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Working alliance, hope, and functional outcome for individuals with schizophrenia: mechanisms of influence

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Working alliance, hope, and functional outcome for individuals with schizophrenia: mechanisms of influence

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Content WORKING ALLIANCE, HOPE, AND FUNCTIONAL OUTCOME FOR
INDIVIDUALS WITH SCHIZOPHRENIA: MECHANISMS OF INFLUENCE
by
Eri Nakagami
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)
May 2009
Copyright 2009 Eri Nakagami
ii
Dedication
This dissertation is dedicated to my mother and father.
You taught me how to value my own process and respect my intuition, while, at
the same time always holding me to the highest standards of integrity and respect for
others. Thank you for challenging me and being such fine examples of dignity, grace,
and generosity. Your unending encouragement, love, and belief in me throughout my
entire life have made me strong and confident in my ability to achieve my goals.
iii
Acknowledgments
I would like to thank all those who helped make this dissertation possible. I
would first like to thank my dissertation advisor Dr. John Brekke. I would like to extend
my heartfelt gratitude to you for your faith in me and this project as well as your guidance
and encouragement throughout my doctoral program. I would also like to acknowledge
Dr. Larry Palinkas and Dr. Ann Neville-Jan for serving on my committee and their
valuable insights and suggestions on this dissertation. Thank you to Christianne Lane,
Dr. Bin Xie, and Dr. Maanse Hoe for helping to resolve my statistics questions.
A special thank you to Dr. Shelley Levin, one of the most genuine and inspiring
visionaries I have ever known. Thank you for the countless ways in which you nurtured
me and for being someone who just knew. You are a source of admiration, care,
strength and undying conviction. No amount of words could do justice to how deeply I
value our connection.
Of course, completing this degree would not have been possible without the love
and support of my family and friends. Thank you for giving me the courage, motivation
to keep going, and helping me make this dream come true! Your support and love
throughout the ups and downs of the doctoral program has been invaluable and I thank
all of you from the bottom of my heart for helping me cross the finish line!
Thank you to my wonderful husband, Rob. I am grateful for all of the hours you
spent reading the seemingly endless pages of manuscript and providing valuable
feedback. I am also indebted to you for your unwavering love, confidence, patience,
encouragement, and sense of humor.
I am also appreciative to the National Institute of Mental Health as well as the
University of Southern California’s School of Social Work for the generous financial
iv
support. Thank you also to all of the providers at Portals for allowing me to conduct my
research and providing any assistance requested.
Maya Angelou said, 'When you learn, teach. When you get, give.” This
dissertation would not have been completed without the courageous, sincere, and
generous consumers at Portals who shared their respective stories. You provided much
of the heart of this dissertation. The consumers at Portals gave me the opportunity to
disprove many misconceptions and better define the work that still needs to be done so
that individuals with schizophrenia can realize the highest vision possible for themselves.
This is a tribute to all of your heroic efforts to live your life fully despite the challenges
brought on by the illness.
v
Table of Contents
Dedication .......................................................................................................................ii
Acknowledgment .............................................................................................................ii
List of Tables................................................................................................................. vii
List of Figures............................................................................................................... viii
Abstract..........................................................................................................................ix
Chapter I: Introduction.................................................................................................... 1
Chapter II: Background and Significance........................................................................ 5
Working Alliance ................................................................................................. 5
Hope..................................................................................................................11
Psychosocial Functioning...................................................................................17
Chapter III: Specific Aims and Hypotheses....................................................................20
Aim 1 .................................................................................................................21
Aim 2 .................................................................................................................21
Aim 3 .................................................................................................................22
Aim 4 .................................................................................................................23
Aim 5 .................................................................................................................23
Chapter IV: Method .......................................................................................................25
Design ...............................................................................................................25
Study Site ..........................................................................................................26
Study Design .....................................................................................................27
Sampling for Quantitative Study .............................................................31
Sampling for Qualitative Study ...............................................................32
Data Collection for Quantitative Study................................................................32
Measures for the Quantitative Data....................................................................33
Data Collection for Qualitative Study..................................................................36
Data Analyses....................................................................................................37
Quantitative Data Analyses ....................................................................37
Mediation Analysis .................................................................................39
Moderation Analysis ...............................................................................41
Qualitative Data Analyses ..................................................................................43
Chapter IV: Results .......................................................................................................47
Description of the Sample..................................................................................47
Mediation Hypothesis.........................................................................................49
Moderation Hypotheses .....................................................................................53
Qualitative Results.............................................................................................54
Importance of the Working Alliance....................................................................57
Appreciation for Services........................................................................57
Trust.......................................................................................................58
