's satisfaction with services and concluded that child satisfaction can be measured in a manner that is reliable and sensitive to program differences, although most studies have been limited by a focus on medical services. Previous studies have also been positively biased by an over-reliance on quantitative measures, which are less likely than qualitative methods to elicit responses that reflect dissatisfaction (Perreault, Leichner, Sabourin, & Gendreau, 1993). Moreover, Godley, Fiedler, and Funk (1998) found qualitative questions to be particularly important in identifying specific aspects of service that might be improved.

Attempting to respond to some of the concerns regarding the measurement of youth satisfaction, Stuntzner-Gibson, Koren, and DeChillo (1995) developed the Youth Satisfaction Questionnaire to gather information about children's opinions of the range of services and activities in which they were involved. The questionnaire included five general satisfaction questions and several questions related to the specific services and activities in which the child participated (e.g., counseling, special education). They concluded that "asking children what they think of the services and activities in which they are involved appears to be both meaningful and potentially useful as an approach to evaluating services" (p. 622).

Using a qualitative approach and studying a population similar to the one described in the current study, McMillen, Rideout, Fished and Tucker (1997) examined the views of former consumers of independent-living programs for youth in out-of-home care. They note that while there have been recent evaluations of independent-living services, few studies have attempted to identify the components of the program that are most beneficial to those leaving care. In focusgroup interviews, former youth were asked to describe the services that were most helpful in teaching them how to live independently and to identify who was most helpful in their transition to independent living. Through the interviews, several prominent themes were identified including specific program components that were viewed as helpful and not helpful; perceptions of the helpfulness of the foster home, caseworkers, and independent-living specialists; and the difficulty of the transition in leaving care.

Despite the important reasons for collecting satisfaction data, several potential problems with the measurement of satisfaction have been noted. Criticisms have most commonly included the lack of variability in quantitative scores and the tendency for clients to consistently report moderate to high levels of satisfaction (Heflinger, Sonnichsen, & Brannan, 1996; Larson, Attkisson, Hargreaves, & Nguyen, 1979; Lebow,1983). Other criticisms have included a lack of specificity in measures, lack of standard scales, sampling bias, and inconsistency in format (Lebow, 1982; Nguyen, Attkisson, & Stegner, 1983).

In the current study, the measurement of adolescents' feedback regarding the strengths and weaknesses of the program used both quantitative and qualitative data collection and analysis. There were several additional strengths to our method of measuring satisfaction. First, several dimensions of the program were assessed, including overall satisfaction, specific program components, and less tangible elements such as emotional support. Second, data were collected by an independent team, rather than by program personnel, which is likely to elicit more objective answers, thereby reducing the tendency of positive response bias. Third, data were collected during face-to-face interviews, a method with a higher completion rate than mailed questionnaires. Finally, data were collected from both those in the program and those having left the program; therefore, any bias related to perception between those currently in and those out of the program can be documented.

Program Description

At the time of the evaluation, the TLP network had 22 sites throughout the state and a total of 110 beds. Individual program sites are operated by several private social-service agencies through contracts with the Department of Social Services. The program settings include congregate care facilities, small group homes, and supervised apartments. A comprehensive approach to services is intended, thus, programs must include 24-hour skilled staffing and supervision of residents and their children; access to licensed child care (preferably on-site); access to educational, counseling, and health services; case management; and a curriculum of parenting and independent-living skills.

Entry into the program begins when a teen parent applies for welfare benefits. If the teen states that she is unable to live at home or with an adult relative or legal guardian, she is referred for an assessment conducted by the Department of Social Services. If the teen does not accept the recommendation (to either return to her parents' or guardians' home or to enter a TLP), she is no longer eligible for welfare assistance; the case is closed after 30 days and referred to an outreach program.

Method

Only those who had been in the program for at least one month were included in the study. At the time of the study, a total of 288 teens had been served by the program for at least one month. Interviewers were able to locate and contact 201 teens. Only two refused to participate, resulting in 199 completed interviews; 127 were former TLP residents and 72 were current program residents. The total response rate was 69% overall.

In-person interviews were conducted during a two-month field period from mid-April to mid-June of 1998. The interviews were conducted by masters' students from the Boston University School of Social Work in a setting chosen by the teen parent, usually in her home. The survey instrument inquired about experiences both while the teen parent was in the program and after she left the program. Data on satisfaction was collected in two ways: by asking participants to rate services according to how helpful they were and by asking the young women three open-ended questions: ( 1 ) What do/did you find helpful about being in the TLP? (2) What do/did you find not helpful about being in the TLP? and (3) What other types of assistance do you think might have been/might be helpful? Finally, the interviewer asked each participant if she had any other thoughts or comments about how TLPs might better serve teen parents.

