An Exploration of the Working Alliance in Mental Health Case Management.

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. LITERATURE REVIEW 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. …