Understanding the working alliance between persons with substance abuse problems and strengths-based case managers ([dagger]).
Subject: Psychotherapy (Social aspects)
Medical case management (Social aspects)
Interpersonal relations (Analysis)
Substance abuse (Care and treatment)
Substance abuse (Social aspects)
Authors: Redko, Cristina
Rapp, Richard C.
Elms, Cindy
Snyder, Mindy
Carlson, Robert G.
Pub Date: 09/01/2007
Publication: Name: Journal of Psychoactive Drugs Publisher: Haight-Ashbury Publications Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2007 Haight-Ashbury Publications ISSN: 0279-1072
Issue: Date: Sept, 2007 Source Volume: 39 Source Issue: 3
Topic: Event Code: 290 Public affairs
Product: Product Code: 8000143 Alcohol & Drug Abuse Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 172776816
Full Text: Abstract--A substantial body of literature has examined the importance of the working alliance in psychotherapy; few works have examined it in the context of case management. Qualitative methods were used to examine how 26 persons with substance abuse problems perceived the working alliance with case managers who practice from the strengths perspective. Clients' narratives emphasized the personal qualities of the case manager and the nature of the client-case manager relationship. Their narratives also reflected two guiding principles of strengths-based case management: personal control over goal-setting, and an emphasis on strengths. Most clients concluded that a positive working alliance helped them to build trust, self-worth, and self-esteem.

Keywords--case management, qualitative research, strengths perspective, substance abuse treatment, working alliance

**********

A therapeutic or working alliance is defined broadly in psychotherapy research as the collaborative and affective bond between therapist and client, a condition considered essential for the therapeutic process (Bachelor & Horvath 1999). The quality of the therapeutic alliance has been found to predict the success of counseling and psychotherapy, regardless of theoretical underpinning, and across clients with a variety of disorders (Hubble, Duncan & Miller 1999). For persons with substance abuse problems, the development of a working alliance early in treatment has been a consistent predictor of successful engagement and retention in treatment (Meier, Barrowclough & Donmall 2005; Barber et al. 1999; Petry & Bickel 1999), but an inconsistent predictor of post-treatment outcomes (Meier et al. 2005).

Most studies that describe the therapeutic or working alliance and its effects come from psychotherapy research (Martin, Garske & Davis 2000; Horvath & Symonds 1991). Conversely, little work has been undertaken to examine the nature of the relationship between client and case manager (Brun & Rapp 2001). This is surprising, since case management is a ubiquitous social service intervention used by health professionals in their work with geriatric populations, adolescents, and persons with substance abuse and/or mental health concerns, developmental disabilities, and HIV/AIDS (Austin & McClelland 1996; Siegal et al. 1995; Fleishman, Mor & Piette 1991).

The current study employs qualitative methods to provide a rich description of the working alliance that develops between individuals with substance abuse problems and case managers who practice from a strengths perspective. Understanding the working alliance can help substance abuse professionals identify how the interaction between client and case manager encourages treatment linkage and engagement and leads to improved outcomes. This article will address two research questions: How do persons with substance abuse problems perceive the working alliance with strengths-based case managers? and How does the working alliance produce change, according to these clients' perceptions? Qualitative methods are best suited to focusing on a description of clients' perceptions because they provide an inductive approach that offers a richer understanding of the working alliance phenomenon and greater clinical relevance than interpretations imposed on the clinical situation from outside (Bachelor 1995). Also, clients' perceptions of the alliance have been more consistent predictors of improvement, when compared to perceptions of health professionals (Horvath & Symonds 1991).

WORKING ALLIANCE: AN OVERVIEW

Terms that have been used to describe the relationship between therapist and client include: therapeutic alliance (Zetzel 1956), helping alliance (Luborsky 1976) and working alliance (Greenson 1965). Although there are some differences among these terms, most definitions have three themes in common: the collaborative nature of the relationship, the affective bond between client and therapist, and the client's and therapist's ability to agree on treatment goals and tasks (Martin, Garske & Davis 2000; Gaston 1990; Bordin 1979). Contemporary approaches for viewing the working alliance represent a spectrum that ranges from a classic psychoanalytic framework based on the model of positive transference to more reality-based perspectives of the therapeutic relationship (Crits-Christoph & Gibbons 2003; Horvath 2000). Greenson (1965) introduced the term working alliance to emphasize the reality-based attachment in addition to the positive transference component of the relationship. He stressed the collaboration between patient and psychoanalyst working purposefully together in the therapy situation.

Psychotherapy research of the past three decades has suggested that the working alliance is a common factor responsible for clients' change in all forms of psychotherapy (Bachelor & Horvath 1999; Luborsky 1976). A pantheoretical formulation emphasizes collaboration and is applicable to other helping processes besides psychotherapy in that "... the working alliance between the person who seeks change and the one who offers to be a change agent is one of the keys, if not the key, to the change process" (italics in original) (Bordin 1979: 252). From this perspective the working alliance is not, in and of itself, considered curative or an intervention, but it is the vehicle through which therapeutic gain may be facilitated (Horvath & Luborsky 1993).

While not an intervention, the working alliance has both technical and relational aspects (Bordin 1994; Gelso & Carter 1994). The technical aspects of the working alliance include goals (general objectives towards which therapy is directed) and tasks (the specific activities the client must engage in to attain goals and benefit from therapy). The bond consists of the affective quality of the relationship between client and therapist. The strength of the working alliance is both affected by and affects the extent to which therapist and client agree on the goals of their work, agree on the tasks that are useful to attain the goals, and experience an emotional bond with each other. The interdependence between relational and technical factors in therapy and positive developments in each facilitate the growth of the other. Furthermore, the interactive nature of the relationship and the integration of the technical and relational aspects distinguish the working alliance from other relationship constructs (Bordin 1994).

