The working alliance: rehabilitation outcomes for persons with severe mental illness

Journal of Rehabilitation,  April-June, 2004  by Chandra M. Donnell,  Daniel C. Lustig,  David R. Strauser

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In order to examine the impact of the working alliance on persons with severe mental illness, four research questions were addressed: (a) Is there a difference between clients who are employed and unemployed with respect to the measured levels of working alliance; (2) For employed clients, is there a relationship between working alliance and satisfaction with their current job; (3) For employed clients, is there a relationship between working alliance and the clients' view of their future employment prospects?; and (4) For unemployed clients, is there a relationship between the working alliance and the clients' view of their future employment prospects? To examine these research questions, a sample of 305 individuals with severe mental illness (meeting DSM IV criteria for schizophrenia, delusional disorders and psychotic disorders, not elsewhere classified) completed a survey that measured their reported level of the working alliance and information related to the outcome measures.

Method

Participants

The subjects for this study were Tennessee Division of Rehabilitation Services (TDRS) clients classified as individuals with severe mental illness who were contacted by telephone during fiscal year 1999-2000. Clients were classified either case status 26-employed or case status 28-unemployed. Researchers contacted 305 clients.

Demographic characteristics of participants are presented in Table 1. Participants ranged in age from 18 to 62 (M = 37.7; SD = 9.9), with 14% (n= 43) between ages 18 and 25, 45% (n =136 between ages 26 and 40, and 41% (n = 126) older than 41. Most participants were never married (44%; n = 125) with 28% (n = 79) divorced, 18% (n = 51) married, 7% separated (n = 20), and 3% (n = 8) widowed. Most respondents were Caucasian (74%; n = 227) with 26% (n = 78) African-American. Forty-six percent (n = 140) had completed high school, 37% had completed less than a high school diploma (n = 113), 17% (n = 50) had completed post high school education, and less than 1% (n = 2) were in special education. More than half (60%; n= 184) of the respondents were female. Most respondents were unemployed (64%; n = 194). Participants also reported a secondary (if any) disability. Thirty-six percent (n = 182) of participants reported a secondary disability.

Instrument

The Bureau of Business and Economic Research/Center for Manpower Studies (BBER/CMS) at The University of Memphis developed a 47-item questionnaire regarding clients' satisfaction with TDRS programs and services, current employment status, and wages and benefits. Two versions of the survey were used. One version was used for employed clients. A modified version of the questionnaire, not including questions about benefits or satisfaction with current employment, was used for unemployed individuals.

For the purposes of this study, specific questions contained in the BBER/CMS questionnaire were used to measure the construct of working alliance. The nine-item instrument, named the Working Alliance Survey (WAS) was developed specifically for this investigation following guidelines proposed by DeVellis (1991). Working alliance was defined as a collaboration between the client and the counselor based on the development of an attachment bond as well as a shared commitment to the goals and tasks of counseling (Bordin, 1979). Specifically, the development of the instrument was guided by two factors: (a) the construct of working alliance, as delineated by Bordin and (b) expert ratings by counselor educators familiar with the concept of working alliance.