ArticleLiterature Review

The Therapeutic Alliance: The Key to Effective Patient Outcome? A Descriptive Review of the Evidence in Community Mental Health Case Management

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Abstract

The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and 'goodness-of-fit' between patients and case managers was sparse with no published Australian studies. The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.

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... trust, self-esteem, desire to connect) (Buck and Alexander, 2006;Redko et al., 2007). Studies have confirmed, moreover, that case manager-client working alliances increased mentally ill patients' medication compliance (Solomon et al., 1995;Howgego et al., 2003;Montreuil et al., 2012) and social functioning (Solomon et al., 1995;Ryan et al., 1999;Coffey, 2003;Calsyn et al., 2006;Hopkins and Ramsundar, 2006;Solomon et al., 2010;Tsai et al., 2013;Melau et al., 2015). Such working alliances also reduced patients' psychiatric symptoms (Calsyn et al., 2006;Rogers et al., 2008;Hicks et al., 2012;Zweben et al., 2015) and homelessness and reduced dropping-out of services (Johansson and Eklund, 2006;Zweben et al., 2015). ...
... In showing working alliances' positive association with improvement in client problem, the present study confirmed many prior results (Solomon et al., 1995;Ryan et al., 1999;Coffey, 2003;Howgego et al., 2003;Calsyn et al., 2006;Hopkins and Ramsundar, 2006;Rogers et al., 2008;Solomon et al., 2010;Hicks et al., 2012;Montreuil et al., 2012;Tsai et al., 2013;Melau et al., 2015;Zweben et al., 2015). The obtained odds ratio of the WAI scores (OR or e (0.02) (wai) ¼ 1.02) indicates that each 1-unit increase in WAI score increased by 2 per cent the likelihood a client respondent's problem had improved. ...
Article
This study was an examination of clients' outcomes in community-based case management, specifically those outcomes' relationships to clients' characteristics and to working alliances between case manager and client. Study data were collected using a survey of adults who received help from community-based social service agencies (n=101). Results showed that client-case manager working alliances promoted improvement in client problems, although improvement was hindered by worsening problem severity. Clients' outcomes were not significantly associated with their health, mental health or substance-use problems, or with social support they enjoyed, or with their gender, ethnicity, age or agency serving them. Based on this study, working alliance is an effective, even essential, intervention alleviating clients' problems.
... In the past decades, working alliance has emerged as a possible general factor explaining psychiatric rehabilitation success (21,22). It was found to have a positive influence on symptoms, level of functioning, social skills, quality of life, medication compliance, days of homelessness, and satisfaction with the care received (23)(24)(25). The working alliance can be described as a genuine cooperation between client and practitioner characterized by agreement on counseling goals, a shared commitment to the tasks of counseling, and the development of a personal bond between both actors (26)(27)(28). ...
... The working alliance can be described as a genuine cooperation between client and practitioner characterized by agreement on counseling goals, a shared commitment to the tasks of counseling, and the development of a personal bond between both actors (26)(27)(28). Previous research showed that working alliance robustly predicts rehabilitation outcome (24,29,30). Gehrs and Goering (31), for instance, found that the quality of the working alliance was positively related to rehabilitation goal attainment. ...
... The therapeutic alliance is a complex idea and process. Howgego et al. (2003) suggest that it is a concept comprising three main elements: ...
... The quality of the therapeutic alliance also appears to be the most important factor in mental health case management outcomes and even in service users adhering to prescribed medication (Howgego et al. 2003;Weiss et al. 2002). In the treatment of depression, therapeutic alliance relates directly to positive outcome, regardless of the treatment provided (Zuroff & Blatt 2006), and in bipolar disorder it has been described as a 'mood stabilizer' (Havens & Ghaemi 2005). ...
... Since COVID-19, many more providers have moved some or all of their services online [9][10][11]. However, unlike many other fields of healthcare, mental healthcare is as much an art as a science [12], with an effective therapeutic alliance an essential prerequisite [13,14]. Although video calls in everyday life have become increasingly routine, they remain, for many patients, relatively novel and, for some, a thoroughly disconcerting experience [15,16] that could theoretically threaten the development and maintenance of therapeutic relationships with healthcare professionals. ...
... "Elderly patients without support if there are concerns about capacity, consent or confidentiality." (R193) 14 Psychosis/paranoia (n = 33) 24% (n = 8). "Paranoid patients may be too fearful to attend hospital premises" (R385) "Most are, in the psychosis service, however some have preferred to not have the video on to avoid eye contact. ...
Article
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COVID-19 has placed additional challenges on mental health services. Video consultations (VCs) have provided a short-term solution to lockdown restrictions but could also increase long-term capacity to meet the anticipated rising demand. A total of 7752 VCs were conducted over six weeks. Thematic analysis of 474 online survey responses identified twenty patient attributes that influenced staffs’ decisions to offer VCs. Their opinions were diverse, at times contradictory, and not always evidence based. There was reasonable consensus (and published evidence to support) of the probable suitability of VC for patients who: are IT savvy and suitably equipped; are teenagers; live in remote/rural locations; have caring responsibilities; have anxiety disorders or express a preference. No consensus was reached regarding eight attributes and there was a corresponding paucity of evidence, indicating the need for further research. Conversely, old age; paranoia, sensory impairment/communication difficulties; high risk and trauma/PTSD (posttraumatic stress disorder) were generally seen as contraindicated by staff, despite published evidence of success elsewhere. It may be possible to overcome staff’s reticence to offer these groups VCs. As staff are effectively the gatekeepers to VC interventions, it is important to understand and support them to overcome reservations that are contrary to the empirical evidence base. This will ensure that their initial anxieties do not become unnecessary barriers to services for those most in need. As with all mental healthcare, such decisions should be made collaboratively, and on an individual basis.
... Researchers have investigated the central role of working alliance in reducing depression (DeRubeis & Feeley, 1990;Feeley, DeRubeis, & Gelfand, 1999), psychosis (Priebe & Gruyters, 1995;Tattan & Tarrier, 2000), and posttraumatic stress disorder symptoms (Marmar, Horowitz, Weiss, & Marziali, 1986). Overall, consumers' reports of greater working alliance with providers have been found to be a significant predictor of consumers' reported reduction in psychiatric symptoms, improvement in quality of life, achievement of individual goals, and increase in social functioning (Howgego, Yellowlees, Owens, Meldrum, & Dark, 2003;McCabe & Priebe, 2004). Provider-consumer relationship factors may not only be associated with consumers' sense of well-being and distress but may also relate to mental health providers' own sense of professional and personal growth (Stein & Craft, 2007;Osborn & Stein, 2015). ...
... positively related to their reports of their general well-being, regardless of their self-reported psychiatric symptoms. Present findings are consistent with a sizable existing literature that highlights the importance of the therapeutic working alliance in client care in a variety of outpatient settings (Howgego et al., 2003, Kidd et al., 2017Lambert & Barley, 2002;McCabe & Priebe, 2004). Previous studies of inpatient settings have examined role of working alliance in relation to treatment adherence (Wykes, Rose, Williams, & David, 2013) and symptom reduction (Arnow et al., 2013). ...
Article
Full-text available
Using a sample of 60 adults with serious mental illness in an inpatient psychiatric hospital, the present study examined the role of therapeutic relationship characteristics between consumers and mental health providers and consumers’ views of recovery-oriented service delivery and individual well-being. Specifically, the present study examined how consumers’ reports of working alliance and provider directiveness were associated with consumers’ views of recovery-oriented service delivery and individual well-being. After controlling for demographic characteristics, self-reported psychiatric symptoms and number of hospitalizations, findings suggested that consumers’ reports of stronger working alliance and higher levels of provider directiveness were significantly related to higher perceptions of recovery-orientation in the inpatient hospital setting. Findings indicated that consumers’ views of stronger working alliance were associated with higher levels of individual well-being. Implications of findings are discussed.
... In the past decades, working alliance has emerged as a possible general factor explaining psychiatric rehabilitation success (21,22). It was found to have a positive influence on symptoms, level of functioning, social skills, quality of life, medication compliance, days of homelessness, and satisfaction with the care received (23)(24)(25). The working alliance can be described as a genuine cooperation between client and practitioner characterized by agreement on counseling goals, a shared commitment to the tasks of counseling, and the development of a personal bond between both actors (26)(27)(28). ...
... The working alliance can be described as a genuine cooperation between client and practitioner characterized by agreement on counseling goals, a shared commitment to the tasks of counseling, and the development of a personal bond between both actors (26)(27)(28). Previous research showed that working alliance robustly predicts rehabilitation outcome (24,29,30). Gehrs and Goering (31), for instance, found that the quality of the working alliance was positively related to rehabilitation goal attainment. ...
Article
Full-text available
Objective: A key aspect of psychiatric rehabilitation is supporting individuals with serious mental illness in reaching personal goals. This study aimed to investigate whether various aspects of the working alliance predict successful goal attainment and whether goal attainment improves subjective quality of life, independent of the rehabilitation approach used. Methods: Secondary analyses were conducted of data from a Dutch randomized clinical trial on goal attainment by individuals supported with the Boston University approach to psychiatric rehabilitation (N=80) or a generic approach (N=76). Working alliance was measured with the Working Alliance Inventory (WAI) from the practitioner's perspective. Rehabilitation practitioners had backgrounds in social work, nursing, or vocational rehabilitation. Multiple logistic regression and multiple regression analyses explored effects of working alliance on goal attainment and of goal attainment on subjective quality of life at 24 months. Analyses were controlled for client- and process-related predictors, baseline quality of life, and rehabilitation approach. Results: The WAI goal subscale predicted goal attainment at 24 months. No effect was found for the bond or task subscale. Goal attainment significantly predicted quality of life at 24 months. These effects were independent of the rehabilitation approach used. Conclusions: A good bond between client and practitioner is not enough to attain successful rehabilitation outcomes. Findings suggest that it is important to discuss clients' wishes and ambitions and form an agreement on goals. Attaining rehabilitation goals directly influenced the subjective quality of life of individuals with serious mental illness, which underscores the importance of investing in these forms of client support.
... One additional aspect that may influence outcomes in the context of IPS might be the relationship established between the job coach and the participant. The importance of working alliance has been highlighted in a range of mental health service contexts (Howgego, Yellowlees, Owen, Meldrum & Dark, 2003;Schweizer et al., 2018) and has recently been explored in the context of IPS (Topor & Ljungberg, 2016). Topor and Ljungberg (2016) explored perceptions of IPS participants about their relationships with their job coach. ...
Article
Introduction Engaging in employment enhances mental health recovery and is therefore of central focus for many occupational therapists working in mental health. Individual placement and support (IPS) is an evidence‐based, supported employment model specifically designed for individuals with severe mental illness who have the desire to work. Despite strong support for IPS in Australia, implementation challenges have been encountered. This study evaluates outcomes achieved by participants engaged with WorkWell, an IPS programme delivered by a large Australian non‐government organisation. In addition to following IPS principles, WorkWell was informed by principles of the collaborative recovery model (CRM). Method De‐identified outcomes data for each participant were analysed by an independent research team. The proportion of individuals engaged with the programme who achieved a competitive employment placement was calculated. Average employment duration and weekly wages were calculated for individuals who achieved a competitive employment placement. Finally, the proportion of individuals who achieved some form of vocationally relevant outcome was calculated. Results Ninety‐seven participants were engaged with the programme. Forty‐eight participants (49.5%) gained a competitive employment position. Average employment duration was 151 days (21.6 weeks) and average weekly wage was $478. Overall, 62 participants (63.9%) were supported to achieve some kind of vocationally relevant outcome (e.g. competitive employment, education, work trial or voluntary work) as a result of their engagement with the programme. Conclusion While the addition of CRM principles appears to have supported positive outcomes for participants, especially in terms of employment duration, results for employment placement rates were lower than expected. While the employment placement rate compares favourably to results from the international literature and numerous programmes in Australia, more development is required to increase the proportion of individuals who are supported into competitive employment positions. Future research should focus on the specific elements of CRM that most contribute to enhancing IPS processes.