Persons with substance abuse problems are often considered one of the more difficult groups to engage in a helping relationship or effective working alliance. Correct or not, this perception may be due to substance abusers frequently being referred to treatment by the criminal justice system and the effects of drug-using environments that can be characterized by mistrust and dysfunctional relationships. Whether or not a working alliance is more difficult to establish with substance abusers, it has been shown to be a predictor of retention in substance abuse treatment (Meier et al. 2005; Barber et al. 1999; Petry & Bickel 1999). The relationships between clients and substance abuse treatment staff have been found to be related to client motivation and readiness for treatment, and these two factors in turn can be predictive of substance abuse treatment retention and outcomes (De Leon 2001; De Weert-Van Oene et al. 2001; Simpson, Joe & Rowan-Szal 1997; Simpson et al. 1997). Other studies provide mixed results on whether the working alliance can predict post-treatment outcomes (Tetzlaff et al. 2005; Barber et al. 2001; Belding et al. 1997; Carroll, Nich & Rounsaville 1997). A common feature of all of these studies is that working alliance is usually measured early in treatment and at only one or two time-points, which may not reflect the changing nature of the relationship and its final influence on engagement, retention and outcome (Meier et al. 2005).

Case Management and Working Alliance

While much has been written about the working alliance in the context of psychotherapy, few studies have addressed the working alliance between case managers and their clients (Brun & Rapp 2001). This is surprising, since case management is a major source of supportive care for many disadvantaged populations (Ballew & Mink 1996). Unlike in many models of psychotherapy, the working alliance is seldom addressed directly in case management. An exception is the strengths-based approach to case management (SBCM), in which one of the fundamental principles, and all practice activities, stress successful development of an effective working relationship (Rapp 2006; Brun & Rapp 2001). The goal of therapy involves finding solutions to treatment of interpersonal and intrapersonal problems, while case management assists individuals in identifying and accessing needed resources and developing a plan to acquire those resources (Ballew & Mink 1996). Additionally, the status and importance attributed to "doing therapy" is generally much higher than that of "doing case management." As a result, the nature of the working alliance may be different as well. Bordin's model has been used to examine the case management working alliance because of its potential to reflect the significance of the relationship from the standpoint of problem-solving. The conceptualization of goals, tasks, and bonds closely mirrors the steps involved in case management planning (Howgego et al. 2003). The strengths-based model of case management assists marginalized individuals in accessing needed resources and improves treatment linkage, engagement, and subsequent outcomes (Rapp 2006). Five principles guide SBCM: (a) client strengths, abilities and assets are emphasized during assessment and planning; (b) clients retain control over goal-setting and the search for needed resources; (c) the relationship between client and case manager is important; (d) the community (especially informal sources) is viewed as a resource and not a barrier; and (e) case management is conducted as an active, community-based process. The principles form the basis for all practice activities. A strengths assessment encourages clients to identify skills, interests, and evidence of past successes and positive traits. The focus on positive attributes is based on the theory of self-efficacy--the hypothesis that people will be more likely to begin and maintain positive behaviors if they recognize that they have engaged in those behaviors in the past (Bandura 1977). Case managers help clients weigh alternatives and consider the short- and long-term implications of their goals, objectives, and strategies, but will not attempt to steer clients in a certain direction or otherwise manipulate the plan (Rapp 2006).

Studies that have examined the working alliance in case management have assessed the relationship in the context of community mental health. Some of these studies have used a retrospective approach to document a strong association between client-rated alliance and positive clinical outcomes, such as reduced symptom severity, improved global functioning and satisfaction with mental health treatment (Neale & Rosenheck 1995; Solomon, Draine & Delaney 1995). Chinman, Rosenheck, and Lam (2000) conducted one of the few prospective studies that has shown a positive association between the client-rated alliance with the case manager and general life satisfaction.

METHODS

This article is based on qualitative interviews and focus group discussions conducted as part of the Reducing Barriers to Drug Abuse Treatment Services Project (RBP), a five-year study funded by the National Institute on Drug Abuse. The RBP is a three arm clinical trial designed to assess the effectiveness of strengths-based case management and motivational interviewing, relative to a standard referral process, in linking clients with treatment services and subsequently engaging them in services. This article focuses on the strengths-based case management arm of the larger trial.

Eligible subjects were: (a) over 18 years of age; (b) diagnosed as having a substance abuse and/or dependence disorder using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA 2000); (c) not suffering from schizophrenia or any other psychotic disorder; and (d) referred to either residential or outpatient substance abuse services. Alcohol abusing or dependent individuals without other substance disorders were not eligible.

The RBP site is located in a centralized intake unit (CIU) in a midwestern region with a county population of 552,000 according to the 2000 census. The CIU is the county's only point of entry for uninsured individuals seeking treatment for substance abuse and mental health problems. Assessment therapists conduct psychosocial, mental health, and substance abuse assessments to determine the nature and extent of clients' problems. Clients are referred to an appropriate level of care within the community treatment system based on American Society for Addiction Medicine (ASAM 2001) criteria and situational factors such as treatment availability and client preference. Referrals are made to eight state-certified, specialty substance abuse treatment programs. Clients generally do not contact the treatment program immediately after the assessment, but must wait to get a specific date from the CIU, which may take from several days to over a week after the assessment. Clients who are admitted to the trial are randomized into the standard services provided by the CIU while awaiting substance abuse treatment, or into one of the clinical trial's two experimental arms. During the next 60 days clients receive up to five sessions of strengths-based case management (Rapp 2006), one session of motivational interviewing (Miller, Rollnick & Conforti 2002), or they receive standard services.

