Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: The importance of the relationship or therapeutic alliance to outcome is fairly well-established in research on services to serious mental illness (SMI), leading some to call for a science of “empirically supported relationships” as a counterpart to the current focus on empirically supported practices. In pursuit of a better understanding of the practitioner perspective of the client-provider relationship, the paper details two studies aimed at refining the definition and measurement of this construct within the context of case management services, which differ significantly from traditional clinic-based psychotherapy services. Methods: The first study uses qualitative methods (observations and interviews) and a grounded dimensional analysis approach (a variation on grounded theory) to delineate key dimensions of the case management relationship as construed by providers (n=14) in two assertive community treatment teams. Drawing upon the findings of that study, the second study undertakes the development of an instrument to assess unique dimensions of the client-provider relationship as rated by mental health providers. Following the development of a preliminary item set, items were administered to a sample of 270 case managers at a professional development conference for assertive community treatment providers. Exploratory factor analysis and Rasch analysis were used to determine the dimensional structure of the measure and assess the fit of the items to that structure. Results: The grounded dimensional analysis of provider narratives showed that providers delineate the importance of several key experiential dimensions of the relationship: mattering to the client, liking and trust, feelings of effectiveness, conflict and disagreement, and parental dependency. Several of these dimensions are not well assessed by existing instruments for measuring the working alliance, such as the Working Alliance Inventory. In the second study, the authors drew upon the qualitative findings to develop a 40-item measure of the relationship as perceived by the case manager. Results of factor and Rasch analyses showed that the items form a two dimensional structure of positive relationship aspects (e.g., mutuality, liking, mattering, and feeling effective) and negative aspects (e.g., conflict, dependency, disagreement). Implications for Research and Practice: These studies demonstrate the need for renewed attention to distinctions between client and provider perspectives on the relationship, as well as on the unique context established in case management services for serious mental illness. Because these services occur in the natural environment (as opposed to a clinical setting) and at times involve a combination of therapeutic and social control functions, the relationship takes on several distinct features that are not tapped by existing instruments. Our findings show that these features form coherent dimensions and may be measured reliably. Taken together, these studies inform the ongoing effort to understand whether and in what ways the relationship matters in SMI services, as well as future efforts to guide the study of empirically supported case management relationships.