... Compared to the psychotherapy literature, there has been less attention to the client-provider relationship in the social work literature. Evidence that does exist comes from a small but growing number of systematic reviews evaluating the associations of the client-provider relationship with outcomes relevant to social service delivery, for example, within the sectors of chronic and severe mental illness (Hewitt & Coffey, 2005;Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003;McCabe & Priebe, 2004;Priebe, Richardson, Cooney, Adedeji, & McCabe, 2011), child welfare (Green, 2006;Karver, Handelsman, Fields, & Bickman, 2006), and substance abuse (Marsh, Angell, Andrews, & Curry, 2012;Meier, Barrowclough, & Donmall, 2005). The main characteristics distinguishing social work research on client-provider relationship from psychotherapy research has been the definition of social service outcomes related to social and economic functioning as compared with the more narrow psychiatric outcomes typically assessed in psychotherapy research. ...
Chapter
Two major developments in the field of social work underscore the role of practice as an important bridge between scholarship and service delivery and as an active strategy for learning, improving outcomes, and advancing the discipline/profession. These include the recalibration of the practitioner–client relationship and the implementation of evidence-based practices. Both of these developments elevate interest in practice strategies, such as relational approaches to care and shared decision-making, that prioritize and privilege client characteristics, needs, values, and preferences along with practitioner expertise. This chapter examines these phenomena including the concept of the client–provider relationship as a central construct in social work practice. It discusses examples of research in these two areas and advocates for a scientific practice where client needs and preferences are a central concern and where the practitioner–client relationship becomes an essential focus of study.
... [24] The focus of such a relationship is to empower and help older adults remain in control of their lives, [25] as well as to improve patient outcomes. [26,27] A relationship that is built on trust should therefore be seen as a prerequisite for acting as an older adult's representative or "voice" when organizing and coordinating care and support. ...
Article
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Background Due to the rise in the number of older adults within the population, healthcare demands are changing drastically, all while healthcare expenditure continues to grow. Person-centered and integrated-care models are used to support the redesigning the provision of care and support. Little is known, however, about how redesigning healthcare delivery affects the professionals involved. Objectives To explore how district nurses and social workers experience their new professional roles as case managers within Embrace, a person-centered and integrated-care service for community-living older adults. Methods We performed a qualitative study consisting of in-depth interviews with case managers (district nurses, n = 6; social workers, n = 5), using a topic-based interview guide. Audiotaped interviews were transcribed verbatim and analyzed using qualitative content analysis. Results The experiences of the case managers involved four major themes: 1) the changing relationship with older adults, 2) establishing the case-manager role, 3) the case manager’s toolkit, and 4) the benefits of case management. Within these four themes, subthemes addressed the shift to a person-centered approach, building a relationship of trust, the process of case management, knowledge and experience, competencies of and requirements for case managers, and the differences in professional background. Discussion We found that this major change in role was experienced as a learning process, one that provided opportunities for personal and professional growth. Case managers felt that they were able to make a difference, and found their new roles satisfying and challenging, although stressful at times. Ongoing training and support were found to be a prerequisite in helping to shift the focus towards person-centered and integrated care.
... Training characteristics. Participants were asked to identify training level (Mallinckrodt & Nelson, 1991) and prior experience in a helping profession or role (Boyer, 2010;Brunero, Lamont, & Coates, 2010;Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003) because of possible variance in the working alliance attributed to these constructs. Participants identified their training level by indicating current enrollment in either a practicum course, a first internship course, or a second internship course. ...
Article
The authors examined whether the working alliance differed among 182 counselors‐in‐training who differed in the frequency of engaging in mindfulness practice. Participants who engaged in mindfulness practices 4 or more times per week reported higher scores on the goal and task components of the working alliance, compared with all other groups.
... The 'recovery shift' in mental health, together with the increase in community-based care has generated recovery-focused research on professional relationships and outcomes in vocational rehabilitation (Catty et al., 2011) and case management (De Leeuw, Van Meijel, Grypdonck, & Kroon, 2012;Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003), and on service users' experiences of professional relationships in several contexts of community-based mental health care (Andersson, 2016;Borg & Kristiansen, 2004;Brekke, Lien, & Biong, 2018;Kidd, Davidson, & McKenzie, 2017;Ljungberg, Denhov, & Topor, 2015;Topor, Bøe, and Larsen (2018); . ...
Article
Full-text available
This article explores how professional relationships may be helpful from the perspective of residents in staffed supportive housing for individuals with severe mental health and/or drug problems. Using in-dept interviews, residents were individually asked to describe a helpful relationship with a self-chosen staff member, the content of the help provided by this staff member and how this help influenced their lives. Using thematic analysis, we found that the residents described mutual relationships that resembled friendships and helpful staff members who carried out a variety of doings. Four domains of doings were identified: small human gestures, filling the hours with ‘friendship’, enabling the residents to take care of their own needs and fighting on behalf of the residents to ensure rights and benefits. To some of the residents, these doings had life-changing impact. We propose that service management within relationship-based practices should be open for friendship resemblance when matching professionals and service users and make room for a diversity of doings rooted in the service users’ perceived needs.
... In this study, we found three central themes that almost exactly correspond to the components of the WA that Bordin (1979) identified: agreement between therapist and patient on the therapeutic goals and therapeutic tasks, and the quality of the personal bond between the patient and the professional. This view of the WA is still widely adhered to in psychotherapy, in other professions, and in multidisciplinary contexts (Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003;Stommel, 2003). Indeed, the WA is an important factor in various treatment contexts (Stommel, 2003). ...
Article
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In the Netherlands, long-term community psychiatric treatment for patients with a severe mental illness (SMI) is poorly developed and lacks a structured, goal-centered approach. Often this form of treatment is provided by community mental health nurses (CMHN’s). Especially in the group of nonpsychotic patients with SMI, it often leads to care-as-usual with limited proven interventions and an unstructured treatment. Interpersonal Community Psychiatric Treatment (ICPT) was developed to provide this group of patients a focus, a theoretical view, and a methodological structure. A pilot study has been conducted on ICPT. As a result, a randomized controlled trial (RCT) was recently conducted in which this study is part. The pilot study showed improvement on a number of treatment outcomes. However, the working alliance (WA) experienced by the patients, although not significant, was considered to be decreased. The aim of study was to gain insight into how the ICPT-elements shape the WA and the possible self-determination of patients in general. The main part of this mixed-methods study was a qualitative study with a Grounded Theory approach. For the selection of the participants, quantitative data from the current RCT has been used. Semistructured interviews have been conducted with 13 participants, divided over three mental health institutions throughout the Netherlands. Interviews and analysis were alternated, so that the interview topics were developed by constant comparison. Eleven participants were female and 11 participants received social benefit. Six of the participants were above 50 years of age. Four participants suffered either from a depressive or anxiety disorder. Seven participants had a borderline personality disorder. The results are linked to Bordin’s theory of the therapeutic alliance, which is agreement on therapeutic tasks, agreement on therapeutic goals, and the quality of the personal bond. The WA could be analyzed from three different perspectives: mutually agreed on goals, tasks, and experienced interpersonal relationship. ICPT had limited influence on the mutually agreed on goals and interpersonal relationship but mainly on the mutually agreed on tasks. In daily practice, ICPT may have a positive influence on the perceived WA. The main factors that affected the perceived WA during ICPT were the tasks that had been mutually agreed on, the use of an agenda, the structure of the sessions, the alliance between the CMHN and the patient, and the patient’s own self-determination. There was a limited influence on the mutually agreed on goals and the quality of the personal relationship between the CMHN and the patient. The present research revealed valuable information about the significance of the WA in ICPT and the opinions of the respondents about ICPT and information about what might be helpful or unhelpful in their relationship with their CMHN.
... Research on a related concept, the working alliance in mental health case management, is less extensive. Some case management research has shown that a stronger client-case manager working alliance is associated with decreased levels of mental health problems, higher functioning, and higher satisfaction with care (4)(5)(6)(7). Effects of this alliance-outcome relationship are similar to those found in psychotherapy studies, with effect sizes (assessed as Pearson r correlation) ranging from 0.19 to 0.32 (3). ...
Article
Objective: The purpose of this study was to examine how the client–case manager working alliance in strengths model case management (SMCM) mediates the relationship between fidelity to the SMCM intervention and clients’ quality of life, hope, and community functioning. Methods: In total, 311 people with severe mental illness, served at seven community mental health agencies in Canada, participated in the study. They were new to SMCM and participated in five structured interviews every 4.5 months for 18 months to measure the quality of the client–case manager working alliance and clients’ quality of life, hope, and community functioning. The team-level SMCM fidelity scale was administered six times over 3 years. Ordinary least-squares path analysis was used to test simple mediation models. Results: Higher fidelity to SMCM was associated with better client outcomes indirectly through the working alliance. Higher SMCM fidelity predicted a stronger working alliance, which in turn predicted greater improvements in client quality of life (at 9 months and 18 months), hope (at 18 months), and community functioning (at 9 months). Conclusions: The results support the view that SMCM is an effective intervention. When the intervention was implemented as planned, it fostered stronger working alliances between clients and case managers and contributed to greater improvements in the quality of life, hope, and functioning of people with severe mental illness. The findings of this study highlight the value of ongoing monitoring of implementation fidelity to achieve high-fidelity interventions that may lead to positive client outcomes.
... The concept of treatment alliance in psychiatry has its origins in psychoanalysis and psychotherapy [36][37][38][39] . However, rather than the transference based psychoanalytic concepts of therapeutic relationships, psychiatry has found it easier to adopt the pan-theoretical construct of working alliance proposed by Bordin [40] , which focuses on a "here and now" approach to alliance. ...
... The synthesis reported in study 2 suggested that CAC improved the alliance in the care dyad, with these findings being confirmatory and complementary. Improvements in the alliance would reduce the double negative impact identified by Howgego et al. (2003). Client fragmentation benefited more than client distress in the case series. ...
Article
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Objectives This study sought to employ the hourglass model to frame the methodological evolution of outcome studies concerning 5‐session cognitive analytic consultancy (CAC). Design Pre‐post mixed methods evaluation (study one) and mixed methods case series (study two). Methods In study one, three sites generated acceptability and pre‐post effectiveness outcomes from N = 58 care dyads, supplemented with qualitative interviewing. The client outcome measures included the Clinical Outcomes in Routine Evaluation Outcome Measure, Personality Structure Questionnaire, Work and Social Adjustment Questionnaire, Service Engagement Scale, and the Working Alliance Inventory. Study two was a mixed methods case series (N = 5) using an A/B phase design with a 6‐week follow‐up. Client outcome measures were the Personality Structure Questionnaire, Clinical Outcomes in Routine Evaluation Outcome Measure, and the Working Alliance Inventory, and the staff outcome measures were the Working Alliance Inventory, Maslach Burnout Inventory, and the Perceived Competence Scale. Results In study one, the cross‐site dropout rate from CAC was 28.40% (the completion rate varied from 58 to 100%) and full CAC attendance rates ranged from 61 to 100%. Significant reductions in client distress were observed at two sites. Qualitative themes highlighted increased awareness and understanding across care dyads. In study two, there was zero dropout and full attendance. Clients were significantly less fragmented, and staff felt significantly more competent and less exhausted. Potential mechanisms of change were the effective process skills of the consultant and that emotionally difficult CAC processes were helpful. Conclusions Cognitive analytic consultancy appears a promising approach to staff consultation, and testing in a clinical trial is now indicated. Practitioner points • CAC is a suitable method of consultation for care dyads struggling to work effectively together in CMHTs. • Staff feel more competent and clients feel less fragmented following CAC, and the benefits of CAC appear to be maintained over follow‐up time. • CAC processes can be difficult for care coordinator and client, but this is not an impediment to change.