The project ethnographer (first author) invited a convenience sample of clients who had been randomly assigned to the strengths-based case management intervention to participate in the present study before entering substance abuse treatment. However, clients who were assigned to the case management group but did not attend any of the sessions were not included in this sample. Only one client refused to participate. Two focus groups were conducted to explore the range of views and opinions clients expressed regarding strengths-based case management. Qualitative interviews were also conducted with the clients individually. A semistructured protocol was used to elicit their perceptions of substance abuse problems and treatment history, including their perceptions of the strengths-based case management services they received. For each qualitative interview or focus group, lasting approximately 90 minutes, clients were compensated $20 for their time. Clients completed an informed consent form approved by Wright State University Institutional Review Board. Throughout this article case examples of drug users are provided under fictitious names to protect the anonymity of research participants.

We used an inductive approach for qualitative data analysis (Patton 2002; Erlandson et al. 1993). According to Lincoln and Guba (1985) inductive data analysis involves taking constructions that have emerged from the context (e.g. interactions between interviewer and interviewee) and reconstructing them in meaningful wholes. Data analysis is developed by unitizing the data (identifying themes), emergent category designation, and negative case analysis. A coding system was created by the ethnographer while examining the correspondence among various themes, by investigating relationships between themes, and by discovering unanticipated relationships. The next step in this kind of analysis was to look for significant recurrences, repetitions, and contradictions between and within themes. This step often contributed to the emergence of other subthemes that opened ground to exploring the data in new and unexpected ways.

The coding system included themes such as "working alliance" which identified all the sections of text in which clients discussed their relationship with the strengths-based case manager. The working alliance theme was subdivided into other codes such as "client reactions towards the case manager" and "case manager reactions towards the client." For instance, "persistence," "support," and "personalization" (treating the client as a person) are examples of emergent categories identified by clients as meaningful for the client/case manager relationship. Afterwards, alternative interpretations for the data were also considered (negative case analysis); particularly data that would tend to refute the ethnographer's reconstructions of reality. For example, the ethnographer checked for occurrences of negative reactions of clients towards the case managers, and how this influenced the working alliance. Audiotapes of focus groups and qualitative interviews were transcribed verbatim and then coded by using NVivo[R], a program designed for qualitative data analysis (Richards 1999; Fielding & Lee 1998).

RESULTS

Characteristics of Study Participants

Sixteen men (61.5%) and ten women (38.5%) who received strengths-based case management services agreed to participate in either a focus group (14) or a qualitative interview (17), while five of these participants participated in both. Average age of participants was 39.0 (SD = 10.55). The study sample was equally divided between African Americans and White participants. Seventeen participants (65.4%) had completed high-school or more. Regarding marital status, 53.8% (14) were single, 38.5% (10) were separated, divorced or widowed, and 7.7% (two) were married or living as married. While receiving the strengths-based case-management services, almost half of the participants, 42.3% (11), were homeless and very few (four, or 15.3%) were employed.

Considering drug of choice, 69.2% (18) of participants preferred to use crack or powdered cocaine, while the remaining 30.8% (eight) preferred heroin and/or nonprescribed opioids. At the time of the CIU assessment, three participants received the additional diagnosis of depressive disorder, two had bipolar disorder, and one participant had obsessive compulsive disorder. The majority of the participants, 84.6% (22), had previously been in some form of substance abuse treatment. Of those, 31.8% (seven) had been to treatment once, and 68.2% (15) had multiple treatment episodes. Fourteen participants (53.8%) had been in treatment within the past two years. Four participants (15.4%) had no previous treatment experience. Participants received an average of 3.5 case management sessions offered by one of the two female strengths-based case managers. Each case manager had a small caseload of about 12 clients per week. One case manager was White with a background in chemical dependency and dual diagnosis while the other was African-American with a background in social work. The case management intervention was guided by a manual created for this study. Case managers received weekly supervision from the Reducing Barriers clinical director.

Personal Qualities of the Strengths-Based Case Manager

Clients frequently started talking about strengths-based case management by identifying the case manager's personal qualities that they valued the most. Harry, an African-American who abused crack, said, "She is a good listener; she listens, she also has some good responses to the things that I say." Aline, a 36-year-old White woman who abused both crack and heroin, mentioned: "She didn't put me down for what I did in my life ... she listened, listened very well." Similarly, Diana, a 33-year-old African-American who used crack, emphasized, "She listened to me, because I was hurting, and I was going through a whole lot."

Clients reported that much of their past experience with other counselors and case managers was not about listening or being listened to--they were just being told what they had to do. Likewise, clients often claimed that other people did not pay any attention to them anymore. By listening carefully to what clients had to say, the strengths-based case manager introduced the possibility of clients developing trust in relationships again. Besides being a good listener, clients perceived the strengths-based case manager as being understanding and nonjudgmental. Harry added, "She took it in, she understood, she wasn't judging me, OK, she wasn't saying 'you was right you was wrong' she wasn't judging me; she was understanding, I think that's a key to a lot of recovery right there."