Two measures of global satisfaction were developed. One measure, global components, was based on an average of ratings for each of the program components. These were calculated separately for each client and were based on the client's perception of receipt of services (i.e., if a client reported not receiving a service, that component was not included in the average score). The second measure, global-qualitative components, was derived from a review of the open-ended responses and the assignment of a subjective code on a five-point scale (very unsatisfied to very satisfied) based on the types of comments that the teen parent made about the program. Those expressing no sentiments were coded as "3" (neither satisfied nor dissatisfied). Inter-rater reliability of the global-qualitative score was calculated and found to be good (r = .77, p

Results

Our results are presented in four sections: description of participants, program components, global satisfaction, and qualitative feedback.

Participants

Table 1 shows a description of clients, and information about those who were current clients in the program and those who were past clients is provided separately. All clients were female. The average age at entry into the program was approximately 18 years. Latinas were the largest racial group served by the program, followed by African Americans, Caucasians, and "other" (generally biracial). The primary language of clients was English, followed by Spanish, with a few whose primary language was Haitian Creole or "other." Most teens were already parenting at the time of intake into the TLP.

In terms of their living situations prior to entering the TLP, most young women had lived with their families in a self-described "permanent" living situation, whereas less than half lived in a "temporary" situation. Because the new living-arrangement requirement allows teens the option of living with their parents, adult family member, or guardian, teens were asked why they were unable to live with their parents or guardian (and therefore required placement in a TLP). The most common reasons reported were that they could not get along with their parents, their parents' homes were too small, they had been kicked out due to pregnancy, or their parents were unavailable (e.g., deceased, out of state, incarcerated).

Regarding previous schooling, approximately half reported that they had been attending school at entry into the TLP An additional quarter were in a general equivalency diploma (GED) program. Most of the young women reported having worked at some time. Typical of teenage employment, these jobs were in the areas of retail, fast food, office work, and other low-skilled occupations.

Program Components

Tables 2 and 3 provide information about clients' perceptions of receiving services and their rating of services as either "pretty helpful" or "very helpful." For many program components, it was not expected that 100% of teens would receive the service. This is the case for child care, prenatal care, early intervention service, school/GED, employment services, and counseling. Child care and early intervention service would only be relevant for those teens who were parenting, and prenatal care would only be appropriate for those who were pregnant. Similarly, the school/GED component would only be needed by those who had not attained a high-school diploma, and employment services would only be needed by those who had a diploma or GED. Thus, those components with higher percentages of participants receiving a service were those that serve most clients; parenting skills, life skills, and health services are targeted towards all teens, regardless of parenting or educational status, and, thus, these components have the highest percentages receiving the service. Columns four and five examine the satisfaction with services received for those who reported receiving the service. These findings are described more fully below.

Current Residents. When asked to rate services according to how helpful they were, more than 80% of current clients reported ratings of pretty helpful or very helpful on four components: child care, prenatal care, early intervention services, and school/GED. Two services, housing search assistance and employment services, had percentages of less than SO% reporting that they were pretty helpful or very helpful.

Former Residents. Responses of former residents were similar to those of current residents. Former residents rated child care ( 91 % ), school/GED ( 81 % ), and follow-up services (80%) as most helpful. Less than 50% of former residents found three components to be pretty helpful or very helpful: life-skills classes (40%), housing-search assistance (40%), and employment services (48%).

In comparing current and former residents, the tables show that those former residents who received child care, housing-search assistance, school or GED programs, and employment services found them slightly more helpful than current residents. Conversely, former residents rated services such as life-skills classes, parenting-skills classes, prenatal care, earlyintervention services, health and safety classes, and counseling as less helpful than did current residents. Follow-up services are available post-program and were, therefore, only reported by former TLP residents. It is unfortunate that less than half (47%) reported receiving such services, because they were frequently rated as helpful.

Global Satisfaction

Two measures of global satisfaction were developed. The global-components measure of satisfaction was a summary score based on ratings of individual program components (four-point scale with 1 = not at all helpful and 4 = very helpful). The mean satisfaction score was 2.87 (SD = .68). The global-qualitative satisfaction score was based on a five-point scale (with 1 = very unsatisfied and 5 = very satisfied). The mean satisfaction score was 3.12 (SD = 1.06). For both measures, a series of analyses involving t-tests, one-way analysis of variance (ANOVA), and correlation was conducted to examine client and program characteristics related to both measures of satisfaction.

