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

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.