Several clients appreciated this understanding and nonjudgmental attitude because they did not feel stigmatized by the strengths-based case managers, which is how they often felt they were treated by other people. Dwayne, an African-American who used crack cocaine, explained: "She was very understanding, when you come into a place like this, everybody has this criteria of a crack head." The listening, understanding, and nonjudgmental attitudes can be key ingredients that promote recovery, as Harry suggested above.

Relationship with the Case Manager

Clients understood the working alliance in terms of the good relationship they were building with the strengths-based case manager. They valued the fact that the case manager was trying to build a good relationship with them, and that the case manager related well with people: Shandi, an African-American female who used crack, said, "Yeah we talked, we got a good relationship." Jack, a White male who used crack, claimed that "She was a godsend, she related to me well. I am sure that she would relate well with whoever the situation was." In many cases, just being present with the client was sufficient to create a good helping relationship. Martin, a 47-year-old White male who used crack, commented on "Just her demeanor, her actions, her questions, the way she went about things." Diana said, "She helped me out a great deal. She was there for me, and I didn't know where I was going."

Clients felt the relationship with the case manager lightened the burden of the addict life-style. Alex, an African-American who used heroin, said, "When I was left talking to her, I felt like I was on a cloud, I was floating, she was very--left a very great impression on me." Experiencing a feeling of lightness, or increased optimism, made clients feel more confident about themselves and about the possibility of making changes in their lives. Harry described this with enthusiasm: "But after I get through talking to her, I'm feeling like I'm on the cloud, you know I feel like there's nothing I can't do." Since clients were so immersed in the confusion of the drug-using life style, they believed they had nobody they could trust. For many, the strengths-based case manager soon became the "friend" they could talk to, the friend they needed, a person they could trust or feel comfortable with. As Harry stated, "Talking with her [case manager] was like talking to a friend, I felt relaxed. I felt comfortable; I feel like I can come from the heart." Rowan, an African-American who used crack, said: "She is the only friend I have; she encourages me. She is my angel."

Clients felt at ease talking with the strengths-based case manager because they could talk at their own pace and time without feeling pressured, so they were able to express their emotions and feelings. By "bringing it out" or by "opening up," clients were also able to build trust in the relationship. For example, Jamar, an African-American who used crack, commented:

Feeling comfortable implies the absence of sources of pain or distress, freedom from stress or anxiety, peace of mind. When clients start to feel comfortable talking about their problems with the case manager, it can encourage them to start talking to other people as well. John, a young White male who smoked marijuana, said, "She helped me bring a side out of me that I try to hide from people, she made me feel comfortable with talking about my problems." In some ways the case manager was modeling the possibility of the client having more positive relationships with other persons again. Greg, a 40-year-old African-American who used crack, commented:

The opportunity to set personal goals was encouraged by his strengths-based case manager.

A common development of the good relationship was summarized by Alex. He reported that the case manager maintained a persistent approach, like making phone calls to check if he was following through with the plans that they had developed. As Alex recalled, "She always gave me that ... uplift, OK, do the right thing, keep on doing what you're doing." She invariably had enough time to help Alex accomplish tasks related to his goals: "When she would take me somewhere, and they might be closed, and I might want to give up, 'well we'll come back tomorrow [the case manager would say], we got enough time, we can stay and do this'!" In short, having the time and being persistent were additional components of the strong working alliance that strengths-based case managers promoted. Arthur, an African-American who smoked marijuana, said: "She was like don't give up, we're gonna get it for you." Archie, a White male who used crack, noted: "She gave me that boost to get off of my butt, and do things that I did." Martin added, "It is just the extra push that does it."

Clients reported that establishing goals and then accomplishing tasks builds the awareness that one can have goals in life. Dwayne, an African-American who used crack, explained: "We set goals that were achievable. It wasn't nothing where I would set myself up for failure, so that really helped out, she was there for me, to help me achieve them." Setting goals frees the person to have more trust in oneself, as explained by Carla, a 30-year-old White female who used heroin: "I'm following all my goals, it just help me to see that I can do it, even though I'm addicted to drugs, doesn't mean that I still can't have goals."

During the focus group discussions, clients were surprised to discover that each case manager had a full case load of clients. Beforehand, they were feeling special and unique, since they had the impression the strengths-based case manager was completely focused on them individually. Harry explained, "It's just like I was her world, whenever, she just completely focused on what I needed, and what was going on in my life, and what needs to be done." Helen, a 42-year-old African-American who used crack, said "Yeah, I'm trying to think how did she have time for you all [other focus group participants] because I thought she was just mine, I mean my case manager."

Feeling special and unique can also be related to the client-driven nature of the relationship. Clients recognized this by observing that case managers usually respected their opinions, feelings, and desires while trying to follow what they, the clients, wanted. Harry said, "I always got positive feedback from her, 'well what do you want to do, and how do you want to do it,' she wanted my input always." Jamar declared, "As we talked she didn't just force the issue of what was wrong with me, and I just felt kind of openly enough to tell her, I told her she uplifted my spirit, which she did, and from there we just had a pleasant thing going." Alex claimed, "All the goals that I've I set forth, she just encouraged me to do them, and she stood by, she was there for me." Alex also had the opportunity of attending sessions with both case managers, because on a particular day his case manager was off sick. He was surprised to observe that although both case managers were different persons with different personalities, they provided him the same quality of service.

