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

Estimates show that 22.1 percent of Americans ages 18 and older have a diagnosable mental disorder in a given year (Regier, Narrow, Rae, Manderscheid, Locke, & Goodwin, 1993), about 1 in 5 adults. These figures translate to approximately 44.3 million people, when applied to the 1998 U.S. Census residential population estimate (The National Institute on Health, 2001). The National Institute on Disability and Rehabilitation Research (NIDRR, 1993) contends that approximately 4 to 5 million of these persons have severe and chronic mental illness. Of the persons comprising this large group, approximately half are adults between the ages of 25 and 44 (Manderscheid & Sonnerschein, 1992). These figures highlight the impact of mental illness on a significant portion of the working age population in the United States. Estimates within the past decade illustrate that of the four to five million persons who have severe mental illness, 70% to 90% are unemployed (Rutman, 1994). "Despite the advent of new program technologies, such as supported employment, and community and psychosocial rehabilitation, programs have not increased their effectiveness in achieving successful employment outcomes for this population" (Fabian, 1999, p.6). Consequently, other aspects of the rehabilitation process need to be examined as contributing factors to the current trends.

The relationship between the counselor and client should be investigated. This relationship, termed the working alliance, consists of mutual trust, respect and involvement in the counseling process. It signifies the existence of a collaborative counseling process, which engages the client and facilitates successful outcomes. The working alliance that is developed and maintained throughout the counseling process between the counselor and the client contains pertinent information that may provide some explanation of what occurs that makes rehabilitation outcomes for this population mostly unsuccessful. The current study investigates the relationship between the working alliance and rehabilitation outcomes for persons with severe mental illness (SMI).

Research conducted by the National Alliance for the Mentally Ill (NAMI, 1997) on employment success for this population within the vocational rehabilitation system reinforces the reality of low employment rates for this population and provides evidence that persons with severe mental illness experience less success at becoming vocationally rehabilitated than most other persons with disabilities (Rogers, Anthony, Toole & Brown, 1991). NAMI (1999) contends that the state-federal public rehabilitation program has failed through their service delivery program to increase the employment rates of persons with severe mental illness. There still exists the challenge to improve the quality and consistency of employment outcomes for this population.

The 1998 Amendments to the Rehabilitation Act stated that individuals with disabilities served in the State-Federal rehabilitation system must be "active and full partners" in the vocational rehabilitation process. Client involvement in the rehabilitation counseling process has been reported as an important factor in increasing the likelihood of successful employment outcomes (Chan, Shaw, McMahon, Koch, & Strauser, 1997). Therefore, a key factor in the development of the client as an active participant in the vocational rehabilitation process is fostering a working alliance between the client and counselor.

As Bolton, Bellini and Brookings (2000) suggested, an important focus of research has been to determine variables that influence successful employment outcomes. Previous studies have typically focused on consumer demographic characteristics as variables, such as: previous employment history, psychiatric diagnosis, ethnicity, gender, marital status, living arrangements, and recidivism. One variable is the counselor-client relationship (i.e., the working alliance) and the value it may have for enhancing employment outcomes for people with SMI. What this seems to call for across rehabilitation models, is the need for attention to individual needs and concerns, an emphasis on the quality of the relationship between the client and the counselor, as well as an understanding of the individuals' perception of the benefit of rehabilitation services. It is imperative within a rehabilitation service model that is client-centered to not ignore the consumer's subjective views regarding the impact of the services they receive (Lustig & Crowder, 2000). Understanding the nature of these factors could potentially yield valuable information toward interventions that may increase employment outcomes for persons with severe mental illness.

The interpersonal interactions that exist between counselors and clients may have a strong impact on the clients' process of recovery. Russinova (1999) reviewed staff's influence on psychiatric rehabilitation outcomes for persons in psychosocial treatment facilities. Russinova maintains that staff/practitioners have the ability to promote hope in the recovery process, but also to provide resources and supports to assist with facilitating this process. This appears to link closely with the three interdependent components of the working alliance: goals, tasks and bonds (Bordin, 1979). The shared agreement between the client and the counselor on the resources and supports that are needed and the client's belief in the counselor's commitment to his/her recovery process help to facilitate a strong level of working alliance. This in turn helps promote successful outcomes for the client. Consequently, the benefit of developing a strong working alliance with persons with psychiatric disabilities could prove to be integral to enhancing successful outcomes for this population.

