| Intensive case management models stress the importance of a continuous, supportive relationship between case manager and client in improving community adjustment and reducing reliance on inpatient treatment. Case manager-client relationships, however, remain largely unexplored. Here, the psychoanalytic construct of the therapeutic alliance was applied to relationships between case managers and clients with severe mental illness. Specific study goals were to characterize alliance at a point well into treatment, and to examine associations among pretreatment, treatment, alliance, and client outcome variables. After two years of work together, 201 clients and their case managers in a multi-site demonstration of intensive case management were asked to characterize their relationship using the Working Alliance Inventory and perceived outcome ratings. Additional outcomes included independent ratings of symptom severity and global functioning, client-rated living skills, and actual hospital days. Using hierarchical stepwise regression procedures, the study yielded four main findings: (1) case manager and client alliance ratings were modestly associated with one another, were unrelated with pretreatment variables, and were differentially related with treatment and client outcome variables; (2) case manager alliance was negatively associated with case manager age and experience, caseload difficulty, and symptom severity, and positively associated with health-sickness, living skills, and case manager perceptions of outcome; (3) client alliance was associated with client perceptions of outcome alone; and (4) neither alliance rating was associated with psychiatric hospital utilization. Overall, the alliance construct was useful for assessing relationships between clients with severe and persistent mental illness and their case managers. Alliance associations with objective treatment measures and independent outcome ratings refute explanations based on "halo" or affectivity effects. Data support prospective studies of alliance in case manager-client relationships, with particular attention to the sources of information used by case managers and clients in making alliance assessments. |