Focusing on Strengths, Seeing the Positives

The working alliance was impacted by the strengths assessment, an activity where case managers help clients identify personal strengths and skills. Clients commented that in some circumstances they were able to recognize some of their personal strengths, while in others, the case managers pointed out some of the strengths that emerged during the working alliance relationship. For instance, if a client showed up on time to appointments with the case manager, or if the client called when an appointment needed to be cancelled and rescheduled, the case manager would suggest that the client was being responsible and that responsibility is a strength. Many of the strengths that clients identified were related to behaviors they demonstrated while interacting with the case manager, like responsibility, determination, and the desire to help oneself.

When clients interacted with the case managers they often expressed negative and overwhelming experiences regarding themselves or their drug-using lifestyles. One of the major roles of the case manager was to show that there were more positive ways to perceive one's life situation, leading clients to slowly change their perceptions to a more positive view. According to Thom, a White male who used heroin, "Letting me take that negative attitude, they always use positive reinforcement to find a way around the road blocks that get thrown up in your way. I think that's the biggest thing I got from them as far as positive influence." In other words, instead of focusing on the negatives, which clients seemed to be constantly doing, strengths-based case managers guided clients to bring out some of the positives; they guided clients to start making some changes. Greg pointed out:

Focusing on strengths or stimulating positive thinking increases a client's sense of self-worth. This is significant because clients often perceived their own selves as their biggest barrier to following through with treatment. Karen, a 55-year-old White female who used crack and alcohol, mentioned:

Building Self-Esteem, Allowing Change

Having the opportunity to talk about oneself and one's drug problems helped clients gradually change views about themselves and improve their self-esteem. Thom observed, "If a person gets to tell other things about themselves, then they start looking at themselves too." Arthur noted, "She basically opened my eyes that there's a lot more potential in me, if I get the awareness that I need about drugs." Yasmin, an African-American female who used crack, said, "That's why I'm doing this--because the more that I can talk about my problems and the drugs, the stronger it makes me inside."

Besides rebuilding self-esteem, clients like Alex (below) commented how the working alliance with the strengths-based case manager helped them build self-confidence:

Strengths-based case managers also helped some clients overcome the stigma of being labeled a drug addict. For instance, Diana described substance abuse treatment as an environment where "everybody gets the same diagnosis and they treat you the same" and her reaction would be "that's not me." In contrast, the strengths-based case manager behaved differently with her because "She actually cared, she's talking to you, trying to see where you're at ... giving some feedback and input." In this context, several clients started to perceive themselves as persons again--not stigmatized addicts, but persons with feelings. Aline mentioned, "It's helped me tremendously, it gives me feelings about myself again."

Relating with the strengths-based case manager gradually stimulated changes. During this process, some clients were able to recover their own identity and a sense of self-worth, as described by Harry:

In short, the working alliance evolved in ways that allowed many clients to build self-esteem, self-confidence, regain a sense of identity different from their previous drug-using life style, and consequently, seek substance abuse treatment. Aline exclaimed, "I have grown so much I mean and I'm still growing, she's made a big difference in my life, because I didn't think there was any hope. Thom said, "Just take a little bit of interest in me, help me get through this, I'll do it. She helped me a great deal, I wouldn't have done it without her. Martin affirmed, "A little bit of help went a long way, a little bit of help went a long way."

DISCUSSION

This article describes how persons with substance abuse problems understood their relationship, or working alliance, with case managers who practice from a strengths perspective. Contacts between client and case manager took place immediately following assessment at a centralized intake facility but before entry into treatment. The analysis of clients' narratives revealed three major themes as they relate to the working alliance: the personal qualities of the case manager, client control over goal-setting, and the focus on client strengths and abilities. Taken together, these aspects of the working alliance assisted some clients in building self-esteem and improving self-efficacy, leading to positive change.

Being a good listener, demonstrating understanding, and maintaining a nonjudgmental attitude were the personal qualities that clients valued most in the case manager. Clients felt free from stigma; they were being treated like persons again. Clients described the relationship as one where they progressively felt more confident and comfortable, and able to talk to their case manager like a friend. The nature of the relationship was also defined in relation to the attitudes demonstrated by case managers: taking time, showing persistence, and maintaining a client-driven approach. Clients valued the fact that case managers took the time necessary so they could express themselves at their own pace. They also remarked on the persistence demonstrated by case managers towards helping them in every possible way: constant phone calls, finding alternative ways to solve a problem or to reach a goal, and "walking that extra mile." Mostly, they appreciated the client-driven attitude of the case managers because they carefully listened to what clients had to say and supported what clients wanted to do.

Clients disclosed spontaneously how the relationship with the case manager stimulated them to start a move towards personal change, at least during the period immediately following assessment. These changes were generated by building trust, bringing out positives, and by increasing clients' sense of self-worth and self-esteem. Clients believed that building trust strengthened the alliance. This trust building process also helped clients to set up some tasks and goals; accomplishing some of the goals helped clients have more confidence in themselves. Learning that one can trust people helped many clients open up to talk about themselves, first with the case manager, and then with other key persons. Consistent with the literature, a positive working alliance may lead to improved relationships with other persons besides the case manager (Greenson 1965; Henry & Strupp 1994).

From the perspective of clients, the working alliance affected change by generating gradual transformations in their sense of self. Clients commented on how acquiring more positive views about themselves increased their levels of confidence, self-worth, and ultimately, of self-esteem. In a similar vein, the change process evoked by the alliance was also related to recovering a sense of worth and of selfesteem. During the process of enhancing clients' self-esteem, interpersonal relationships were also improved, according to participants' perceptions. Clients also indicated that the working alliance triggered some of the changes they were starting to make. In particular, several clients acknowledged that interacting with the case manager reassured them that seeking substance abuse treatment was "the right thing to do."