... Further, a branch of the recovery-oriented research has explicitly focused on the helpful aspects of professional relationships (Ljungberg et al., 2015). In accordance with relationship-focused studies on psychotherapeutic interventions (Gelso, 2014;Horvath, Del Re, Flückiger, & Symonds, 2011;Laska, Gurman, Wampold, & Hilsenroth, 2014) and psychiatric interventions (Moran et al., 2014;Priebe, Richardson, Cooney, Adedeji, & McCabe, 2011), relationship-focused studies on various forms of community-based interventions for people diagnosed with SMI have found that the quality of the therapeutic alliance (mutual trust and respect, and agreement on aims and on how they are to be pursued) predicts the outcome for the service users (Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003;Kidd, Davidson, & McKenzie, 2017). ...
Article
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Introduction In the aftermath of the deinstitutionalisation in western countries, new community‐based mental health services have been established. An essential object of studies in this new institutional landscape has been helpful professional relationships, but we still lack knowledge about helpful relationships in community‐based institutional supportive housing. Aim To explore how staff members describe their relationships with residents who have identified them as helpful. Methods Qualitative interviews with nine staff members were analysed using thematic analysis. Results “Reciprocity” was identified as the main theme, and two subthemes were developed; “Something influential about the resident” and “Value for the staff member”. Discussion The findings are discussed and related to existing conceptualisations of reciprocity in professional relationships, and an additional conceptualisation is suggested. Implications for practice To promote reciprocity, managers should consider both parties’ personal preferences when matching professionals and service users. Further, professionals should get involved in ways that open up for being influenced and inspired by several of the service user’s characteristics. They should allow themselves to enjoy the company of the service user in ways that promote multifaceted reciprocity.
... Within mental health care, the trust relationship between care provider and care receiver is of great importance in the effectiveness of therapy (see for example: Anthony et al. 2010;Day et al. 2005;Howgego et al. 2003). STS and sociology of technology literature focus on how the use of (eHealth) technology affects the interpretation of one's own body and the relationship with health professionals. ...
Article
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Quality of life (QoL) is an important outcome measure in mental health care. Currently, QoL is mainly measured with paper and pencil questionnaires. To contribute to the evaluation of treatment, and to enhance substantiated policy decisions in the allocation of resources, a web-based, personalized, patient-friendly and easy to administer QoL instrument has been developed: the QoL-ME. While human values play a significant role in shaping future use practices of technologies, it is important to anticipate on them during the design of the QoL-instrument. The value sensitive design (VSD) approach offers a theory and method for addressing these values in a systematic and principled manner in the design of technologies. While the VSD approach has been applied in the field of somatic care, we extended the VSD approach to the field of mental healthcare with the aim to enable developers of the QoL-instrument to reflect on important human values and anticipate potential value conflicts in its design. We therefore explored how VSD can be used by investigating the human values that are relevant for the design of the QoL-ME. Our exploration reveals that the values autonomy, efficiency, empowerment, universal usability, privacy, redifinition of roles, (redistribution) of responsibilites, reliability, solidarity, surveillance and trust are at stake for the future users of the technology. However, we argue that theoretical reflections on the potential ethical impact of a technology in the design phase can only go so far. To be able to comprehensively evaluate the usability the VSD approach, a supplementary study of the use practices of the technology is needed.
... We set out to collate and synthesise information pertaining to interventions that aim to support effective therapeutic alliance between nursing staff and users of mental health services, which has been shown to be central to positive outcomes in both psychotherapy and broader engagement contexts ( Cruz and Pincus, 2002 ;Duncan et al., 2010 ;Howgego et al., 2003 ;Martin et al., 20 0 0 ;Messer and Wampold, 20 02 ;Priebe and McCabe, 2006 ). The central finding of note, in the authors' view, is the dearth of studies in this area. ...
Article
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Background: Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships. Objectives: We aimed to collate and critique papers reporting on interventions targeted at improving the nurse-patient therapeutic alliance in mental health care settings. Design: Systematic literature review. Data sources: The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted. Review methods: Original journal articles in English language were included where they reported on interventions targeting the nurse-patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment. Results: Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality. Conclusions: The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.
... Therapeutic alliance, the relationship between a patient and a psychotherapist makes important and positive effects in treatment outcome and effectiveness studies. Having positive alliance, trust and genuineness in psychotherapist-patient dyad could make a therapy effective (Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003). In a study, sample consisted of people suffering from childhood abuse-related posttraumatic stress disorder (PTSD) and successful therapy outcomes were result of therapeutic alliance and emotional regulation capacity (Cloitre, Chase Stovall-McClough, Miranda, & Chemtob, 2004). ...
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Victimology concerns victims of various traumas from accidents, disasters, assaults to wars. Survivors of trauma are also an area in clinical psychology since it is interested in the assessment and diagnosis of psychopathology and psychotherapy. Stress and mental health are intertwined; increased stress results in difficulties in feeling, thinking and behaving. The stress symptoms are an intrusion, avoidance, negative cognitions and mood, and arousal and reactivity. A trauma survivor might develop post-traumatic stress disorder. Healing trauma is so comprehensive that many professionals work from different aspects. From attorneys to mental health workers, many professionals deal with the aftereffects of trauma. Engaging with details of the trauma endangers not only the victims but also the professionals working with the victims. These professionals end up having psychological effects such as secondary trauma, vicarious trauma, compassion fatigue, countertransference and occupational burnout. Trauma has serious effects on its victims but not all effects are negative and paralyzing. Trauma victims might change their priorities in a way that they report more personal control over their life. This phenomenon is called posttraumatic growth. The paper aims to collaborate victimology with clinical psychology by highlighting psychopathology and psychological assessment.
... The nature of the role adjunct support plays in iCBT program use is also unclear. It has been suggested that adjunct support may leverage the advantages of therapeutic alliance [101,102], which might include principles of persuasion (eg, users feel the need to respond to social cues [18]), it may establish process expectations and social accountability [ ...
Article
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Background: Internet-based cognitive behavioral therapy (iCBT) is a persuasive system as its design combines therapeutic content, technological features, and interactions between the user and the program to reduce anxiety for children and adolescents. How iCBT is designed and delivered differs across programs. Although iCBT is considered an effective approach for treating child and adolescent anxiety, rates of program use (eg, module completion) are highly variable for reasons that are not clear. As the extent to which users complete a program can impact anxiety outcomes, understanding what iCBT design and delivery features improve program use is critical for optimizing treatment effects. Objective: The objectives of this study were to use a realist synthesis approach to explore the design and delivery features of iCBT for children and adolescents with anxiety as described in the literature and to examine their relationship to program use outcomes. Methods: A search of published and gray literature was conducted up to November 2017. Prespecified inclusion criteria identified research studies, study protocols, and program websites on iCBT for child and adolescent anxiety. Literature was critically appraised for relevance and methodological rigor. The persuasive systems design (PSD) model, a comprehensive framework for designing and evaluating persuasive systems, was used to guide data extraction. iCBT program features were grouped under 4 PSD categories-Primary task support, Dialogue support, System credibility support, and Social support. iCBT design (PSD Mechanisms) and delivery features (Context of use) were linked to program use (Outcomes) using meta-ethnographic methods; these relationships were described as Context-Mechanism-Outcome configurations. For our configurations, we identified key PSD features and delivery contexts that generated moderate-to-high program use based on moderate-to-high quality evidence found across multiple iCBT programs. Results: A total of 44 documents detailing 10 iCBT programs were included. Seven iCBT programs had at least one document that scored high for relevance; most studies were of moderate-to-high methodological rigor. We developed 5 configurations that highlighted 8 PSD features (Tailoring, Personalization [Primary task supports]; Rewards, Reminders, Social role [Dialogue supports]; and Trustworthiness, Expertise, Authority [System credibility supports]) associated with moderate-to-high program use. Important features of delivery Context were adjunct support (a face-to-face, Web- or email-based communications component) and whether programs targeted the prevention or treatment of anxiety. Incorporating multiple PSD features may have additive or synergistic effects on program use. Conclusions: The Context-Mechanism-Outcome configurations we developed suggest that, when delivered with adjunct support, certain PSD features contribute to moderate-to-high use of iCBT prevention and treatment programs for children and adolescents with anxiety. Standardization of the definition and measurement of program use, formal testing of individual and combined PSD features, and use of real-world design and testing methods are important next steps to improving how we develop and deliver increasingly useful treatments to target users.
... That those with a stronger initial alliance were more likely to achieve a goal suggests that there was a stronger collaboration on goal setting, and this suggests that working alliance and goal achievement should be a part of routine outcome reviews along with mental health recovery for the provision of the most appropriate support environment or support person. The effect of working alliance on recovery was similar to those obtained in earlier studies (Howgego et al., 2003;Martin et al., 2000). The high client scores on the WAI raise the issue of (Trochim, 2006). ...
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This article examines the relationships between goal setting and achievement, working alliance and recovery in an Australian mental health community-managed organisation. The study gathered data over a 14-month period after the introduction of routine outcome measures. Both goal achievement and the strength of the working alliance were shown to have a positive effect on the personal recovery of the clients in the study. Both working alliance and goal achievement are robustly supportive at whatever point a person is on in the recovery journey. The brief goals card used is a useful adjunct to other tools.
... Association of the therapeutic alliance with psychotherapeutic outcomes has led to further investigation in fields beyond psychotherapy (Green, 2006). For example, researchers have investigated the alliance in cognitive behavioural therapies for depression and anxiety (Webb et al., 2011;Westra, Constantino, & Aviram, 2011), insomnia (Constantino et al., 2007) as well as other areas such as community mental health practice (Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003;Kirsh & Tate, 2006) and vocational rehabilitation (Lustig, Strauser, Rice, & Rucker, 2002). ...
Article
Objective A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme. Method This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison. Results A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance. Conclusion These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.
... First, the instrument takes into account the perspectives of both the client and the professional. Several studies have shown there is only a low to moderate correlation between the working alliance scores of clients and those of professionals [12,31,32,34,51,[54][55][56][57][58]. Thus, the current study took both perspectives into account in the construction of the instrument and developed two versions of the instrument-one for the client and one for the professional. ...
Article
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Background In this study, we aimed to identify and define the fundamental components of the working alliance in multidisciplinary (Flexible) Assertive Community Treatment teams with shared caseloads, in order to support their daily practice and further research. Methods After reviewing the literature, concept mapping with professionals and clients was used to define the working alliance in (F) ACT teams. The resulting concept maps formed the basis for the working alliance assessment instrument, which was pilot tested with professionals and clients through cognitive interviews with a think-aloud procedure. Results The study led to the development of a twenty five-item assessment instrument to evaluate working alliances in multidisciplinary teams (WAM) that was comprised of three subscales: bond, task/goal and team. Two different versions were developed for clients and professionals. Conclusions The WAM instrument was developed to determine the quality of the working alliance in (F) ACT teams. Future research will focus on testing its psychometric properties and predictive value.
