Client-Therapist Alliance in Substance Abuse Intervention: Comparisons Between Social Workers and Nurse Care Managers

Background/Purpose: Health care has been a major source of growth for the profession of social work. Moreover, social workers have played an increasingly vital role in addressing issues of addiction, substance abuse, and recovery. As social workers become more immersed in work related to drug addiction, it is critical to evaluate how well the profession performs in a context where other healthcare professions perform similar roles. One way is to use the Revised Health Alliance Questionnaire (HAQ II).

The HAQ II is a 19-item survey given to clients examining their relationship with their therapist. The survey includes statements about the therapist as a person and a professional, the helpfulness of the therapist, and the client’s bond with the therapist.  The HAQ-II has high reliability and validity. Scores on the HAQ-II are also predictive of patient outcomes.

Methods: We analyzed HAQ-II scores for social workers and nurse care managers (NCMs) from the Addiction Health Evaluation and Disease (AHEAD) Management Study in Boston, Massachusetts, which collected data from 2006 to 2010. There were a total of 503 participants who participated in the study and 282 participants were randomized to receive chronic care management, which included sessions with a social worker as well as sessions with a NCM. Social workers and NCMs both conducted substance abuse, psychiatric, medical, and social assessments as well as relapse prevention counseling.  The social work intervention also included motivational enhancement therapy. NCMs were responsible for contacting and re-engaging patients who had been absent for a month.  Participants completing two or more visits with the social worker were eligible to complete the HAQ-II social work survey; participants who completed two or more visits with the NCM were also eligible to complete the HAQ-II nurse survey. Surveys were given to clients at or after the second visit with the NCM or social worker.

We examined the 60 participants who completed the HAQ-II for both social workers and NCMs. Paired t-tests compared patients’ mean HAQ-II ratings across the two provider groups. We also estimated a robust cluster regression model controlling for client's age, sex, race and ethnicity, and drug and alcohol dependence to evaluate the impact of provider profession on alliance ratings, accounting for the repeated respondent ratings.

Results:  Ratings for social workers were significantly higher than ratings for NCMs via paired t-test (106.7 vs. 97.1; t₅₉=3.60; p < .001); the NCM group also showed higher intragroup variance. Adjusting for respondent background covariates, the robust cluster regression model (accounting for repeated measures on subjects) confirmed that ratings of social workers were, on average 9.6 points higher compared to ratings of NCMs (95% CI: 4.05-15.05; p<0.001).

Conclusions and Implications: Social workers demonstrate best practices in relationship-building with clients. Social workers may potentially play an important role educating those from other health professions on strategies for healthy alliance building with substance abusing clients in treatment. As healthcare moves increasingly towards an inter-professional framework, the role of social workers in modeling provider-patient interactions may take center stage.