Clients' narratives about the working alliance also have implications for the strengths-based model that guided implementation of case management. Three of the guiding principles of strengths-based case management are reflected in the themes describing the importance of relationship, personal control over goal-setting, and emphasis on strengths. The client's control over goal-setting integrated the process of building trust, self-worth, and self-esteem. Clients also reiterated that assessing one's strengths, often understood as bringing out the positives, slowly induced change and increased self-esteem. Study participants pointed out how bringing out the positives is more than just positive thinking; it is a collaborative interaction with the case manager that reminds them that they already have the ability to make changes. These findings provide support for case managers' adherence to the strengths-based model.

Study Limitations

Some persons with substance abuse problems (about 20%) did not participate in any meetings with case managers after being assigned to that arm of the trial. These individuals were not part of the sample, as the intent of this study was to examine the working alliance. This may have been due to their unwillingness to link with treatment. Had these individuals participated with a case manager they may have recounted a distinctly different experience with the working alliance, one that would not have been so positive.

Further, it is possible that clients may have felt an obligation to present their case manager and their interactions in the most favorable light possible, perhaps out of loyalty to their case manager. Clients may have expected that positive comments about the alliance were what researchers really wanted. This possibility may have been minimized somewhat since these results were extracted from broader interviews that did not focus on the working alliance alone. Interviews also contained discussions about subjects' treatment history, including expectations regarding treatment and their perceptions about their own substance use.

The view that clients have of the working alliance is likely influenced by a number of personal factors and environmental considerations such as homelessness, being court referred, and previous experience with treatment professionals. Although these factors were present among people in the current study, there were an inadequate number of participants to draw conclusions about the effect of these on working alliance. Future studies with more homogeneous groups (e.g., all persons who are homeless) will help to determine the influence of those characteristics on the type of working alliance that develops. Many of the clients involved in the study were also involved with other professionals at the same time they were meeting with strengths-based case managers. These relationships may also have influenced the view that clients had about their work with case managers.

Another limitation is related to the experimental nature of this study. Most experimental studies employ carefully selected and highly trained therapists who may be more prone to develop uniformly positive alliances with their clients. For instance, studies of manual-based psychotherapies usually show very positive client-rated alliance scores, near the top of the scale. For this reason, a greater range of poor/positive alliances may be expected in naturalistic studies (Crits-Cristoph & Gibbons 2003; Crits-Cristoph & Connolly 1999).

Implications For Treatment Professionals

The observations of these persons about their case managers have implications for other treatment professionals as well. Although persons with substance abuse problems are seen as difficult to engage, our findings suggest that this is not necessarily the case. The persons in this sample responded positively to the same characteristics that psychotherapy clients value: being heard and being respected. Treatment professionals who provide services to persons who have alcohol or other drug problems will be challenged to establish a productive working alliance with them. While treatment professionals' theoretical orientation and training in specific treatment approaches or therapeutic techniques are valuable in some clinical situations, the persons in this study didn't directly identify them as important to the working alliance. Although certain skills may enhance the ability to assist clients, these may only be useful in the context of a trusting and respectful relationship where clients are shown respect and given help in identifying their personal strengths.

Initial contacts between substance abuse clients and treatment professionals are all too frequently driven by rote and repetitive completion of admission paperwork, rather than an opportunity to listen to goals or promote strengths. Practice settings that are driven by emphasizing and diagnosing pathology do not offer clients or professionals an opportunity to show respect for the efforts that individuals have made to improve their lives. This is in direct opposition to what the individuals in this study described as being important.

The challenge for treatment professionals in all of these settings is to engage clients in a working alliance as described by the individuals in this study. When focus group participants were asked what one recommendation they would give to treatment professionals to improve their early relationship with client,s one participant responded deliberately and emphatically, "Tell them [the worker] to just put their pen and their forms down and listen to what I have to say!" This most basic of human needs, to be heard, can facilitate development of a working alliance that leads to positive change.

REFERENCES

American Psychiatric Association (APA) 2000. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Fourth Edition. Text Revision. Washington D.C.: American Psychiatric Association.

American Society of Addiction Medicine (ASAM). 2001. Patient Placement Criteria for the Treatment of Substance-Related Disorders. Second Ed. Chevy Chase, MD: American Society of Addiction Medicine.

Austin, C.D. & McClelland, R.W. (Eds.) 1996. Perspectives on Case Management Practice. Milwaukee, WI: Family International Inc.

Bachelor, A. 1995. Clients' perception of the therapeutic alliance: A qualitative analysis. Journal of Counseling 42 (3): 323-37.

Bachelor, A. & Horvath, A. 1999. The therapeutic relationship. In: M. Hubble; B.L. Duncan & S.D. Miller (Eds.) The Heart and Soul of Change: What Works in Therapy. Washington D.C.: American Psychological Association.

Ballew, J.R. & Mink, G. 1996. Case Management in Social Work: Developing the Professional Skills Needed for Work with Multiproblem Clients. Springfield, IL: Charles C Thomas.

Bandura, A. 1977. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 84 (2): 191-215.

Barber, J.P.; Luborsky, L.; Gallop, R.; Crits-Christoph, P.; Frank, A.; Weiss, R.D.; Thase, M.E.; Connolly, M.B.; Gladis, M.; Foltz, C. & Siqueland, L. 2001. Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse collaborative cocaine treatment study. Journal of Consulting and Clinical Psychology 69 (1): 119-24.