... While the working alliance in psychotherapy (usually referred to as the "therapeutic alliance") has been thoroughly researched with consistent positive results (Fluckiger et al., 2012(Fluckiger et al., , 2018Horvath, 2018;Wampold, 2015), the evidence base of the working alliance in mental health case management interventions is small with more variable research methods than psychotherapy research (De Leeuw et al., 2012;Kidd et al., 2017;McCabe & Priebe, 2004). Overall, mental health case management studies show a relationship between the working alliance and client outcomes, such as better functioning, lower depression, overall life satisfaction, and improved quality of life (Ashford et al., 2010;De Leeuw et al., 2012;Howgego et al., 2003;Kidd et al., 2017;Kondrat, 2012;Kondrat & Early, 2010;Latimer & Rabouin, 2011;McCabe & Priebe, 2004;Sandu et al., 2021;Tsai et al., 2013). Some proposed underlying mechanisms of change within the working alliance include having clear goals, having small caseloads, affirming a person, mutual respect, adopting structured interventions, and being a responsive case manager (Baldwin et al., 2007;De Leeuw et al., 2012;Farrelly & Lester, 2014;Fluckiger et al., 2018;Kidd et al., 2017;Wampold, 2015). ...
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The purpose of this study was to examine clients’ perceptions of the client-case manager working alliance in the context of receiving the Strengths Model of Case Management. Twenty people with severe mental illness, with a SMCM case manager, participated in semi-structured, qualitative interviews. Using first and second cycle coding, data were analyzed thematically. People in the study attributed personal life changes to their relationship with their case manager. They valued their case managers’ flexibility and highlighted their work on a wide range of goals of their choosing. Case managers approached the SMCM intervention responsive to their clients’ preferences and choices. The working alliance serves as a key element of the SMCM intervention. Clients describe the working alliance as helping to improve their lives. This study supports the implementation of SMCM with people with severe mental illness due to its focus on fostering a strong working alliance.
... The importance of building and maintaining a positive relationship between service provider and client is well documented. Considered as a "quintessential integrative variable" that cuts across different modes of treatment and models of service delivery (Wolfe & Goldfried, 1988, p.449), the impacts of high quality therapist-client relationships are not confined to outcomes of psychotherapy such as patient satisfaction and treatment adherence (Krupnick et al., 1996;Ross, Polaschek, & Ward, 2008), but also that of psychiatric treatment (Alverson, Alverson, & Drake, 2000;Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003;McCabe & Priebe, 2004), substance abuse treatment (Connors, DiClemente, Carroll, Longabaugh, & Donovan, 1997;Miller & Rollnick, 2012), medical care (Cooper-Patrick et al., 1999;Hall, Horgan, Stein, & Roter, 2002), and change-oriented interventions for offenders (for reviews see, Gleicher et al., 2013;Horvath, Re, & Symonds, 1991;Kennealy et al., 2012;Manchak, Skeem, Kennealy, & Louden, 2014;Polaschek & Ross, 2010;Skeem, 2007;Skeem & Manchak, 2008). Meta-analytic reviews have found the therapist-client relationship to be the single highest contributor of variance in therapeutic outcomes (e.g. ...
Technical Report
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Aims The aim of this study was to explore dynamics of the dual role relationship between offenders and Community Corrections officers, in the context of implementing the new Practice Guide for Intervention (PGI) model of community supervision. A secondary aim was to examine the extent to which differences in officer characteristics or performance contribute to offender ratings of the dual role relationship. Methods Community Corrections officers (n = 30) were recruited to administer the Dual-Role Relationships Inventory-Revised (DRI-R) to offenders under their supervision (n = 103). In addition to diagnostic and descriptive analyses, this study employed a novel multilevel modelling design to estimate variance in DRI-R scores that may be attributed to differences at the offender and at the officer level. Results Offenders gave almost uniformly positive ratings of their supervising officer on the DRI-R, with evidence of ceiling effects for each of the factorial and Total scores on the measure. Multilevel models indicated that non-significant levels of variance could be attributed to differences across officers or particular officer-level predictor variables. At the offender level there was a marginal association between number of sessions attended with the current supervising officer and ratings on the Toughness subscale. Conclusion The results of this study suggest that Community Corrections officers may be consistently delivering the PGI and other supervision content in a manner that promotes quality dual role relationships with offenders. However, it is likely that the validity of these outcomes were influenced by offender response biases that were potentially exacerbated by methodological constraints imposed on the study. Future research and evaluation on relationships between community-based offenders and supervising officers may benefit from development of robust procedures for the selection and assessment of offenders.
... However, these opportunities are limited. It should be remembered that the psychotherapeutic process -as research showsis effective for about 60%-70% of people who use it and, moreover, it provides the greatest benefits to those who can build a good relationship with their psychotherapist (Hall, ferreira, Maher, latimer, & ferreira, 2010;Howgego, yellowlees, owen, & Meldrum, 2003;Karver et al., 2008;Szymańska, Dobrenko, & Grzesiuk, 2015. As modern models show, a good relationship with a psychotherapist directly explains the effectiveness of psychotherapy . ...
Book
The aim of the research described in the book was to check whether there are re�lationships between the parental mistakes that women who are bringing up pre�school children experienced in their families of origin (on the part of their mother and their father) and any parental mistakes that they themselves make. It investi�gated how the experience of parental mistakes in families of origin and parental mistakes made by mothers are related to traits of the mothers, such as: personality, value system, satisfying needs, locus of control, mother’s parental goals and child’s temperamental features. The study also examined whether mothers’ experiencing of parental difficul�ties (parental stress) is related to their inability to achieve their parental goals and whether these difficulties determine their parental mistakes. It explored whether women who experienced more child-rearing mistakes in childhood more strongly experience difficulties in raising their own children, as a result of which they make more child-rearing mistakes. Ultimately, one of the most important research goals was to check whether one can predict the level of parental mistakes made by mothers, given information about parental goals, parental difficulties experienced and ways of dealing with these difficulties (stress). The study was conducted on a sample of 402 mothers with children aged three to six years, i.e., preschoolers. There was an equal representation of mothers of girls and boys in the sample. In the study sample, the largest group of mothers was be�tween 28 and 39 years old. The vast majority of mothers in the sample had a uni�versity degree. In order to calculate the results and answer the questions posed in the work, the method of structural equation modelling was used, which aimed to check the correctness of the structural model, presenting the relationship between mothers making parental mistakes, the inability of mothers to achieve their parental goals, experiencing of parental difficulties and their stress response, namely, applying pressure, withdrawing from the upbringing situation, seeking help or taking cog�nitive distance. In order to answer the questions about the relationship between parental mis�takes experienced by mothers in childhood, their parental mistakes, their person�ality traits, needs, system of values, locus of control and parental goals and the temperamental characteristics of their children, cluster analysis was used, which calculate data mining algorithms. The text mining method was used to transform qualitative data — such as words describing mothers’ parental goals — into nu�merical data. It was therefore used to prepare the database for analysis. The results of this analysis confirmed the correctness of the structural model, which assumed that the inability of mothers to achieve parental goals is related to their experiencing parental difficulties (stress) as well as their use of non-adap�tive stress responses, such as applying pressure or withdrawing from the upbringing situation. As a consequence of using non-adaptive reactions to stress, the mother makes parental mistakes. The study revealed that among the mothers who experi�enced more parental mistakes in childhood, the structure discussed above is strong�ly interrelated. Among the mothers who experienced fewer parental mistakes, the correlations between variables are weaker and some do not occur at all (the struc�ture breaks down). Given information about whether mothers can achieve their parental goals, whether mothers experience parental difficulties and the nature of their stress response, it is possible to predict the parental mistakes of aggression and strictness as well as mothers’ self-accentuation and indulging the child. For other parental mistakes, the prediction is moderate or weak. The results also revealed that mothers who experienced fewer parental mistakes in childhood also made fewer parental mistakes themselves, had more developed “Plus” personality traits — particularly integrated personality traits — had needs which were better met, had less of an external locus of control and demonstrated certain values more strongly — especially values associated with kindness, reliability and caring for others; these mothers also developed in their children the features of an integrated personality and tried to prevent their children from developing disharmonized personality traits. It was shown that the children of these mothers were characterized by an easier temperamental type. The mothers who experienced more parental mistakes in childhood also com�mitted more parental mistakes, had similar “Plus” and “Minus” personality traits at a similar level — especially such values as power over resources and power over people, but mostly had lower values — had lower needs and their children had a much more difficult temperamental type than mothers who experienced fewer parental mistakes. Summing up, the research results allow us to conclude that certain parental mistakes or a tendency to manifest parental mistakes is inherited. This may bedue to the fact that the mother, whether consciously or not, imitates the behavior of her parents, and by modeling she learns how to be a parent. What’s more, the findings regarding the stress response with parental mistakes revealed that the group of mothers who experienced more parental mistakes is more prone to ex�periencing parental difficulties and stress. These mothers are less able to deal with the difficulties they encounter in the upbringing process of their children and, as a consequence, they make more parental mistakes
... People receiving mental health care are more likely to share personal information needed to inform treatment options. Research supports that a trusting relationship with a clinical provider can strengthen alliance and prevent crises or other serious negative outcomes (Arnow & Steidtmann, 2014;Howgego et al., 2003). To improve partnerships, clinical providers can offer options and have a conversation, even when yielding to the individual's request is not feasible. ...
Article
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There is increased interest over the last decade in the use of Shared Decision Making with individuals with serious mental illness to improve engagement in treatment and clinical outcomes. We conducted semi-structured qualitative interviews with 15 individuals with serious mental illness treated in an outpatient transitional care clinic serving people immediately after discharge from a psychiatric hospitalization. Parallel interviews were conducted with a variety of clinical providers ( n = 9). Using latent thematic analysis, six themes were identified including: (1) Differences in the Use of SDM, (2) Consideration of Past Experiences, (3) Decisional Power Preferences, (4) Use of SDM in Psychiatry Versus Other Areas of Medicine, (5) Dignity and Disengagement, and (6) External Forces Impacting SDM. Implications for clinical practice and research using a shared decision-making approach within this treatment setting are further discussed.
... In reviewing the research on therapeutic alliance and psychotherapy outcomes, Lambert and Barley (2001) demonstrated that the alliance accounts for twice the effect on outcomes as the particular therapeutic technique. In mental health services overall, the therapeutic alliance has been shown to reduce symptom severity and to improve global functioning, community living skills, quality of life, and patient satisfaction with treatment (Howgego et al. 2003;Kidd et al. 2017). Treatment engagement, a common challenge in working with people with severe mental illnesses, appears to be influenced by the quality of the therapeutic alliance (Dixon et al. 2016) and Borg and Kristiansen (2004) examined the alliance from the perspective of service users, and found that common characteristics of helpful relationships included service providers applying their skills in a collaborative way, conveying hope, sharing power, being available when needed, and being willing to stretch the boundaries of the professional role. ...
Article
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Person-centered care has been gaining prominence in behavioral health care, and service planning has shifted towards “person-centered care planning” (PCCP), where individuals, in partnership with providers, identify life goals and interventions. A strong therapeutic alliance has been identified as key to a person-centered approach, but little is known about how the therapeutic relationship influences person-centered processes and outcomes. Using an explanatory sequential mixed methods design, this study investigated: (1) the association between the therapeutic alliance and PCCP, and (2) how the therapeutic relationship influences the process and outcomes of PCCP. Quantitative analyses found that a strong working alliance predicted greater personcenteredness. Qualitative analyses revealed two central themes: (1) the importance of connection, continuity, and calibration of the relationship to set the right conditions for PCCP, and (2) PCCP as a vehicle for engagement. Findings demonstrated that the therapeutic alliance is inextricably linked to the PCCP process, each influencing the other.