Global Components. No demographic characteristics of the clients were found to be related to satisfaction (the characteristics examined included parenting status (pregnant, parenting, or pregnant and parenting], race, age, primary language [English versus nonEnglish], and citizenship [U.S. versus non-U.S.]). Program characteristics that were tested included number of full-time staff as percentage of total staff, number of college-educated staff as percentage of total staff, staff turnover (average loss of staff in months), and capacity of the TLP. One relationship was found to be significant; capacity of the TLP was negatively correlated with program satisfaction (r = -.22, p

Neither teen's length of stay in the program nor (for those who had exited) length of time since leaving the program was related to program satisfaction. However, whether the teen was in or out of the program at the time of interview was related to her satisfaction; those who were in the program had higher mean satisfaction scores (3.01) compared with those who were out (2.79; t = 2.27, p

Also examined were variables that examined the teens' personal situation at entry: housing situation, educational status, employment, and reason for entering the TLP Those who attended a GED program prior to entering the TLP were more satisfied than those who had not (3.03 vs. 2.81; t = 1.98; p

Global-Qualitative Components. When the analysis used the measure of satisfaction based on subjective reading of client comments, similar, but not identical, patterns were found. The capacity of the TLP again was negatively correlated (r = -.14, p

In addition, the subjective method of measuring satisfaction uncovered some additional relationships. Length of stay in the TLP was positively correlated with satisfaction (r = .14, p

Qualitative Feedback

Open-ended data were coded into categories based on a content analysis. The research team coded responses for the following questions: (1) What is/was helpful about the TLP?; (2) What is/was not helpful about the TLP?; and (3) Do you have any additional thoughts or comments about the TLP? Tables 4 and 5 list the teens' responses to the first two questions and the frequency with which the responses were given. Because the questions were asked in an open-ended format, teens often gave more than one response for each question. For example, when asked what was helpful about the TLP, one respondent replied, "A roof over our heads, family environment, counseling, schooling and child care." This particular response received five different codes. Thus, the total number of responses for these open-ended questions is greater than the number of teens interviewed.

What Is/Was Helpful. When asked what is/was helpful about the TLP, most responses (24%) were regarding programming. Frequently mentioned components included parenting classes, counseling, and early intervention services. In teens' own words, specific responses in this category included "I learned how to act with kids, discipline without hitting, how to talk to kids, about cooking and eating balanced meals" and "money management, help with stress, understanding and dealing with children of all ages."

Emotional support from staff and/or residents was the second most frequently mentioned (20%) helpful aspect of the TLP. Examples of these responses included "I was confident talking to them about anything"; "Living here is the biggest support I've had"; "They ask how you're doing every day. If you have a problem, they're there for you"; "They help you figure out your goal, help you know when you might get into trouble and tell you to make the choice. They help you to be mature"; and "You could see other people in your situation. There was support among teens."

Fourteen percent of the responses emphasized the program's ability to meet their basic needs. Included in this category were comments related to food, shelter, and transportation. Illustrative comments that describe the helpfulness of meeting basic needs include "I'd probably be living on the streets otherwise" and "They help us with transportation and to do our errands."

What Is/Was Not Helpful. When asked what was not helpful about the TLP, 26% of the responses mentioned rules, curfews, and lack of privacy. Teen comments included the following: "It's supposed to be independent living, but it feels like they're babysitting us"; "The rules change every month and the staff doesn't follow through with rules or commitments"; "It took so much to get to the next level that I rarely got to earn more privileges"; and "They're always watching you; having to raise my kid to their requirements; treating everyone the same despite maturity."

Another area of dissatisfaction was the report of conflicts with staff or other residents (20% of responses). Specific comments include "Bad communication between staff and residents. They didn't listen to our point of view" and "The other people who live here are very difficult to live with."

Fourteen percent of the comments were related to a specific piece of programming that respondents did not like. Additionally, 8% of the comments stated that the TLPs had a lack of services. Other comments focused on the physical facility or the program environment (e.g., "Chaos-too many people and babies").

Additional Comments. When asked for additional comments about the TLP, some respondents elaborated on previous statements while others described the changes that they would make to improve the TLP The most common responses included giving residents more independence and privacy (19% of responses), expanding programming (13% of responses), and increasing consistency and organization in the TLP ( 11 % of responses). For example, "Don't give us so many consequences for the littlest things we do wrong"; "Loosen up on rules for those over 18. It feels like incarceration. It's not right when you're paying rent"; and "Programs seem like a punishment for having children rather than helping."