Barber, J.P.; Luborsky, L.; Crits-Christoph, P.; Thase, M.E.; Weiss, R. Frank, A.; Onken, L. & Gallop, R. 1999. Therapeutic alliance as a predictor of outcome in treatment of cocaine dependence. Psychotherapy Research 9 (1): 54-73.

Belding, M.A.; Iguchi, M.Y.; Morral, A.R. & McLellan, T. 1997. Assessing the helping alliance and its impact in the treatment of opiate dependence. Drug and Alcohol Dependence 48 (1): 51-59.

Bordin, E.S. 1994. Theory and research on the therapeutic working alliance: New directions. In: A.O. Horvath & L. S. Greenberg (Eds.) The Working Alliance: Theory, Research, and Practice. New York: John Wiley & Sons, Inc.

Bordin, E.S. 1979. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice 16 (3): 252-59.

Brun, C. & Rapp, R.C. 2001. Strengths-based case management: Individuals' perspectives on strengths and the case manager relationship. Social Work 46 (3): 278-88.

Carroll, K.M.; Nich, C. & Rounsaville, B.J. 1997. Contribution of the therapeutic alliance to outcome in active versus control psychotherapies. Journal of Consulting and Clinical Psychology 65 (3): 510-14.

Chinman, M.J.; Rosenheck, R. & Lam, J.A. 2000. The case management relationship and outcomes of homeless persons with serious mental illness. Psychiatric Services 51 (9): 1142-47.

Crits-Christoph, P. & Connolly, M.B. 1999. Alliance and technique in short term dynamic therapy. Clinical Psychology Review 19 (6): 687-704.

Crits-Christoph, P. & Gibbons, M.B.C. 2003. Research developments on the therapeutic alliance in psychodynamic psychotherapy. Psychoanalytic Inquiry 23 (2): 332-49.

De Leon, G. 2001. A commentary on "Retention in substance dependence treatment: The relevance of in-treatment factors." Journal of Substance Abuse Treatment 20 (4): 263-64.

De Weert-Van Oene, G.H.; Schippers, G.M.; De Jong, C.A. & Schrijvers, G.J. 2001. Retention in substance dependence treatment: The relevance of in-treatment factors. Journal of Substance Abuse Treatment 20 (4): 253-64.

Erlandson, D.A.; Harris, E.L.; Skipper, B.L. & Allen, S.D. 1993. Doing Naturalistic Inquiry: A Guide to Methods. Newbury Park, California: SAGE.

Fielding, N.G. & Lee, R.M. 1998. Computer Analysis and Qualitative Research. Thousand Oaks, CA: SAGE.

Fleishman, J.A.; Mor, V. & Piette, J. 1991. AIDS case management: The client's perspective. Health Services Research 26 (4): 447-48.

Gaston, L. 1990. The concept of the alliance and its role in psychotherapy: Theoretical and empirical considerations. Psychotherapy: Theory, Research, Practice, Training 27 (2): 143-53.

Gelso, C.J. & Carter, J.A. 1994. Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology 41 (3): 296-306.

Greenson, R.R. 1965. The working alliance and the transference neurosis. Psychoanalytic Quarterly 34: 155-81.

Henry, W.P. & Strupp, H.H. 1994. The therapeutic alliance as interpersonal process. In: A.O. Horvath & L.S. Greenberg (Eds.) The Working Alliance: Theory, Research and Practice. New York: John Wiley & Sons.

Horvath, A.O. 2000. The therapeutic relationship: from transference to alliance. In Session: Psychotherapy in Practice 56 (2): 163-73

Horvath, A.O. & Luborsky, L. 1993. The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology 61 (4): 561-73.

Horvath, A.O. & Symonds, B.D. 1991. Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology 38 (2): 139-49.

Howgego, I.M.; Yellowlees, P.; Owen, C.; Meldrun, L. & Dark, F. 2003. The therapeutic alliance: The key to effective patient outcome? A descriptive review of the evidence in community mental health case management. Australian and New Zealand Journal of Psychiatry 37 (2): 169-83.

Hubble, M.A.; Duncan, B.L. & Miller, S.D. (Eds.) 1999. The Heart and Soul of Change--What Works in Therapy. Washington DC: American Psychological Association.

Lincoln, Y.S. & Guba, E.G. 1985. Naturalistic Inquiry. Beverly Hills, CA: SAGE.

Luborsky, L. 1976. Helping alliance in psychotherapy. In: J. Claghorn (Ed.) Successful Psychotherapy. New York: Brunner-Mazel

Martin, D.J.; Garske, J.P. & Davis, M.K. 2000. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology 68 (3): 438-50.

Meier, P.S.; Barrowclough, C. & Donmall, M.C. 2005. The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. Addiction 100 (3): 304-16.

Meier, P.S.; Donmall, M.C.; Barrowclough, C.; McElduff, P. & Heller, R.F. 2005. Predicting the early therapeutic alliance in treatment of drug misuse. Addiction 100 (4): 500-11.

Miller, W.R.; Rollnick, S. & Conforti, K. 2002. Motivational Interviewing: Preparing People for Change. Second Ed. New York: Guilford Press.

Neale, M.S. & Rosenheck, R.A. 1995. Therapeutic alliance and outcome in a VA intensive case management program. Psychiatric Services 46 (7): 719-21.

Patton, M.Q. 2002. Qualitative Research and Evaluation Methods. Third Edition. Thousand Oaks, CA: SAGE.