... The concept of the central connection between the provider and recipient of mental health care initially emerged within the psychoanalytic discipline as 'the alliance'; an agreement on goals, tasks and bond in the context of formal therapy (Bordin 1979). Later, the conceptualization was broadened to include multiple therapeutic formats as 'the therapeutic relationship', in contexts such as care coordination and nursing roles in a range of settings (Farrelly et al. 2014;Kirsh & Tate 2006), where it remains correlated with outcomes (Cruz & Pincus 2002;Howgego et al. 2003). A recent meta-analysis has confirmed the impact of the relationship on outcomes within mental health care, even when accounting for treatment specific processes and presenting problems (Fl€ uckiger et al. 2018). ...
Article
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Therapeutic relationships have been widely recognized as crucial to good outcomes in psychotherapy. However, there is comparatively little research on what constitutes and impacts therapeutic relationships in the context of child and adolescent mental health services (CAMHS). Relationships within CAMHS are inherently complex, with multiple relationships taking place between young people, parents or carers and staff members of various disciplines. The Delphi method was used to gain consensus regarding the definition of therapeutic relationships, what helps to build and what hinders the formation of a good relationship in the context of CAMHS. Three expert groups (young people, carers and staff) totalling 88 participants were invited to complete an online Delphi survey across three rounds. Consensus was reached to define the therapeutic relationship as trust, reliability and absence of judgemental attitudes (n = 19 statements). Factors that help build good relationships predominantly referred to staff behaviours of setting up open communication channels, showing acceptance of the young person’s difficulties and being consistent (n = 88 consensus agreement statements). Factors that hindered a good relationship were inconsistencies and lack of clear communication between all groups (n = 18 consensus agreement statements). Effective therapeutic relationships require key behaviours and approaches from clinicians. It is essential that staff members are open and honest in facilitating discussions about parental involvement within the relationship and that staff provide consistent and trusting support to young people and family members. Our findings demonstrate that key stakeholders agree on important aspects and that these could be a catalyst for renewed training and support structures.
... The therapeutic relationship in the community should be cooperative and mutually reliable. A positive therapeutic relationship has a significant effect on the treatment outcome [24] and is the most powerful predictor of recovery [25,26]. Therefore, it is particularly important to consider the effect of coercion perceived by patients on the therapeutic relationship for recovery. ...
Article
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Aims: The purpose of this study is to analyze the effect of the perceived coercion of people with mental illness living in a community on their therapeutic satisfaction and life satisfaction, mediated by therapeutic relationships. Methods: We evaluated several clinical variables (symptoms, psychosocial functioning, and insight), levels of perceived coercion, therapeutic relationships, therapeutic satisfaction, and life satisfaction in 185 people with mental illness (Mean age = 47.99, standard deviation (SD) = 12.72, male 53.0%, female 45.9%) who live in the community and use community-based mental health programs. The data collected were analyzed to test the proposed hypotheses using structural equation modeling (SEM). Results: The correlation analysis of all variables showed that clinical variables had statistically significant correlations with therapeutic relationship, therapeutic satisfaction, and life satisfaction, but no significant correlation with perceived coercion. Furthermore, perceived coercion was found to have significant predictive power for treatment satisfaction and life satisfaction mediated by therapeutic relationship. Specifically, the lower the perceived coercion, the better the therapeutic relationship. This, in turn, has a positive effect on the therapeutic satisfaction and life satisfaction of participants. Conclusion: Based on these findings, we suggest strategies to minimize coercion in a community.
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A. GROENENDIJK, J. VAN HECKE ACHTERGROND Door de vermaatschappelijking van zorg wordt de thuiscontext steeds meer de plaats van behandeling voor mensen met een ernstige psychiatrische aandoening. DOEL Theoretische reflectie op de veranderde zorgcontext in de thuissituatie en de invloed op de therapeuti-sche relatie METHODE Kwalitatieve review van eigen ervaring, de wetenschappelijke literatuur en recente handboeken over out-reachende zorg. RESULTATEN Uit onze analyse komt de therapeutische relatie naar voren als een belangrijke algemene factor voor het behandelresultaat in de thuiscontext. De werkrelatie heeft een meer gelijkwaardig en reciprook karakter. Uitgaan van de nood van de hulpvrager verstevigt de therapeutische relatie. Begrenzing van de persoonlijke betrokkenheid van de hulpverlener en het respect voor de autonomie van de hulpvrager vormen belangrijke uitdagingen binnen een context waar vormelijke professionele begrenzingen zoals in een consultatieruimte of ziekenhuis ontbreken. CONCLUSIE De kenmerken van een therapeutische relatie binnen de thuiscontext stellen de hulpverlener voor uit-dagingen wat betreft betrokkenheid bij en distantie tot de patiënt. De noodzaak om in te grijpen in de leefwereld van patiënt leidt vaak tot een ethische dilemma. Een dialectisch intervisiemodel dat zowel ruimte biedt voor het exploreren van de emotionele betrokkenheid als voor een systematische ethische reflectie wordt voorgesteld als instrument voor de praktijkvoering. TIJDSCHRIFT VOOR PSYCHIATRIE 60(2018)5, 326-332 TREFWOORDEN outreaching, sociale psychiatrie, therapeutische grenzen, therapeutische relatie essay omgeving. Soms is hij of zij omringd door derden, al dan niet familiaal verwant. Ook wordt het moment en zelfs de duur en frequentie van de sessies mee bepaald door de zorgvrager, die thuis moet kunnen en willen geven. Boven-dien is binnen de specifieke context van de Vlaamse gees-telijke gezondheidszorg de outreachende zorg, in tegen-stelling tot andere zorgvormen, vaak gratis. In dit artikel gaan we in op de effecten van de veranderde zorgcontext op de therapeutische relatie tijdens de behan-deling door een outreachteam. Aangezien de externe grenzen van een therapeutisch instituut of consultatie wegvallen, wordt de professionele begrenzing van de hulpverlener op emotioneel, mentaal en fysiek vlak uitge-daagd. De grotere gelijkwaardigheid en reciprociteit van artikel Met het opstarten van outreachende teams beoogt men in eerste instantie een vermaatschappelijking van zorg voor mensen met een ernstige psychiatrische aandoening. De zorgvrager zal tijdens de behandeling zo veel mogelijk blijven functioneren in zijn of haar vertrouwde omgeving. Zo hoopt men effecten van institutionalisering en stigma-tisering te vermijden en de patiënt de tijd te geven om in zijn of haar thuismilieu te herstellen (Van Hecke e.a. 2011). Het verschuiven van de zorg naar de omgeving van de patiënt heeft ook een belangrijk, vaak niet geëxpliciteerd effect op de therapeutische relatie (Davidson e.a. 2005). Zo zal het in eerste instantie de hulpverlener zijn die zich naar de hulpvrager beweegt. Deze opent als het goed gaat let-terlijk de deur en stelt zich voor in zijn of haar eigen
Chapter
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The therapeutic working alliance in mental health services is one of the most important tools used in addressing mental health challenges and facilitating recovery (Castonguay, Constantino & Holtforth, 2006; Johannson & Eklund, 2003). Research around this area seems to focus on the theoretical structure of the alliance and on the impact of care provider and care receiver personal characteristics on the nature of the alliance. Although the dominant discourses that have affected the evolution of psychiatry have been explored, it seems as if this research may have not been extensively applied to the therapeutic alliance in practice. In this chapter, it is hypothesised that the identification and exploration of dominant discourses in mental health may shed light on how they influence the behaviour of the care provider and care receiver in the therapeutic alliance. Furthermore, this process may illuminate the types of knowledge that care providers and care receivers need in order to steer the knowledge-power balance in a manner that facilitates a care receiver-friendly therapeutic destination and plots the best route to it.
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Background: The treatment of severe mental illnesses is increasingly taking place in a domiciliary setting due to the deinstitutionalisation. AIM: Theoretical reflection on the influence of home treatment on the therapeutic alliance. METHOD: Qualitative review of possible effects of home treatment based on own experiences, the scientific literature, and recent handbooks on community mental health. RESULTS: The therapeutic relationship appears to be an important general factor in the outcomes of community mental health approaches. The working alliance has a more egalitarian and reciprocal nature. It improved when the scope of treatment was defined by the needs of the client. Boundaries concerning both the extent of personal involvement of the caregiver and the autonomy of the client presented important challenges in a context that lacks formal professional boundaries such as those seen in a consultation room or a hospital. CONCLUSION: Characteristic features of the therapeutic alliance during home treatment pose a challenge to the caregiver in terms of balancing interpersonal involvement and distance. The need to intervene in the personal life of the patient often causes ethical dilemmas. A dialectical form of intervision is proposed to explore the emotional involvement of the caregiver and to systematically reflect on possible ethical issues as a tool for daily practice.
Article
To investigate working alliance and other factors in case managers' perceptions of client improvement, data were collected from 95 case manager–adult client pairs from community-based agencies. Per the multiple regression results, client improvement as perceived by case manager increased with level of working alliance as perceived by case manager, and with manager age and social work education at the bachelor's level and master's level. Such improvement decreased with level of client substance abuse as perceived by manager. No association was found between client improvement as perceived by case manager and four further tested factors: level of working alliance as perceived by client; homogeneous gender and ethnicity of client and case manager; case manager work experience; duration of client working with the current case manager. Implications for practice and education are discussed.
Article
Background: Treatment alliance has an impact on several key patient outcomes in all psychiatric disorders, including bipolar disorder (BD). It has been suggested that the construct of treatment alliance is different among patients from routine psychiatric settings compared to psychotherapeutic settings. However, research on the composition of treatment alliance in psychiatric disorders, such as BD, is relatively limited. Aim: To determine whether a broader construct of treatment alliance was prevalent among outpatients with BD. Methods: This is a cross-sectional study, conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (September 2018 to September 2019). A consecutive sample of 160 remitted adult outpatients with BD on mood stabilizers for at least a year were selected. The principal instrument to assess treatment alliance was the Working Alliance Inventory-client version (WAI-Client). Other potential constituents of the alliance explored were perceived trust in clinicians assessed by the Trust in Physicians (TRIP) scale, perceived support from clinicians assessed by the Psychosocial Care by Physicians (PCP) scale, and perceived treatment satisfaction assessed by the Patient Satisfaction Questionnaire (PSQ). Associations between scores on all scales were determined by correlational and multiple regression analyses. Exploratory factor analysis of combined items of all scales was conducted using a principal components analysis. Results: Scores on all the three WAI-Client subscales were significantly correlated with each other (r = 0.66-0.81; P < 0.0001). The total TRIP scores were associated with the total WAI-Client scores (r = 0.28; P < 0.01). The total TRIP scores and the total PCP scores were also significantly associated with the WAI-Client scores on the Task subscale (r = 0.28-0.29; P < 0.01). The total TRIP scores were significantly associated with the total PSQ scores (r = 0.45; P < 0.0001). Factor analysis yielded two independent and coherent factors, which explained 69% of the variance in data. Factor-1 ("alliance and support"), which explained about 41% of the variance, was comprised of a combined WAI-Client goal-task-bond component as well as the PCP support items. Factor-2 ("trust and satisfaction"), which explained about 28% of the variance, consisted of all the TRIP trust and the PSQ treatment satisfaction items. Conclusion: A broader construct of treatment alliance in BD was found. Apart from collaborative components, this construct included patients' perceptions regarding trust in clinicians, support from clinicians, and treatment satisfaction.