Research conducted by Svensson and Hansson (1999) also provides support for developing the working alliance. Their study examined the working alliance between individuals with schizophrenia at an in-patient treatment facility and their therapists every five weeks throughout the treatment period. They found that persons with schizophrenia with a poor or low level of working alliance showed a drop out rate of 72%. This finding may be indicative of the necessity of a strong alliance in order to help maintain client contact. For this population, as well as others with SMI, the initial goal of therapy should be to take steps to maintain therapeutic contact with the client. It is important that clients are interested and genuinely invested in their therapeutic process so that they continue to access treatment. Initiating and fostering a strong alliance is critical to the client's success by insuring, at the very least, that the client is present and engaged in the process of treatment.

Bordin (1979) theorized that the working alliance between the client and counselor as the key to change in the client. The development of the working alliance is dependent on the level of collaboration between the client and counselor. Problems associated with the development of the working alliance in counseling are characteristic of the manner in which the client functions outside of counseling. The development of a strong working alliance in counseling may assist the client in overcoming self-defeating thoughts and behaviors outside of counseling. This would seem to be of paramount importance for clients with SMI, who more often than not, are in the management role of their illness.

Often, self-defeating thoughts and behaviors that are inherent to the nature of severe mental illness, are a major handicap for persons with SMI. The manifestation of these symptoms and the general population's lack of understanding of these manifestations, may cause bias and negative attitudes that often hinder the development of social relationships. The working alliance not only enhances the relationship between the counselor and the client, but could also prove to be instrumental in nurturing feelings of acceptance and support and dissipating feelings of isolation and bias.

The collaborative relationship between the counselor and the client is widely accepted and viewed as being central to effective psychotherapy outcomes (Krupnick, Sotsky, Simmens, Moyer, Elkin, Watkins, & Pilkonis, 1996). Significant strides in research have been made to examine this concept for persons with SMI. As these studies have found the working alliance to be pertinent to increasing successful outcomes for persons with SMI, it has become imperative that this relationship be examined in relation to persons with SMI who access vocational rehabilitation services. This paper will examine the impact of the working alliance on the treatment outcomes of clients with severe mental illness within the state-federal rehabilitation system.

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.

Review of relevant literature indicated that working alliance consists of three interdependent components, specifically, goals, tasks, and bonds (Bordin, 1979). Items contained in the BBER/ CMS questionnaire were analyzed with respect to their relevance to Bordin's conception of working alliance. The principal researcher chose items that addressed core ideas contained in Bordin's components of working alliance. Eleven items were chosen for review by six expert raters. Criteria for selection as an expert rater included: (a) a Doctorate degree in counseling or counseling psychology, (b) experience as a counselor educator, and (c) familiarity with the concept of the working alliance. All of the experts have taught graduate courses in counseling techniques.

Expert raters were asked to judge the relevance of the items to the concept of the working alliance and to choose the component (i.e. goals, bonds, or tasks) of the working alliance most closely associated with the item. Expert raters rated each item on a five point Likert-type scale from 5-very relevant to 1-not related. Items with a mean rating of 4.0 or higher were retained. This procedure reduced the item pool from eleven items to nine items (see Table 2 for items). For each item, the percentage of raters specifying a particular component of the working alliance was calculated. For example, if four raters judged item two to be associated with the bonds component and two raters assigned the item to the tasks component, then item two would be proportionally assigned as .66 to the bonds component and .33 to the tasks component. This proportional partition was computed for each item and assigned into the appropriate component of the working alliance. For each component of the working alliance (i.e., bonds, tasks and goals), a linear equation was calculated using the proportion assigned by each expert rater. For example, the bonds component was computed as .16 (item 1) + .66 (item 2) + 1.0 (item 5) + .33 (item 8) + .16 (item 9) + .16 (item 11). Bordin (1994) conceptualized the working alliance as consisting of three equally important, interdependent components. In order to weight each component of the working alliance equally, the scores for bonds, tasks, and goals components were standardized. Finally, the three standardized scores were added together to produce a working alliance total score. For the Working Alliance Survey, and measures of the client's view of their future employment prospects and satisfaction with current job, a low score indicates a stronger working alliance and a more positive view of their future job prospects and satisfaction with their current job. With respect to the standardized working alliance score, a score of zero is at the mean and a negative score indicates a stronger working alliance. The internal consistency reliability coefficient (Cronbach's alpha) for the working alliance scale in this study was .80.

