Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: Embedded within a primarily quantitative study of the predictive validity of consumer/case manager versions of two alliance measures– the WAI (Horvath, 1981) and the HAq-II (Luborsky et al., 1996), the goal of this qualitative sub-study was to explore how case managers reconcile expectations of consumer relational progress with actual outcomes, nine months post consumer-entry into ICM. As reported at SSWR in 2004, case managers' standardized alliance measures reflected positive alliances with clients that predicted some client outcomes. However concordance between case manager/client alliances at any one point in time was low, suggesting that case managers and clients don't always agree on what contributes to relational progress. As reported at SSWR in 2006, consumers' qualitative responses about what they expected, and liked and disliked about their case managers indicated desire for more social interactions with them, yet case managers often failed to value informal socialization. This current sub-study attempts to build on earlier findings by concretizing the ways in which case managers reconcile their expectations with the actuality of early relationships with clients. Methods: Data from 49 case managers, employed at 19 non-urban agencies in Eastern Pennsylvania was gathered, using an exploratory, one-group, repeated measures design (NIMH Grant #5RO3MH52734-02). Quantitative and qualitative data were collected at baseline and after three, six and nine months post-client entry into ICM. Most were White, college graduates and had three years or less experience in this position. Consumers had DSM-IV diagnoses of schizophrenia or schizo-affective disorder. NVivo software was used to analyze verbatim responses to questions about case managers' expectations for consumers (asked during the initial interview), their perceptions of their helpfulness towards the consumer (asked at 3, 6 and 9 months), and whether the relationship turned out as expected at 9 months. Results: Case managers commonly reported expectations of improvement in illness management, housing, and participation in job related activities at nine months. A majority described surprise at how the relationship turned out. Of those positively surprised, many noted the quick development of trust in the relationship. However, slightly more than half indicated being disappointed, citing consumers' difficulties with maintaining appropriate boundaries. Respondents indicated that these relational dynamics impeded progress towards anticipated instrumental goals. These findings, alongside previous findings of consumer's desires for more informal contact, support the possibility that tensions between differences in relational expectations may negatively impact instrumental goals. Implications for research and practice: The broader alliance research literature demonstrates that early positive relationships are key to favorable consumer outcomes. Analysis of the language case managers use to describe the dilemmas they encounter reveals ambiguity that quantitative alliance measures fail to capture. To improve case management practice we must better understand these ambiguities as they may result in service disruptions if not addressed. Additional combined qualitative and quantitative research on the consumer/ ICM alliance, beyond 9 months, is needed to explore and further concretize case managers' understanding of their relationship with consumers, in their own words.