When asked about additional services that might be helpful to TLP residents, the majority of teens responded that they needed help finding housing so that they could move into independent-living situations. Other suggestions included better transportation, more staff, neighborhood information for new residents, financial planning for the future, workshops on domestic violence, and help getting a driver's license.

Although the question asked specifically for improvement suggestions and, thus, the comments tended to focus on problems, some teens reiterated their positive comments (e.g., "I really like the program. It's a good place because it would be harder on my own. It helps you plan for being a parent and your future" ).

Discussion

Both the quantitative and qualitative data provide evidence that the teen parents' experiences in the program and feelings about the program varied in important ways. Some teens reported great experiences (e.g., "living here is the biggest support I've had" ), and others reported poor experiences (e.g., "programs seem like a punishment for having children rather than helping"). The majority of teens report a mixed experience and perceive some aspects of the program as helpful and some as not helpful. The data suggest some areas of program strength and other areas in which efforts aimed at program improvement can be directed.

Although component ratings demonstrated variability, several components were rated particularly high. Child care and school/GED services were received by the majority of teens and were rated highly by both current and former program participants. This suggests that the teens are well aware of major barriers to self-sufficiency (lack of child care, lack of diploma) and are appreciative of these services when made available. The three program components demonstrating the lowest satisfaction ratings were lifeskills classes, housing-search services, and employment assistance. Both housing-search services and employment assistance are concrete types of assistance that are critical to the teen's continued development beyond the TLP Although both can be limited by factors outside of the program's control (e.g., the housing market and the labor market), a primary intent of the program is to strengthen the teen's ability to lead a self-sufficient lifestyle. Thus, both program- and system-level efforts appear to be needed. In particular, housing-search services and employment services might be linked to the program's follow-up services. This would help to ensure the young family remained in safe housing and that the young woman could take steps to increase her employability and earning potential. Follow-up services were rated highly by those who had left, but, unfortunately, this was a program component that lacked wide coverage. Sites have reported that with limited staff time, particularly when programs are full, they are restricted in their ability to sufficiently follow up with clients; however, they are also aware of this program weakness and are developing means to strengthen this component (Collins, Lane, & Stevens, 1999). Allocation of specific funds and staff resources, as well as definition of the concrete steps to engage in follow up (e.g., timing and methods of contacts), appear needed. At the same time, system-level advocacy is warranted at the local and state levels to increase the supply of affordable housing within the community, create access to nontraditional and well-paying jobs, and enhance a variety of transitional housing and employment services.

Certain characteristics of the programs and the clients themselves were related to satisfaction. Level of satisfaction was higher for those in smaller programs, for those who were currently in the program versus those who had left, for those who had attended a GED program prior to entry into the TLP, and for those who had not been placed for reasons of abuse. Several explanations can be proposed for these identified relationships. Smaller programs offer more individualized attention, engender a more homelike atmosphere, and restrict the likelihood of "chaos." It is interesting that those respondents currently in the program reported higher satisfaction; staff commonly stated that teens are more grateful for the program after they have left than while they are in, but the data suggest otherwise. This relationship only held for the satisfaction measure that was based on program components; however, it was not observed for the satisfaction measure based on open-ended comments. Thus, while teens are receiving services, they appear to recognize the utility of those services to a greater degree than after they leave.

We suspect that the reason those who have attended a GED program prior to entry are more satisfied is because the program facilitated the completion of the GED (a goal in which they had already demonstrated some interest) and possibly assisted them in attaining further education. Those who had not previously attended a GED program may have been more resentful than appreciative of the education requirement. Finally, satisfaction was lower for those who had been placed for reasons of abuse. These young women are likely to be dealing with a variety of feelings associated with victimization experiences that may not be directly addressed by the programs. One nonsignificant, but important, finding is the lack of a relationship between demographic characteristics and satisfaction; this suggests the program provides generally equitable treatment.

The second satisfaction measure was based on open-ended responses and was not limited to measuring satisfaction with program components. Length of stay was related to this second measure but not the first. It may be that a longer length of stay is needed to develop the type of relationships within the program that result in a higher level of satisfaction, or it may be that those who stay are more satisfied with the program. Also noteworthy is that those who entered because of the new DTA requirement were found to be more satisfied. At first this seems surprising, because teens who had been living on their own might be expected to be more resentful of moving into a group living situation. It may suggest, however, that these teens had few other problems (e.g., no history of abuse or victimization, no previous eviction) and, therefore, were not dealing with serious personal issues and could appreciate the program to a greater extent than those who had other issues with which they were coping. Teens who have lived on their own may also be highly cognizant of how difficult it can be, and thus may be more grateful for support provided, as opposed to those who have not been on their own and have idealized visions of what it would be like.