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Introduction As digital technologies become an integral part of mental health care delivery, concerns have risen regarding how this technology may detract from health professionals’ ability to provide compassionate care. To maintain and improve the quality of care for people with mental illness, there is a need to understand how to effectively incorporate technologies into the delivery of compassionate mental health care. The objectives of this scoping review are to: (1) identify the digital technologies currently being used among patients and health professionals in the delivery of mental health care; (2) determine how these digital technologies are being used in the context of the delivery of compassionate care and (3) uncover the barriers to, and facilitators of, digital technology-driven delivery of compassionate mental health care. Methods and analysis Searches were conducted of five databases, consisting of relevant articles published in English between 1990 and 2019. Identified articles will be independently screened for eligibility by two reviewers, first at a title and abstract stage, and then at a full-text level. Data will be extracted and compiled from eligible articles into a data extraction chart. Information collected will include a basic overview of the publication including the article title, authors, year of publication, country of origin, research design and research question addressed. On completion of data synthesis, the authors will conduct a consultation phase with relevant experts in the field. Ethics and dissemination Ethical approval is not required for this scoping review. With regards to the dissemination plan, principles identified from the relevant articles may be presented at conferences and an article will be published in an academic journal with study results. The authors also intend to engage interested mental health professionals, health professional educators and patients in a discussion about the study findings and implications for the future.
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This study explores the experiences and perspectives of service providers with regard to the process of psychological self-sufficiency (PSS) among students in the Health Profession Opportunity Grants (HPOG) program. Based on a social work theory of PSS as our organizing framework, combined qualitative content analysis (inductive to deductive) was conducted with two service provider focus groups ( n = 16) and three student focus groups ( n = 27). The overarching theme of nontraditional, student-centered, holistic staff approaches which lead to the pathway from uncovering perceived employment barriers to discovering employment hope emerged with four phenomenological categories. The findings supported the adaptations of service providers’ different roles when providing student-centered approach in service delivery to reach maximal PSS for a better outcome in case management.
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Introduced in 1954, the terms of "advanced nursing practice" take into account advances and newly developed practices. They are based on care, prevention and health education missions, as well as research and the defence of the rights of users and their family. In a context where the first advanced practice nurses (APNs) in mental health in France are coming to the end of their training and where the health care directorate is recommending that psychosocial rehabilitation is integrated into all psychiatric teams, the role of APNs in this field could include the provision of support to area teams in the gradual setting up of these practices and their direct implementation with users. The establishment of the function of case manager appears to be key to providing the support required to meet the specific needs of each patient. Copyright © 2019 Elsevier Masson SAS. All rights reserved.
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Background: There is strong evidence that collaborative practice in mental healthcare improves outcomes for patients. The concept of collaborative practice can include collaboration between healthcare workers of different professional backgrounds and collaboration with patients, families and communities. Most models of collaborative practice were developed in Western and high-income countries and are not easily translatable to settings which are culturally diverse and lower in resources. This project aimed to develop a set of recommendations to improve collaborative practice in Malaysia. Methods: In the first phase, qualitative research was conducted to better understand collaboration in a psychiatric hospital (previously published). In the second phase a local hospital level committee from the same hospital was created to act on the qualitative research and create a set of recommendations to improve collaborative practice at the hospital for the hospital. Some of these recommendations were implemented, where feasible and the outcomes discussed. These recommendations were then sent to a nationwide Delphi panel. These committees consisted of healthcare staff of various professions, patients and carers. Results: The Delphi panel reached consensus after three rounds. The recommendations include ways to improve collaborative problem solving and decision making in the hospital, ways to improve the autonomy and relatedness of patients, carers and staff and ways to improve the levels of resources (e.g. skills training in staff, allowing people with lived experience of mental disorder to contribute). Conclusions: This study showed that the Delphi method is a feasible method of developing recommendations and guidelines in Malaysia and allowed a wider range of stakeholders to contribute than traditional methods of developing guidelines and recommendations.Trial registration Registered in the National Medical Research Register, Malaysia, NMRR-13-308-14792.
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Electroconvulsive therapy is a treatment that, since its first administration, has been a major topic for debate within the scientific world. In recent years, the debate has become increasingly focused on the short- and/or long-term efficacy of electroconvulsive therapy, its appropriateness in clinical settings, its mechanism of action, the impact evaluation of transient and/or persistent adverse effects, and the drafting of international guidelines, etc . From the authors’ point of view, these themes are inevitably crossed by three other fundamental issues of significant psychological, relational, ethical, and medico-legal impact. Still, they are less studied than purely biomedical issues in recent times. Therefore, the aim of this article is to focus on the following cross-cutting issues: the therapist-patient relationship, the patient’s perspective, the attitude on electroconvulsive therapy, and informed consent. This short review refers to the international literature on ECT published since 2000. Analyses of the three previously listed topics are, in part, made within the context of Italian medical settings.
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Background. In this study, we aimed to retrieve and operationalize the building blocks of the working alliance in multidisciplinary teams with shared caseloads, for use in daily practice and research to support (Flexible) Assertive Community Treatment teams. Methods. After reviewing literature, concept mapping with professionals and clients was used to define working alliance in (F)ACT. The resulting concept maps formed the basis for the instrument. The instrument was pilot tested with professionals and clients by means of cognitive interviews with a think-aloud procedure. Results. The study led to development of a twenty-five item instrument to assess Working Alliance in Multidisciplinary teams (WAM), comprised of three subscales: bond, task/goal and team, with a version for clients and professionals. Conclusions. The WAM was developed to determine the quality of the working alliance in ACT teams. Future research will focus on testing its psychometric properties and predictive value.
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Background Although self-rating mania scales have been developed, a lack of such instruments validated for the Greek population is noted. This study aims to examine the validity, reliability and psychometric properties of the Altman Self Rating Mania Scale (ASRM) adapted in Greek (G-ASRM). Methods A sample of 86 consecutive inpatient and outpatient bipolar patients diagnosed by the DSM-5 criteria and 37 healthy controls were assessed by using the Young Mania Rating Scale (YMRS) and the Montgomery Asberg Depression Rating Scale (MADRS), and self-administered the G-ASRM. Factor analysis, test-retest analysis, measurement invariance tests, mean differences, Pearson's Correlation analysis and ROC analysis were used to confirm the validity of G-ASRM as a scale, test its reliability, study its psychometric properties in different subgroups and establish a cut-off value for indicating the presence of (hypo)mania in BD patients. Also, regression models were built to expose dependencies between YMRS and G-ASRM items. Results Monofactoriality of the scale was verified, based on Exploratory Factor Analysis (EFA). Cronbach's alpha was 0.895. G-ASRM is highly correlated with YMRS (r = 0.856, p < 0.0005) and uncorrelated with MADRS (r = −0.051, p = 0.623). Test- retest r-coefficient was calculated at 0.85. The optimal cut-off score, set at ≥6 for (hypo)mania assessment, is in agreement with the results reported for the original version. Limitations of the study are that the scale was not normed on diagnostic groups other than bipolar, nor was it administered longitudinally, so as to assess its sensitivity to symptom changes overtime. Conclusion The G-ASRM can be validly and reliably used in the Greek population for the assessment of (hypo)mania in bipolar patients.
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Schizencephaly is an extremely rare developmental birth defect or malformation characterized by abnormal clefts in the cerebral hemispheres of the brain, extending from the cortex to the ventricles, which may be unilateral or bilateral. This case report describes the general characteristics of a psychological home care program, reporting the main theoretical and technical elements in a 12-years-old case of type II Schizencephaly. The aims of the psychological home treatment were acceptance of the new treatment reality, a reduction in aggression and anxiety, and psychological support for the patient and family. In the psychological home care, patient’s awareness of illness was developed, along with family orientation, psychoeducation, relaxation techniques, and cognitive distraction. It can be observed that a significant improvement in the affective and emotional state was achieved within the patient’s clinical framework.
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Due to the outbreak of the Coronavirus Disease-2019 (COVID-19) pandemic and consequent confinement measures, young people are vulnerable to mental health problems. The current study compared a group of 440 young adolescents (10-12 years) and a group of 330 emerging adults (18-25 years) to investigate the extent to which perceived social support and psychological capital (PsyCap) were differentially associated with mental health problems. Participants were asked to report their current psychosocial adaptation status during the COVID-19 pandemic, and data were collected via online questionnaires during a relatively severe period of COVID-19 in China. Results of the multi-group path analysis indicated that the effect of perceived social support on mental health problems was mediated by PsyCap for young adolescents, but not for emerging adults. These results were discussed with respect to the mechanism of how social support and PsyCap serve as protective mental health factors for youth in the context of the COVID-19 pandemic.
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Published literature has demonstrated that strong case manager–client working alliances foster improvement among clients. Reflecting a case-management context, this study explored how working alliances, as perceived by clients, are related to interpersonal capacities (or social support); intrapersonal dynamics; severity of problems facing client; and other client and case manager characteristics. The study included 101 clients and their 26 case managers at four nonprofit social-service agencies. Working alliances, as perceived by clients, were observed to be associated positively with 3 variables: working alliance as viewed by case manager, length of time client worked with case manager, and client female gender. In turn, client mental-health or substance-use problem was linked to client unfavorable perception of working alliance. No link was observed between client perception of alliance and 6 variables: client social support, goal achievement, problem severity, client–case manager shared ethnicity, case manager work experience, and client age. The findings suggest that working alliance is collaborative and interactive throughout the helping process. This impacts social work training protocols. Case managers who must establish working alliances with clients need the relevant collaboration skills, which may need to be introduced and practiced at in-service meetings or workshops.
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Research around the world has consistently shown that people with serious mental illness (SMI) are often subject to stronglyheld stigmatizing attitudes held by others in society (e.g., dangerousness, incompetence, inability to work). As a result, people with SMI often experience "internalized stigma" or "self-stigma" which reflects the process by which stigmatizing attitudes are internalized, leading to the loss of previously held or hoped for identities (e.g., self as student, self as worker, self as parent, etc.) and the adoption of identities based on stigmatizing views (e.g., self as dangerous, self as incompetent). In order to reduce the common devastating phenomenon of self-stigma, Narrative Enhancement and Cognitive Therapy (NECT) is a structured, groupbased treatment aimed to reduce self-stigma. It combines psychoeducation to help replace stigmatizing views about mental illness with empirical fndings, cognitive restructuring geared toward teaching skills to challenge negative beliefs about the self, and elements of narratology focused on enhancing one's ability to narrate one's life story. Since its development, nearly a decade ago, it has been implemented in fve different countries and fve languages and studied in three countries with results supporting its positive impact on decreasing self-stigma and improving other positive outcomes. In this paper we briefly review literature on stigma and self-stigma within the context of SMI, the need for treatment focused on decreasing self-stigma, the theoretical rational for the NECT, the format of the intervention and the existing published research.
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The Working Alliance Inventory (WAI) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI.
