Examining the Working Alliance as a Mediator of the Relationship Between Fidelity to the Strengths Model of Case Management and Client Outcomes

Abstract

The strengths model of case management (SMCM) is a recovery-oriented intervention for people with severe mental illness that focuses on leveraging individual and environmental strengths to meet clients’ goals. SMCM has a small, growing evidence base. This thesis is comprised of two studies examining the working alliance between people with severe mental illness and their strengths model case managers. The working alliance as a mediator of the relationship between fidelity to SMCM and clients’ quality of life outcomes was explored. Data for study one were drawn from a sample of 311 people with severe mental illness from seven mental health organizations in three Canadian provinces. The participants were new to SMCM and participated in five structured interviews every 4.5 months for 18 months. The team-level SMCM Fidelity Scale was used to examine how closely teams followed the model, every six months for two years, and then one year later, at three years. Ordinary least squares path analysis was used to test the simple mediation models. A moderator of mediation, to account for agency location, was also tested, as an exploratory analysis. In the second study, using convenience sampling, twenty people with severe mental illness, with a current SMCM case manager, participated in semi-structured, qualitative interviews. Data were analyzed thematically, beginning with a start list of codes based on the research questions, the SMCM model, the previously tested mediation model, and the working alliance and SMCM literature. Both studies expanded the construct of the working alliance in SMCM intervention settings. Study one showed that higher SMCM fidelity predicted better client outcomes (quality of life and hope), indirectly, through the working alliance. Independent of the working alliance, SMCM fidelity was not associated with client outcomes. In an exploratory analysis, earlier outcomes predicted later working alliance. In study two, people with severe mental illness attributed personal life change to their relationship with their case manager. They valued their case managers’ flexibility and highlighted the work they did together on a wide range of practical goals of their choosing. From clients’ perspectives, case managers approached the SMCM intervention responsive to clients’ preferences and choices. Clients’ perceptions of the working alliance aligned with three key elements commonly used to conceptualize the working alliance: the bond, and agreement on goals and tasks (Bordin, 1979). Both studies showed that the working alliance serves as a mechanism of change in SMCM, supporting the effectiveness of SMCM and highlighting the need to implement interventions and training activities that focus on developing strong working alliances between case managers and clients with severe mental illness.