Procedures

Each month the Tennessee Division of Rehabilitation Services provided the Bureau of Business and Economic Research/Center for Manpower Studies (BBER/CMS) at The University of Memphis with a list of clients. Staff at the BBER/CMS contacted clients by telephone 60 days after closure and administered the questionnaire by phone. If the initial attempt to contact the client was unsuccessful, six additional attempts were made to contact the client. The participants for this study were a sub-sample of a larger survey of all Tennessee Division of Rehabilitation Services clients. The BBER/CMS attempted to contact 10,387 clients. Of this number, 46% (n = 4754) were contacted and completed the questionnaire. All respondents were former clients. The BBER/CMS was unable to contact 47% (n = 4913), while 7% (n = 722) were contacted but refused to respond. Approximately 43% of the questionnaires were unusable due to missing data and frequency of items marked "not sure", "does not apply", and no response answers. Of the 2732 usable questionnaires, 305 participants were classified as individuals with severe mental illness and were used for analysis.

Data analysis

For the first research question, "Is there a difference between clients who are employed and unemployed with respect to measured levels of working alliance?", a t-test was conducted on the continuous variable of the Working Alliance Survey (WAS) in order to compare employed clients with unemployed clients. For the second research question, "For employed clients, is there a relationship between working alliance and satisfaction with their current job?", a Pearson r correlation between the continuous variables of the WAS and satisfaction with their current job was calculated for employed clients. For the third research question, "For employed clients, is there a relationship between working alliance and the client's view of their future employment prospects?", a Pearson r correlation between the continuous variables of the WAS and future employment prospects was calculated for employed clients. Finally for research question four, "For unemployed clients, is there a relationship between working alliance and the client's view of their future employment prospects?", a Pearson r correlation between the continuous variables of the WAS and future employment prospects was calculated. An alpha level of .05 was used for hypothesis testing.

Since the study was an ex post facto research design, specific demographic and disability related factors were considered as potential sources of error in the results. Based on previous research (Bolton et al., 2000; Wilson, 2000) two variables were considered: (a) the existence of a secondary disability and (b) the participant's ethnicity. The difference between individuals with a secondary disability and without a secondary disability was not statistically significant, t (281) = -1.76, p > .05; [.sup.~2] < .01. The second variable considered for statistical control was ethnicity.

This variable was collapsed into two groups, Caucasian and non-Caucasian. The difference between individuals who are Caucasian and non-Caucasian was not statistically significant on the continuous variable of working alliance (t (303) = - .33, p > .05; [.sup.~2] < .000). The two variables, secondary disability and ethnicity, were not considered appropriate for statistical control.

Results

Using a t-test, a significant difference was found on the variable of working alliance for the employed group (M= - 1.05; SD = 2.01) versus the unemployed group (M = 1.28; SD = 3.32; t (303) = -6.73,p < .001) with an effect size, as measured by [[eta].sup.2], of .13. For employed clients, the measure of working alliance correlated significantly with satisfaction with current job (r = .23; p < .05), and their view of future employment prospects (r = .70; p < .001). For unemployed clients, the measure of working alliance correlated significantly with the client's view of their future employment prospects (r = .54; p < .001).

Discussion

Four research questions guided this study. First, the results indicated that employed clients measured stronger on the working alliance with their counselor than unemployed clients, as measured by the WAS. According to Cohen (1988), the effect size as measured by eta squared (.13) can be considered a medium effect. Second, the results indicated that for employed clients, the stronger the measured level of working alliance the more satisfied the client was with their current job. The correlation coefficient as measured by r (.23) can he considered a small effect (Cohen). Third, the results indicated that for employed clients, the stronger the measured level of working alliance the more positive the client viewed their employment future. According to Cohen, the effect size as measured by r (.70) can be considered a large effect. Finally, the results indicated that for unemployed clients, the stronger the measured level of working alliance the more positive the client viewed their employment future. This result can also be considered a large effect (r = .54; Cohen).

