The working alliance between clients and helpers has been identified as a common factor of treatment effectiveness, yet very little research has explored variables associated with working alliance between mental health case managers and their consumers. This study explored the potential covariates of working alliance within community mental health case management. Specifically, the study explored to what degree the case manager is related to consumer perceptions of working alliance, to what degree consumers' perceived mental illness stigma is related to working alliance, and the extent to which the relationship between perceived stigma and working alliance is different for different case managers. Cross-sectional data were collected from 160 people receiving case management services and were analyzed using hierarchical linear modeling. Case managers accounted for about 11% of the variance in working alliance scores, which represents a moderate effect. Perceived stigma approached a statistically significant relationship with working alliance. The interaction between case managers and stigma was significantly related to working alliance. Case managers are an important source of variance in the relationship between stigma and working alliance. Future attempts to study working alliance should include case managers and consumers' perceived stigma as independent variables.
KEY WORDS: case management; mental illness; mental illness stigma; working alliance
Recovery in mental illness represents a real possibility for people with severe mental illness (SMI) such as schizophrenia and bipolar disorder. Recovery can be understood as consumers' movement toward a self-defined, satisfying fife within the community and does not necessarily equate to symptom remission (Anthony, 1993). Recovery in mental illness is a paradigm shift away from past beliefs that people with SMI need help to be maintained in the community toward a belief that people with SMI can thrive in the community (Kruger, 2000). At the national level, the President's New Freedom Commission on Mental Health (2003) has called for the provision of treatment approaches that support consumer movement toward recovery.
Another shift in mental health services is a call for evidence-based practices (EBP),which are interventions that have demonstrated an empirical track record of success with regard to consumer outcomes (Gambrill, 1999). In community mental health, this means ensuring that people living with SMI are provided the most effective treatment and interventions available (Mueser, Torrey, Lynde, Singer, & Drake, 2003). Coupled with recovery, the EBP movement challenges mental health treatment providers and researchers to use and develop treatment approaches that focus on moving consumers toward recovery (Anthony, Rogers, & Farkas, 2003). The working alliance between consumers and helpers is thought to be an important ingredient in effective treatment (Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003). As such, this article explores the working alliance between mental health case managers and consumers, examining factors that might be related to a strong working alliance.
Working Alliance Defined
The working alliance--which also has been called the therapeutic alliance, therapeutic bond, and helping alliance--has been variously defined within the psychotherapy literature (Martin, Garske, & Davis, 2000). In case management research, researchers have generally used Bordin's (1979) pan-theoretical definition of the working alliance (Howgego et al., 2003). Bordin argued that his conception of the working alliance is applicable to any change-oriented activity, such as case management, and that it is the vehicle through which change-oriented activities are successful. He conceptualized the working alliance as consisting of three components: (1) the therapist's and client's agreement on the goals of therapy, (2) the therapist's and client's agreement on the tasks of therapy, and (3) the positive bond between the therapist and the client. Bordin's definition of the working alliance has been operationalized by Horvath and Greenberg (1989) in the Working Alliance Inventory (WAI), which includes Bordin's three components and an overall measure of the working alliance.
In a meta-analysis of the effects of the working alliance in psychotherapy, Horvath (2001) reported an average weighted effect size between working alliance and therapy outcome of 0.21, indicating that working alliance is significantly related to therapy outcome, with perceptions of a stronger working alliance associated with positive therapeutic outcomes. As with studies of the working alliance in psychotherapy, studies in case management have found a significant association between strong working alliances and positive treatment outcomes, such as fewer days hospitalized (Priebe & Gruyters, 1993), greater community living skills (Neale & Rosenheck, 1995), lower reported symptom severity (Neale & Rosenheck, 1995;Tyrrell, Dozier, Teague, & Fallot, 1999), better medication compliance (Solomon, Draine, & Delaney, 1995), fewer days homeless (Chinman, Rosenheck, & Lam, 2002), and greater fife satisfaction (Chinman et al., 2002; Solomon et al., 1995;Tyrrell et al., 1999).Thus, studies of the working alliance have shown this treatment process to be a therapeutic vehicle for consumer recovery.
Factors Affecting Working Alliances between Treatment Providers and Consumers
Although the effect of the working alliance on consumer treatment-related outcomes has been shown to be a catalyst of mental health recovery, only a few studies have explored variables that affect the development of the working alliance between consumers and their community providers. An exception is the work of Draine and Solomon (1996), who studied effects of client characteristics of history of criminal arrests, homelessness, age, number of hospitalizations, and ethnicity on the working alliance, as measured by the Working Alliance Inventory (WAI). They found that being older (over 45 years of age) was associated with client perceptions of stronger working alliance. In addition, they found that having a history of criminal arrests was associated with higher ratings of the bond and tasks subscales. Klinkenberg, Calsyn, and Morse (1998) studied the effects of client and program characteristics--such as number of program contacts and services provided, days housed, income, gender, ethnicity, and education level--on the working alliance. Of these variables, only ethnicity was associated with working alliance: Caucasians had lower working alliance scores than did members of other ethnic groups.
A number of other factors, which have not been studied previously, may be statistically related to the strength of working alliances between case managers and their consumers. Stigma surrounding mental illness presents a significant barrier for individuals suffering from SMI to seeking out needed help and, ultimately, entering into a recovery process (President's New Freedom Commission on Mental Health, 2003). Indeed, individuals with SMI, as well as the general public, hold beliefs that people with SMI are devalued and discriminated against by members of the public, being viewed as unworthy of friends, a .job, or housing and viewed as less than human (Link, 1987; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). Link (1987) called this phenomena "perceived stigma."
Research on the impact of perceived stigma suggests that people with SMI compared with people without an official psychiatric label are affected by how much perceived stigma they hold, with effects including lower income, greater unemployment, and stronger feelings of demoralization (Link, 1987). Individuals who do not have an official SMI label are unaffected by the degree to which they perceive stigma of individuals with SMI (Link, 1987). In studies of people receiving psychiatric treatment, greater levels of perceived stigma have been associated with lower self-esteem (Markowitz, 1998), greater depressive symptoms (Kanhng & Mowbray, 2005; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2002), less participation in social leisure activities (Perlick et al., 2001), lower feelings of belonging (Prince & Prince, 2002), greater emotional discomfort (Lysaker, Davis, Warman, Strasburger, & Beattie, 2007), and negative perceptions of quality of life (Rosenfield, 1997). In addition, perceived stigma held by people with SMI has been associated with one treatment-related process. Sirey et al. (2001) found that individuals who have higher perceived stigma have lower odds of being medication compliant. A direct effect of perceived stigma on working alliance has yet to be studied. However, the relationship between perceived stigma and medication compliance (Sirey et al., 2001) suggests that perceived stigma can be a barrier to treatment engagement. Therefore, perceived stigma may also be a barrier to the development of a strong working alliance.
Another factor that has been neglected by researchers studying the working alliance is the direct role that treatment providers play in the development of the working alliance. Neither Draine and Solomon (1996) nor Klinkenberg et al. (1998) explored the effects of case managers on consumer perceptions of the working alliance. Ryan, Sherman, and Judd (1994) argued that case managers themselves significantly differ in their implementation of case management services "in ways that are not tied to the particular type of service under study" (p. 965). Ryan et al. argued that provider effects confound the effects of treatment and can significantly affect the effectiveness of treatment for consumers. They explored the effects of case managers on consumers' length of tenure in the case management program (short-term versus long-term tenure). They found that case managers significantly correlated with the length of time...