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Using data collected from people who are homeless and have a mental disability, this study assessed which person-related characteristics predicted the formation and the strength (therapeutic alliance) of a relationship with a clinical case manager. Although all persons were assigned a case manager, those people who reported forming a relationship with a case manager were more likely to be men and African-American, had more social support, received more public support and education, and subjectively reported more psychological problems. People who were less likely to report forming a relationship with a case manager spent more days intoxicated in the past 30 and more days homeless in the past 60, and were more overtly psychotic. Among clients who reported forming a relationship with a case manager, the alliance was strongest for women, Whites, those who had spent more days homeless in the past 60, and those who reported subjective psychological problems. The results are organized into a framework for understanding the development of a clinical case manager relationship. Implications for outreach to clients who are homeless and have a mental illness are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
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Recruited a convenience sample of 22 rehabilitation therapist–client dyads in early-stage relationships from an active rehabilitation program. Both rehabilitation therapists and clients completed the Working Alliance Inventory (WAI), a Modified Goal Attainment Scale (M-GAS), and the Problem List at Time 1 and 3 mo later. There were significant correlations between the working alliance and rehabilitation outcomes at Time 1 and Time 2. This relationship was stronger when rehabilitation therapist perceptions, rather than client perceptions, were assessed. Rehabilitation therapist and client perceptions, scored on the WAI and M-GAS, showed moderately high congruence. Also, a significant perceived change in problems, but not rehabilitation goals, occurred between Time 1 and Time 2. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The Working Alliance Inventory (WAI; A. O. Horvath and L. S. Greenberg [see PA, Vol 76:24600]) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.
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Objective: This paper reports on a study designed within the framework of the National Survey of Mental Health and Wellbeing to: estimate the prevalence of psychoses in urban areas of Australia; identify profiles of symptomatology, impairments and disabilities; collect information on services received and needed; and explore quality of life issues in a broadly representative sample of people with psychotic illnesses. Method: The study was conducted over four areas in the Australian Capital Territory, Queensland, Victoria and Western Australia, as a two-phase survey: (i) a census and screening for psychosis of all individuals who made contacts with mental health services during a period of 1 month in 1997; and (ii) interviews with a stratified random sample (n=980) of the screen-positive individuals (n=3800) using a standardised instrument. Results: The point prevalence (1 month) of psychotic disorders in the urban population aged 18-64 is in the range of 4-7 per 1000 with a weighted mean of 4.7 per 1000. People with psychotic disorders experience high rates of functional impairments and disability, decreased quality of life, persistent symptoms, substance-use comorbidity and frequent side effects of medication. Although the utilisation of hospital-based and community mental health services, as well as of public and non-governmental helping agencies, is high, the majority live in extreme social isolation and adverse socioeconomic circumstances. Among the many unmet needs, the limited availability of community-based rehabilitation, supported accommodation and employment opportunities is particularly prominent. Conclusions: The so-called 'low-prevalence' psychotic disorders represent a major and complex public health problem, associated with heavy personal and social costs. There is a need for a broad programmatic approach, involving various sectors of the community, to tackle the multiple dimensions of clinical disorder, personal functioning and socioeconomic environment that influence the course and outcome of psychosis and ultimately determine the effectiveness of service-based intervention.
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The burgeoning field of case management for long-term psychiatric patients has been handicapped by a lack of conceptual models that delineate the diverse activities of case managers. Based on the actual practice of case management, the author outlines a model of clinical case management that moves beyond the view of the case manager as a systems coordinator, service broker, or supportive companion. Using a contemporary biopsychosocial model of mental illness, the clinical case management model integrates the clinical acumen, personal involvement, and environmental interventions needed to address the overall maintenance of the patient's physical and social environment. Clinical case management involves 13 distinct activities, including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psychoeducation, and crisis intervention.
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To estimate the national annual cost of rehospitalization for multiple-episode schizophrenia outpatients, and to determine the relative cost burden from loss of medication efficacy and from medication noncompliance, the yearly number of neuroleptic-responsive multiple-episode schizophrenia inpatients in the United States who are discharged back to outpatient treatment was estimated. The cohort at risk for future relapse and rehospitalization was determined. The research literature on the expected rates of relapse for schizophrenia patients on maintenance antipsychotic medication was reviewed; in particular, monthly relapse rates under the optimal medication conditions of compliant patients taking optimal doses of a depot neuroleptic (optimal neuroleptic dose) and under the less optimal conditions of patients stopping medication (medication noncompliant) was estimated. Using established noncompliance rates from the literature, it became possible to estimate a "real world" rehospitalization rate for this cohort, as well as the relative burden accruing from loss of medication efficacy and from medication noncompliance. Finally, cost estimates for index hospitalizations and rehospitalizations were derived from data on national expenditures for inpatient mental health care. The monthly relapse rates are estimated to be 3.5 percent per month for patients on maintenance neuroleptics and 11.0 percent per month for patients who have discontinued their medication. Postdischarge noncompliance rates in community settings are estimated to be 7.6 percent per month. These estimates were entered into a survival analysis model to determine the real world relapse rate of this cohort. An estimated 257,446 multiple-episode (> or = two hospitalizations) schizophrenia patients were discharged from short-stay (< or = 90 days) inpatient units in the United States during 1986. The estimated aggregate baseline inpatient cost for the index hospitalizations of this cohort was $2.3 billion (1993 dollars). Within 2 years after discharge, the aggregate cost of readmission approached $2 billion. Loss of neuroleptic efficacy accounted for roughly 60 percent of the rehospitalization costs and neuroleptic noncompliance for roughly 40 percent. The economic burden due to loss of efficacy is relatively higher during the first postdischarge year, whereas the burden from noncompliance is higher in the second year. Because loss of medication efficacy and medication noncompliance act synergistically on relapse, substantial inpatient cost savings can be realized by linking better pharmacologic treatments of schizophrenia with more effective strategies to manage medication noncompliance.
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The article traces the development of the concept of the therapeutic working alliance from its psychodynamic origins to current pantheoretical formulations. Research on the alliance is reviewed under four headings: the relation between a positive alliance and success in therapy, the path of the alliance over time, the examination of variables that predispose individuals to develop a strong alliance, and the exploration of the in-therapy factors that influence the development of a positive alliance. Important areas for further research are also noted.
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The quality of the therapeutic alliance was compared in sessions of psychodynamic-interpersonal and cognitive-behavioral therapy, and the alliance's relationship to various session impacts was investigated. As part of the Sheffield Psychotherapy Project 2 (D. A. Shapiro, M. Barkham, A. Rees, G. E. Hardy, S. Reynolds, & M. Startup, 1994), 57 clients diagnosed with major depression received 16 sessions of either psychodynamic-interpersonal or cognitive-behavioral therapy. Coders used the Working Alliance Inventory to rate 1 high-impact and 1 low-impact session from each client. Results indicated significantly greater alliance scores for cognitive-behavioral therapy sessions on the whole. Also, for the samples as a whole, high-impact sessions were characterized by higher alliance scores than those for low-impact sessions, and alliance was positively related to therapists' ratings of session depth and smoothness and to clients' ratings of mood.
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This study describes medication compliance rates among a group of homeless mentally ill subjects who received assertive community treatment. The medication compliance of 77 homeless persons who had been referred to an assertive community treatment program was prospectively evaluated at baseline and quarterly for 1 year. A minority of the cohort (29%) was compliant at entry into the assertive community treatment program. Compliance significantly increased after 3 months (57%) and remained high through the year. Medication compliance was associated with fewer psychiatric symptoms but not with better housing placements or fewer days in the hospital. Medication compliance rates among a cohort of homeless persons with severe mental illness were markedly higher after they entered a program of assertive community treatment.
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Advances in psychopharmacology have produced medications with substantial efficacy in the treatment of positive and negative symptoms of schizophrenia and the prevention of relapse or symptom exacerbation after an acute episode. In the clinical setting, the individual patient's acceptance or rejection of prescribed pharmacological regimens is often the single greatest determinant of these treatments' effectiveness. For this reason, an understanding of factors that impede and promote patient collaboration with prescribed acute and maintenance treatment should inform both pharmacological and psychosocial treatment planning. We review the substantive literature on medication adherence in schizophrenia and describe a modified health belief model within which empirical findings can be understood. In addition to factors intrinsic to schizophrenia psychopathology, medication-related factors, available social support, substance abuse comorbidity, and the quality of the therapeutic alliance each affect adherence and offer potential points of intervention to improve the likelihood of collaboration. Because noncompliance as a clinical problem is multidetermined, an individualized approach to assessment and treatment, which is often best developed in the context of an ongoing physician-patient relationship, is optimal. The differential diagnosis of noncompliance should lead to interventions that target specific causal factors thought to be operative in the individual patient.
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• This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia. Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not. These results underscored the prognostic value of assessing the alliance and the need to identify factors that contribute to its development and maintenance with schizophrenic patients.
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• Much concern has been expressed over the possible burden placed on family and community members by programs that emphasize community treatment of severely disturbed patients. In this study, the social costs of an experimental in-community program were compared with those of a traditional approach using short-term hospitalization plus aftercare. Six objective and one subjective measures of the burden placed on the family members of patients in both groups were obtained. Community burden was assessed through police records of frequency of patient arrests, number of suicidal gestures that required medical attention, and frequency of emergency room use. All measures showed that the total in-community program resulted in no more burden on the family or community than the traditional approach. The large amount of support provided to patients, families, and community members in the experimental approach is emphasized in explaining these results.
Article
The therapeutic alliance as rated by therapists and patients was assessed every 5 weeks throughout the treatment period in an in-patient treatment program for schizophrenic and other long-term mentally ill patients. The patients (N = 26) also assessed perceived curative factors (Curative Factors Questionnaire) and made therapy session evaluations (Session Evaluation Questionnaire). The most important patient rated factors showing a relationship with therapist-rated alliance were in the initial phase of treatment depth in the therapy sessions, in the working phase the experience of involvement in the treatment, and in the discharge phase perceived helpfulness of encouragement and reassurance. The investigation of curative factors, session evaluations, and alliance as rated by patients showed a relationship in the initial phase between alliance and encouragement, reassurance and awareness, in the working phase between alliance and depth in sessions and "talking to someone who understands," and in the discharge phase between alliance and self-understanding and problem solution.
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• A conceptual model for the development of communitybased treatment programs for the chronically disabled psychiatric patient was developed, and the results of a controlled study and follow-up are reported. A community-treatment program that was based on the conceptual model was compared with conventional treatment (ie, progressive short-term hospitalization plus aftercare). The results have shown that use of the community program for 14 months greatly reduced the need to hospitalize patients and enhanced the community tenure and adjustment of the experimental patients. When the special programming was discontinued, many of the gains that were attained deteriorated, and use of the hospital rose sharply. The results suggest that community programming should be comprehensive and ongoing.
Article
Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualizaton of the alliance. Results from 3 studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. Data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations were also observed between the WAI and other relationship indicators. Results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in the reviewed studies are encouraging, the high correlations between the 3 subscales of the inventory bring into question the distinctness of the alliance components. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Results of 24 studies (based on 20 distinct data sets) relating the quality of the working alliance (WA) to therapy outcome were synthesized using meta-analytic procedures. A moderate but reliable association between good WA and positive therapy outcome was found. Overall, the quality of the WA was most predictive of treatment outcomes based on clients' assessments, less so of therapists' assessments, and least predictive of observers' report. Clients' and observers' rating of the WA appear to be more correlated with all types of outcomes reported than therapists' ratings. The relation of WA and outcome does not appear to be a function of the type of therapy practiced, the length of treatment, whether the research is published, or the number of participants in the study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Compared 6 measures of working alliance: the California Psychotherapy Alliance Scales (CALPAS), the Penn Helping Alliance Scales (PHAS), the Vanderbilt Therapeutic Alliance Scale (VTAS), Working Alliance Inventory—Observer Form (WAI—O), Working Alliance Inventory—Client Form, and Working Alliance Inventory—Therapist Form. All measures had high internal consistency. Observers were able to reach high levels of interrater reliability on all the observer-rated measures (CALPAS, PHAS, VTAS, WAI—O). Evidence of construct validity was found for the CALPAS, VTAS, and WAI—O, given that they were all highly correlated with each other. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Reviews and elaborates the psychoanalytic concept of the working alliance. It is argued that various modes of psychotherapy can be meaningfully differentiated in terms of the kinds of working alliances (WA) embedded in them. Moreover, the strength, rather than the kind of WA, will prove to be the major factor in change achieved through psychotherapy. Strength of alliance will be a function of the goodness of fit of the respective personalities of patient and therapist to the demands of the WA. The WA includes 3 features: agreement on goals, assignment of tasks, and the development of bonds. (36 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
A review of the psychotherapy research literature of the last decade shows that considerable advances of clinical significance have been made toward defining and measuring components of the treatment relationship. The relevance of the therapeutic alliance for predicting outcome in diverse models of treatment is emphasized, and the implications of the findings for clinical training, practice, and research are discussed.