Implications for Counselors

A general treatment goal of any therapeutic interaction should be to establish and maintain the working alliance. This goal is even more relevant when dealing with persons with severe mental illness, as it may motivate the client to actively engage in treatment. The benefit of developing a strong working alliance with persons with psychiatric disabilities is integral to enhancing successful rehabilitation outcomes for this population. As previously stated, the working alliance that is developed in counseling can often be characteristic of the manner in which the client functions outside of counseling. To this end, counselors should work toward a central focus on building and maintaining the working alliance. Specifically, counselors need to actively work to engage and maintain contact with clients, as well as developing a relationship that the client can model and transfer to relationships outside of the counseling process.

Professionals in outpatient treatment settings purport that establishing a working alliance is of paramount importance in order to motivate the client to engage in treatment (Attridge, Ball & Ball, 2002). Due to the high numbers of persons with severe mental illness who drop out of treatment, establishing the working alliance is key to insuring, that at the very least, clients participate in treatment. Counselors should be aware that persons with SMI face extreme bias and negative attitudes, which may prevent meaningful interactions from occurring. This experience of stigma may impede the recovery process with feelings of discouragement and low self-esteem, and possibly disrupt the counseling relationship (Wahl, 1999). With this knowledge, through the setting of mutually beneficial goals and tasks in collaboration with the client, counselors relay a message of respect and interest, which fosters a sense of empowerment within the client. Rusch & Corrigan (2002) also suggest that client participation in setting and exploring goals may increase client motivation and interest in treatment. In a case study examining the impact of the working alliance on treatment outcomes for a person with bipolar disorder, Salzman (1998) indicated, "the importance of a mutually respectful therapeutic alliance cannot be underestimated in the treatment". It is suggested that this holds true for all persons with severe mental illness.

The findings of this study suggest that for persons who are either, employed or unemployed, the level of working alliance correlated significantly with their view of future employment prospects. This relates directly to the long-term impact that a strong working alliance can have on client outcomes. Practitioners should be more keenly and clinically aware of their role in facilitating and maintaining a strong working alliance. It points out the need for targeted training that will enable counselors to not only understand the ramifications of collaborating with the client but, will also provide specific information on how to help reduce stigma, empower, facilitate, and maintain the alliance throughout the counseling process. A stronger clinical focus on the working alliance within rehabilitation counseling education programs, will not only help to increase successful employment outcomes, but other long-term therapeutic goals as well.

Limitations

Conclusions about the results are limited by the following considerations. First, this study utilized an ex post facto design. A limitation of ex post facto designs is the difficulty determining a causal link between variables. Other factors may have affected the outcome. For example, clients may have refused service when the initial counselor contact was problematic in terms of the development of a working alliance. Thus, there may have been some pre-selection of client and counselor. Other variables that could affect the outcome include family and financial support, training of the counselor, and the duration of service. Second, the BBER/CMS was unable to contact slightly less than half of the potential respondents (47%) or were contacted but refused to reply (7%) and it is unclear whether non-respondents differ significantly from respondents. Third, interviews were completed during the 1999-2000 fiscal year with Tennessee Division of Rehabilitation Services clients. Consequently, the interpretation of the results should be limited to the sample examined at the time of the study. Fourth, although care was taken to provide evidence of the reliability and validity of the measure of working alliance, more evidence is needed to substantiate the reliability and validity of the Working Alliance Survey. Finally, only the client's view of the strength of the working alliance was used to measure working alliance. While research provides evidence that client ratings of the alliance are stronger predictors of treatment outcomes than counselor ratings (Connors et al., 1997; Horvath & Symonds, 1991; Luborsky, 1994), the validity of the measure of working alliance may be increased if both counselor and client were asked their perception of the working alliance.

Future Research

Given the results of this study, there are several recommendations to be made regarding future research in this area. This study developed a measure of working alliance (WAS) based on existing survey questions, not originally designed to address the working alliance construct. However, a number of measures have been previously developed (Horvath, 1994, and Horvath & Greenberg, 1989). It would be important to replicate this study utilizing instruments that have previously been developed and have been widely used in research on the working alliance.

Future replication of this study may also benefit from administering the working alliance measure at various time periods throughout the counseling interaction. Previous research (Krupnik et al., 1996) has indicated that the association and magnitude of outcome variance explained was considerably stronger when utilizing a mean alliance score. Administering the measures at various intervals during the therapeutic process, and examining the mean score, may allow researchers a more comprehensive understanding of the working alliance versus an examination at the conclusion of services, which may be confounded by client satisfaction with outcomes. Similarly, replication of this study may also benefit from an examination of the counselors' views of the working alliance. Counselors and clients often have divergent views on the therapeutic process and treatments, which can impact perception of the working alliance. Input from the counselors may be pertinent to determining the formation and strength of the therapeutic relationship (Chinman, Rosenheck & Lam (2000).

