Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: Although a growing evidence base supports the importance of the client-provider relationship for outcomes in community-based services for persons with serious mental illness, little research attention has been given to the precursors of this relationship. While the studies that examine this issue focus primarily on characteristics of the client (e.g., illness severity), it stands to reason that provider attitudes and behaviors shape the client-provider relationship. Adopting an attribution theory framework, we hypothesize that the way in which providers think about and respond to challenging client behaviors influences the interpersonal context of services. This presentation describes the results of a study that examines the impact of provider causal explanations, or attributions, for a common challenging client behavior, medication nonadherence, on the quality of the working relationship. Method: Data were collected from 152 client-provider dyads from a large, urban, public mental health clinic, as a part of a multi-site study of treatment pressures in mental health services. The dependent variable of interest was the client-provider relationship as perceived by the client and operationalized by Yamaguchi's (1999) measure of the case management working relationship, which consists of two subscales capturing both positive and negative aspects of the relationship between case managers and their clients. Focal independent variables capturing aspects of providers' attributions for client medication nonadherence, were derived from their written responses to the open-ended question: “Thinking about all the clients you have worked with who are prescribed psychiatric medications, please list the reasons you can think of why they may not take their medications.” Using an established method of coding attributions (Leeds Attributional Coding System, Munton et al., 1999), provider responses were rated to measure multiple dimensions of their attributional patterns. Provider attributional complexity, defined as a greater level of differentiation in causal explanations, was measured as a simple count of the number of attributions that were generated by providers. Ordinary least squares (OLS) regression was used to determine the impact of provider attributional characteristics on clients' perceptions of the quality of the case management relationship. Results: Analyses indicated that clients were more likely to report experiencing a positive relationship and less likely to report experiencing a negative relationship with their provider when that provider demonstrated a greater level of attributional complexity for understanding medication nonadherence among their clients. Furthermore, these relationships remained significant when the model controlled for the possibly confounding influence of other provider characteristics (level of training and experience) and client functioning and symptomatology. Implications for Practice: The study suggests that mental health providers who reason about medication nonadherence in a more differentiated manner positively influence their clinical interactions with clients, buffering clients' potential experiences of relational negativity and conflict, while at the same time, contributing to the development of positive experiences in the client-provider relationship. These findings suggest that training and supervision efforts that help providers think about complex clinical issues in a differentiated manner may result in improving the quality of clients' relationships with their mental health providers.