Article
The Working Alliance Inventory was used to measure the strength of the therapeutic relationship between seriously mentally disabled case management clients and their case managers in a randomized trial of consumer-provided case management services. It was found that while there was no difference in the strength of the alliance between the consumer and nonconsumer teams of case managers, there were positive relationships between alliance and some outcomes, including quality of life, symptomatology, attitudes toward medication compliance, and satisfaction with mental health treatment.
Article
Case management has been an integral part of psychiatric practice in the United States for over a decade and has generated a large body of literature. The application of case management principles to the care of people suffering from psychiatric disorders is becoming increasingly popular in the United Kingdom and Europe and literature is now beginning to be published. However, no definitive statements about the efficacy of case management have been made due to a range of conceptual and methodological problems. The present paper is a critical review of the case management outcome literature. Reported outcomes are reviewed in the context of study design and service characteristics. The authors conclude that case management practice can have at least some impact on patients' use of services (including marked decrease in in-patient bed days); satisfaction with services; engagement with services; and social networks and relationships when it is delivered as a direct, clinical service with high staff: patient ratios. A set of recommendations are suggested for the future practice and presentation of research into case management.
Article
Much concern has been expressed over the possible burden placed on family and community members by programs that emphasize community treatment of severely disturbed patients. In this study, the social costs of an experimental in-community program were compared with those of a traditional approach using short-term hospitalization plus aftercare. Six objective and one subjective measures of the burden placed on the family members of patients in both groups were obtained. Community burden was assessed through police records of frequency of patient arrests, number of suicidal gestures that required medical attention, and frequency of emergency room use. All measures showed that the total in-community program resulted in no more burden on the family or community than the traditional approach. The large amount of support provided to patients, families, and community members in the experimental approach is emphasized in explaining these results.
Article
A total of 143 clients and their case managers in a Veterans Affairs (VA) intensive case management program modeled on the Program for Assertive Community Treatment rated their therapeutic alliance after two years in the program. Strong case-manager-rated alliance was associated with reduced symptom severity and improved global functioning as rated by independent assessors; it was also associated with higher client ratings of community living skills and more positive outcome as perceived by both clients and case managers. Strong client-rated alliance was associated only with more positive client-perceived outcome. Alliance ratings were not associated with use of inpatient psychiatric hospitalization. The case manager-client alliance appears to be a significant component of therapeutic effectiveness.
The authors attempted to identify factors that commonly contributed to the decision to rehospitalize patients who made heavy use of mental health services. The case notes of 50 patients with frequent readmissions to the South Australian Mental Health Services over a three-year period were examined to identify which of 15 factors most frequently contributed to hospital readmission. Lack of insight or denial of illness was cited in 62.2 percent of the patients' 442 total admissions, followed by relationship problems (61.1 percent), suicidal ideation (44.8 percent), and noncompliance with medication (43.2 percent). When the 15 factors were combined into four major categories, social factors were found to contribute to 38.9 percent of admissions, followed by factors related to psychiatric and physical illness (31.1 percent), dangerousness to self or others (20.3 percent), and substance abuse (9.7 percent). The substantial contribution of social factors to the readmission of patients to acute mental health services is strong evidence that the mental health system must provide appropriate targeted resources and assertive, continuous case management to avoid social crises. Issues surrounding drug and alcohol abuse among heavy users of services must be actively addressed.
Article
In this study, we assessed the quality of the helping alliance between patients and clinical case managers in psychiatric community care and examined its value as predictor of treatment outcome. Patients were interviewed about five different aspects of the helping alliance using simple questions and visual analogue scales. The duration and degree of hospitalization and changes in the patients' working and accommodation situations during a 20-month follow-up period were obtained as outcome criteria for 72 patients with mostly psychotic disorders receiving long-term treatment. The patients' general view of the helping alliance was quite positive. Some aspects of the helping alliance were significantly correlated with hospitalization and changes in working situation during the follow-up period, which indicated a better outcome for patients who experienced the helping alliance more positively. The findings suggest that the helping alliance may be a relevant therapeutic factor not only in psychotherapy, but also in complex psychiatric treatment settings.
Article
The community care reforms will produce a new kind of key worker who will organise and budget for packages of care: the care manager. Care management goes live in April 1993 but is still poorly rehearsed and its performance may yet disappoint. This overview sets out the origins of case management, its transformation into care management, and the principles guiding its practice. To spell out how the concept works, plans for care management in Southwark's mental health services are described.
Article
This paper reviews studies of patients who are heavy users of psychiatric services and identifies areas in which further research and evaluation are indicated. Extensive searches were conducted of the English language psychiatric and psychological literature before 1994. Important references from initially identified studies were followed up. More than 200 articles were reviewed, 72 of which are described in this review. The 72 papers were selected because they dealt with three questions: What is heavy service use? What patient characteristics contribute to it? What service delivery characteristics contribute to it? Criteria for identifying and defining heavy users of psychiatric services vary among studies. Few studies of heavy service users have attempted to examine use of all psychiatric services, both inpatient and community based. In most studies, 10 to 30 percent of patients are identified as heavy users, those who utilize between 50 and 80 percent of service resources. This group consists of a constantly changing cohort of patients who generally have psychotic illnesses as well as comorbid personality disorders and high levels of drug and alcohol misuse. Few studies have examined social issues such as isolation, homelessness, and social support, although these factors appear to contribute significantly to heavy service use. Few attempts have been made to define heavy-user groups in fiscal terms. More research on heavy users of psychiatric services is clearly needed to improve providers' ability to plan appropriately targeted mental health services for this disabled group of patients who use expensive resources.
Article
It was hypothesized that members of an older cohort of seriously mentally ill community mental health clients would develop stronger alliances with intensive case managers. Eighty-six clients participating in a study of case management services completed a measure of working alliance and structured interviews. It was found that older cohort clients, those age 45 or older, showed much stronger alliances with their case managers than younger clients.
Article
This preliminary study assessed the effects on outpatient medication compliance of converting inpatients with schizophrenia from oral to depot neuroleptic medication. Subjects consisted of 93 neuroleptic-responsive inpatients with schizophrenia from three New York City hospitals who were part of a one-year prospective longitudinal study of medication compliance. Forty patients were converted to depot neuroleptic medication while hospitalized; the other 53 remained on oral medication. Symptoms, side effects, and medication compliance of the two groups were compared at one, six, and 12 months postdischarge. Inpatients converted to depot medication had significantly better compliance at one month postdischarge. Differences in demographic characteristics, symptoms, hospital site, and baseline attitudes toward medication did not account for this finding. The initial positive effect on compliance waned, and no significant between-group differences in compliance were found at six and 12 months postdischarge. Conversion to depot medication before hospital discharge may facilitate medication compliance during transition to outpatient treatment, but other interventions are needed to maintain compliance over time.
Article
Medication non-compliance, a pervasive problem among persons with serious, chronic mental illness, has been linked to increased inpatient resources use in public mental health systems. The objective of this analysis was to determine which factors are associated with medication compliance in this population so that more appropriate screening and intervention programs can be designed. Using knowledge gained from clinical research on compliance in schizophrenia and research testing the Health Belief Model as a conceptual framework in studying compliance behavior, we conducted a secondary analysis of data collected in the Mississippi public mental health system in 1988. The study subjects were schizophrenic patients (n = 202), the majority of whom were low-income, African-American males. Data sources included structured interviews with patients and family members, as well as state hospital and community mental health clinic administrative records. Receipt of consistent outpatient mental health treatment and belief that one had a mental illness were significantly associated with higher levels of medication compliance in this population of seriously mentally ill patients. Our results suggest that screening programs to identify those at highest risk for non-compliance in this population might be more productive if they included a review of inpatient and outpatient mental health service utilization patterns, in addition to formal assessment of patients' attitudes and beliefs about their illness. This study illustrates an approach to examining predictors of a policy-relevant health behavior in a minority population within a public mental health system.
Article
Goals: The goals of this study are 1) to determine causes and patterns of relapse for a cohort of "revolving door" schizophrenia inpatients, and 2) to assess the feasibility of starting a new psychopharmacologic intervention before discharge, either depot therapy or an atypical antipsychotic. Methods: Consecutive admissions to an acute inpatient unit in New York City were screened for "revolving door" criteria. Patients had to have a primary diagnosis of schizophrenia or schizoaffective disorder and have either 1) two hospitalizations in the last year, or 2) three hospitalizations in the last three years. Patients were then assessed for probable causes of relapse for the index and prior two hospitalizations. Treatment selection, based on this information, was trichotomized to: 1) oral conventional antipsychotic, 2) depot conventional antipsychotic (either haloperidol or fluphenazine decanoate), or 3) atypical antipsychotic (either risperidone or clozapine). Results: Sixty-three out of 131 screened admissions met the above revolving door criteria. They were indeed "revolving", having an average of 1.3 hospitalizations per year over the last 3 years and were only out of the hospital for five months (median) before index admission. The treatment selection process was hampered by lack of information about events leading to relapse, and by the lack of outpatient participation in the medication selection process. Of the 50 patients with complete histories about precipitants for the index episode, the most common reason for rehospitalization was judged to be medication noncompliance (n = 25; 50%), followed by medication nonresponse (n = 13; 26%). Not surprisingly, medication recommendations were closely linked to the assessed reason for relapse (depot therapy [n = 27; 49%] with medication noncompliance; atypical antipsychotic [n = 20; 37%] with medication nonresponse [X2 = 26.9, p < .001]). These two recommendations were implemented before discharge for about one-half of the cases. Patient refusal was a relatively greater problem for depot recommendation while constraints in the outpatient environment were more problematic for patients recommended for atypical antipsychotics. Conclusions: Medication noncompliance and medication nonresponse, in that order, were judged to be the most common causes of relapse for "revolving door" inpatients. Both depot therapy and atypical antipsychotics were commonly recommended and ultimately accepted by about 2/3rds of patients. Choice between depot and atypical was driven by the assessed cause of relapse. In summary, it seems possible to identify "revolving door" inpatients, and to target specific medication interventions within the time frame of an acute inpatient admission.
Article
The Working Alliance Inventory was used to measure the strength of the therapeutic relationship between seriously mentally disabled case management clients and their case managers in a randomized trial of consumer-provided case management services. It was found that while there was no difference in the strength of the alliance between the consumer and nonconsumer teams of case managers, there were positive relationships between alliance and some outcomes, including quality of life, symptomatology, attitudes toward medication compliance, and satisfaction with mental health treatment.