Petry, N.M. & Bickel, W.K. 1999. Therapeutic alliance and psychiatric severity as predictors of completion of treatment for opioid dependence. Psychiatric Services 50 (2): 219-27.

Rapp, R.C. 2006. Strengths-based case management: Enhancing treatment for persons with substance abuse problems. In: D. Saleebey (Ed.) The Strengths Perspective in Social Work Practice. Fourth Ed. Boston: Pearson.

Richards, L. 1999. Using NVivo in Qualitative Research. Thousand Oaks, CA: SAGE.

Siegal, H.A.; Rapp, R.C.; Kelliher, C.W.; Fisher, J.H.; Wagner, J.H. & Cole, P.A. 1995. The strengths perspective of case management: A promising inpatient substance abuse treatment enhancement. Journal of Psychoactive Drugs 27 (1): 67-72.

Simpson, D.D.; Joe, G.W. & Rowan-Szal, G.A. 1997. Drug abuse treatment retention and process effects on follow-up outcomes. Drug and Alcohol Dependence 47 (3): 227-35.

Simpson, D.D.; Joe, G.W.; Rowan-Szal, G.A. & Greener, J.M. 1997. Drug abuse treatment process components that improve retention. Journal of Substance Abuse Treatment 14 (6): 565-72.

Solomon, P.; Draine, J. & Delaney, M.A. 1995. The working alliance and consumer case management. Journal of Mental Health Administration 22 (2): 126-34.

Tetzlaff, B.T.; Kahn, J.H.; Godley, S.H.; Godley, M.D.; Diamond, G.S. & Funk, R.R. 2005. Working alliance, treatment satisfaction, and patterns of post-treatment use among adolescent substance users. Psychology of Addictive Behaviors 19 (2): 199-207.

Zetzel, E. 1956. Current concepts of transference. International Journal of Psychoanalysis 37: 369-75.

([dagger]) This research was supported by National Institute on Drug Abuse (NIDA) grant #DA15690 for a study entitled "Reducing Barriers to Drug Abuse Treatment Services"; Richard C. Rapp, Principal Investigator, Robert G. Carlson, Co-Principal Investigator. Special gratitude to the late Harvey A. Siegal, founder of the Center for Interventions, Treatment, and Addictions Research. The authors thank Tracy D. Daus for qualitative interview transcription. The views expressed in this article do not necessarily reflect those of NIDA or any government agency.

Cristina Redko, Ph.D. *; Richard C. Rapp, M.S.W. **; Cindy Elms, M.S.W. ***; Mindy Snyder, M.A. *** & Robert G. Carlson, Ph.D. ****

* Research Assistant Professor, Center for Interventions, Treatment, and Addictions Research (CITAR), Wright State University, Dayton, OH.

** Assistant Professor, Center for Interventions, Treatment, and Addictions Research (CITAR), Wright State University, Dayton, OH.

*** Case Manager, Center for Interventions, Treatment, and Addictions Research (CITAR), Wright State University, Dayton, OH

**** Professor and Director, Center for Interventions, Treatment, and Addictions Research (CITAR), Wright State University, Dayton, OH

Please address correspondence and reprint requests to Cristina Redko, Ph.D., Center for Interventions, Treatment and Addictions Research, Wright State University Boonshoft School of Medicine, 3640 Colonel Glenn Highway, Dayton, OH, USA 45435. Telephone: 937-775-3856, Fax: 937-775-3395; email: cristina.redko@wright.edu
I can be mad and talk to her 'cause she knows how to "bring it
   out of you" easy. She knows how to bring out ... you talking
   to her without pushing you to talk. I found I'm real comfortable
   with her, and I'm not comfortable with everybody. Yeah
   I'm very comfortable 'cause I can just like open up with
   her ... I just feel like I can trust her, I'm like that, if
   I feel like I can trust you I'll open up, but I got to have
   that feeling that I can trust you, and I felt like that, I
   could trust her from day one.


She's making the transition a lot easier, she made it easier for
   me to want to talk to somebody else, 'cause that was my problem,
   that would be where I would relapse. She made it easier
   for me to bring out the stuff that I am ... not to be scared to
   talk about how I feel to somebody else, without the fear of
   them trying to judge me, since I'm in the program [SBCM], I
   got to talk to them [his family], so it's making it little easier of
   me not wanting to hold it in, just talk to them too.


She wouldn't let me stay focused on the negatives, I know my
   biggest barrier is always me, when I'm trying to do something
   positive, a lot of times I just have that fear of success, like I
   was really scared to win, that was one thing she helped me
   knock down. She helped me knock it down, she gave me some
   just positive things to do ... she just kind of led the way
   willing to help.


She made me feel worthy enough to go and get help, I was
   down, low enough, so she really helped me a lot. Worthy, she
   was always giving me a positive attitude, she said good things
   about me, and how the things that I was doing ... like making
   a schedule, and getting things done.


When I sit and talk to her, things that she didn't know about,
   she would listen, she would ask questions, and she would like
   learning, and I would feel at ease. I gave it the truth and kept it
   real and she gave me support. I don't have that self confidence
   in me, she tried to tell me, she gave me self confidence.


You have an identity, and she's helping you relearn your identity,
   'cause you lose it out there in the street, you don't have
   that same identity anymore, now the identity is within the
   drugs. She actually took the time to show you that it is not
   about the drugs, it's about you, and the things that you want
   to accomplish in life; I feel that that is the biggest difference
   right there.
Gale Copyright: Copyright 2007 Gale, Cengage Learning. All rights reserved.