Some teen comments speak to the feelings of support within the group (e.g., "You could see other people in your situation. There was support among teens.") and others speak to dissatisfaction with the group (e.g., "The other people who live here are very difficult to live with" ). Although the program model is not treatment-oriented and, therefore, does not use the group-living experience to provide a therapeutic environment, development of supportive relationships is encouraged both among the teens and with staff. Given the challenges the young women face after leaving the program, and thus the need for ongoing encouragement and support, more explicit attention to the initiation, maintenance, and termination of various social networks and support mechanisms might be an additional means of adding to the teens' repertoire of life skills. Similar issues are raised and addressed by the program in terms of the support provided to the young women by the fathers of their children as well as other family members. Program sites vary in the extent to which the fathers and other family members are included in programming. Such variation is, in part, due to the individualized circumstances of the teens; some are virtually alone in the world, and others have ongoing and positive contact with the father of their children and their family members. Programs attempt to include fathers when appropriate (e.g., in parenting- and life-skills classes), but sites also acknowledge that this is another area where programming could be improved and extended.

Based on client statements, the main dissatisfactions with the program are lack of independence and too many rules. This is not a surprising finding; group living is not easy, and adolescence is a stage of life during which the struggle for increased independence is critical. As in any group-living situation (whether a formal program, a chosen informal arrangement, or a family), all individuals must adjust and respect each other for a satisfactory experience. To limit dissatisfaction in this area, the program can aim to find ways to allow as much independence and as few rules as possible. For example, most of the programs pool the adolescents' food stamps and conduct joint menu planning, shopping, and meal preparation. One site, however, did not do this, stating that by allowing each teen to make these decisions herself, it is "one less thing the program is controlling." Moreover, the type of house rules must be responsive to this particular population. These teens are adolescent mothers who receive welfare. Their needs are not the same as those of runaways or homeless or abused adolescents (although some may have suffered these circumstances). Workers in programs with a history of serving these other populations need to be especially sensitive to the difference in population and be certain that they do not transfer program philosophy and rules to this new population without reflection and justification.

Some comments of teens suggest a misunderstanding of the program intent. The program is not an independent-living program, although some teens view it as such. Furthermore, although a portion of their welfare benefit is used to pay program fees, it is not "rent" and the relationship is not one of landlord to tenant. While it is not unusual for program participants to have different ideas of the nature of the program than either program designers or program staff, clearer communication about the nature of the program is needed to help with this aspect of program dissatisfaction.

In conclusion, we comment briefly on two broader issues: the utilization of client-satisfaction data and the relationship of client-satisfaction data to outcomes. For the most part, the feedback provided by the teen mothers appears appropriate and a reflection of reality, thus providing important information about program operations. Ways to institutionalize client feedback are needed in this program model, as well as in other programs serving youth. Although house meetings occur at most program sites to provide a forum for discussion of house issues, no formal mechanism exists to consistently gather data about client satisfaction or to use such information for program improvement. Ongoing data collection is needed and is relatively easy and inexpensive. Individual program sites can use such data primarily regarding issues related to staff relationships and the nature of the individual house rules. This data can also be used as part of the contract monitoring process for individual sites. Additionally, data regarding program components and the larger issues of program philosophy (e.g., the careful balance between a group model and encouragement of independence) should be used to guide the ongoing development of the program model.

Finally, although the relationship between client satisfaction and client outcome is an important one, our focus here was not on outcome but on satisfaction and the improvement of programs. Like Godley, Fiedler, and Funk (1998), we believe that consumer satisfaction need not be directly related to outcome to be an important goal for policymakers and practitioners. Consumers of services have a right to be treated in ways that they view with satisfaction. Programs cannot successfully affect outcomes unless program participants remain in the program for a sufficient period. We suspect, therefore, that attention to increasing program satisfaction will result in more teens staying with the program for longer periods, which may, in turn, lead to attainment of important outcomes.

References

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Mary Elizabeth Collins is assistant professor, Boston University School of Social Work, 264 Bay State Road, Boston, MA 02215. Cristi Lemon and Elizabeth Street are former graduate students of Boston University School of Social Work.

Authors' note: This study was completed under contract to the Massachusetts Department of Transitional Assistance.

Original manuscript received: June 15, 1999 Accepted: November 2, 1999 Final revision received: November 15, 1999

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