Finally, while this study found no significant differences based on ethnicity, given recent research into race and ethnic differences in rehabilitation outcomes (Wheaton, 1995; Wheaton, Wilson, & Brown, 1996; Wilson, 1999; Wilson, 2000) it would appear relevant for future studies to also examine the impact of ethnicity on the working alliance. Additionally, this further examination of the impact of ethnicity on the working alliance, should be reviewed from the perspective of the counselor as well as the client.

Conclusion

The results of this study mirror those of other studies on this population and illustrate that the development of the working alliance is central to the overall success of outcomes for persons with severe mental illness. If clients have stronger working relationships, they may be able to use the treatment to improve their lives to such a degree that they experience a more general satisfaction with life and better employment outcomes. Again, a strong relationship with the counselor can assist the client in social interactions and situations that exist beyond the counseling process. Specifically, for a group that lacks a "predictive nature" of the disability, the therapeutic relationship may become more central to long-term care situations. The correlation between the working alliance and future employment prospects indicates both the immediate benefit of a strong working alliance within the counseling relationship, but also the long-term implications for rehabilitation clients with severe mental illness. Chinman et al. (2000) concluded that the strength of the working alliance is relevant not only to the clients progress during therapeutic treatment, but also assists with improving their lives and has implications for increasing general satisfaction with life. This study reiterates the benefit of developing a strong working alliance with persons with psychiatric disabilities and prompts for further investigation into this construct and the potential implications for increasing successful outcomes.
Table 1
Demographic Characteristics of Participants

 Total sample Employed
 (N = 305) (n = 111)

Age 37.7 (M) (9.9(SD) 35.7 (M) 10.2 (SD)
18 - 25 43% 20%
26 - 40 45% 47%
41 + 41% 33%
% female 60 65

Ethnicity
 Caucasian 74% 26%
 African-American 19% 71%

Marital status
 married 18% 22%
 widowed 3% 3%
 divorced 28% 30%
 separated 7% 3%
 never married 44% 37%

Education
 < High School Diploma 37% 39%
 High School Diploma 46% 45%
 Post High School 17% 16%
 Special education <1% <1%

% secondary disability 36 43

 Unemployed
 (n = 194)

Age 38.9(M) 9.6 (SD)
18 - 25 11%
26 - 40 42%
41 + 47%
% female 58

Ethnicity
 Caucasian 81%
 African-American 29%

Marital status
 married 16%
 widowed 3%
 divorced 27%
 separated 9%
 never married 45%

Education
 < High School Diploma 35%
 High School Diploma 46%
 Post High School 18%
 Special education 1%

% secondary disability 32

Table 2
Working Alliance Survey items

1. Did the vocational rehabilitation counselor and staff seem
 committed to helping you find a job?
2. Did your counselor try to match your skills with the jobs
 available at the time?
3. Did your counselor try to understand your problems and needs?
4. Did your counselor help you try to solve your problems?
5. Did your counselors and staff treat you with dignity and respect?
6. Did you feel that you received all the services specified in
 your rehabilitation plan?
7. How involved were you in developing your vocational goals?
8. How involved were you in selecting your program services?
9. How involved were you in developing your service providers?


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Chandra M. Donnell

The University of Memphis

Daniel C. Lustig

The University of Memphis

David R. Strauser

The University of Memphis

Chandra M. Donnell, Ph.D., The University of Memphis, Center for Rehabilitaion and Employment Research, 113 Patterson Hall, Memphis, TN 38152-6010. Email cdonnell@memphis.edu
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Author:Strauser, David R.
Publication:The Journal of Rehabilitation
Geographic Code:1USA
Date:Apr 1, 2004
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Psychiatric Rehabilitation Idealized: Multi-Setting Uses and Strategies over the Course of Severe Mental Illness.
Augmenting vocational outcomes of supported employment with social skills training. (Vocational Outcomes of Supported Employment).
Career counseling with clients who have a severe mental illness.
Enhancing personal empowerment of people with psychiatric disabilities.

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