Sense of Connection ..............................................................................59
vi
Medication..............................................................................................60
Critical Importance of the Working Alliance for Recent Enrollees .......................61
Self-concept ...........................................................................................61
Sources of Hope ................................................................................................62
Spirituality...............................................................................................62
Support from members...........................................................................63
Support from family ................................................................................64
Distinct Sources of Hope for Each Group...........................................................65
Positive results of medication and new adaptive coping skills.................65
Other members’ success........................................................................66
Accomplish goals ...................................................................................66
Goals .................................................................................................................67
Maintaining medication treatment...........................................................67
Work, school, and live independently .....................................................68
Find meaning and purpose.....................................................................68
Acceptance of illness..............................................................................69
Differences between Group 1 and Group 2 on Goals.........................................69
Criticisms ...........................................................................................................70
Therapeutic alliance ...............................................................................70
Goals......................................................................................................70
No education about diagnoses or medication .........................................71
Chapter V: Discussion...................................................................................................73
Findings from the Quantitative Study .................................................................74
Findings from the Qualitative Study ...................................................................75
Working Alliance ................................................................................................76
Self-Concept......................................................................................................76
Sources of Hope ................................................................................................80
Goals .................................................................................................................81
Alliance Varies Over Time..................................................................................85
Lack of Education about Diagnoses or Medications ...........................................86
Conclusion.........................................................................................................87
Limitations..........................................................................................................90
Future Direction .................................................................................................91
References....................................................................................................................95
vii
List of Tables
Table 1: Purposes for Mixed Methods ..........................................................................28
Table 2: Interview Questions ........................................................................................ 37
Table 3: Criteria for design quality and interpretive rigor............................................... 45
Table 4: Quantitative Sample Characteristics ............................................................... 48
Table 5: Means, Standard Deviations, and Zero-Order Correlations Among
10 Observed Variables.................................................................................... 50
Table 6: Means, Standard Deviations, and Zero-Order Correlations Among
10 Observed Variables for Group 1.................................................................51
Table 7: Means, Standard Deviations, and Zero-Order Correlations Among
10 Observed Variables for Group 2.................................................................51
Table 8: Qualitative Sample Characteristics .................................................................55
Table 9: Shared and Distinct Themes Between the Two Groups..................................57
viii
List of Figures
Figure 1: Hypothesized mediation mode.......................................................................22
Figure 2: Illustration of the sequential explanatory design.............................................30
Figure 3: Mediation model ............................................................................................ 41
Figure 4: Estimated mediation model ...........................................................................53
ix
Abstract
Despite progressive documentation of the effectiveness of community-based
psychosocial rehabilitation programs, relatively little progress has been made during the
past twenty years in delineating the treatment process variables related to successful
psychosocial outcomes for persons with schizophrenia. Studies and narratives
demonstrate that a strong working alliance is a prerequisite to treatment regardless of
the type of therapy being provided. Moreover, the hope that individuals with
schizophrenia derive through the consumer-provider relationship appears essential to
achieving successful outcomes. Working alliance and hope are also highlighted as
important elements in the current recovery and empowerment literature. Although often
discussed singularly or in pairs, to date researchers have not examined the confluence
of working alliance, hope, and psychosocial functioning with respect to persons with
schizophrenia who are involved in community-based psychosocial rehabilitation
programs.
This study examined the relationship and causal ordering between consumer
working alliance, hope, and psychosocial functioning outcomes of individuals with
schizophrenia participating in community-based psychosocial rehabilitation services.
The study used a mixed methods sequential explanatory design which featured the
consecutive collection and analysis of quantitative data and qualitative data, with the two
methods combined during the final interpretation phase. The selection of sequential
explanatory design for the study arose from the use of the qualitative results to enhance
the exploration, explanation, and interpretation of the mainly quantitative investigation.
The study had five aims: 1) Investigate the empirical relationship between
consumer working alliance, consumer hope, and consumer psychosocial functioning; 2)
Evaluate if consumer hope mediates the relationship between consumer working
x
alliance and psychosocial functioning; 3) Examine if the abovementioned mediation
relationship is moderated by the study participants’ length of attendance (less / more
than three months); 4) Gain insight into issues and contexts related to consumers’
working alliance, hope, and psychosocial functioning through qualitative semi-structured
interviews; and 5) Explore and explain the quantitative results with the qualitative results
to better understand the relationship and causal ordering between consumer working
alliance, consumer hope, and consumer psychosocial functioning.
100 individuals diagnosed with schizophrenia stratified by their length of
attendance (less / more than three months) were randomly selected from a community-
based psychosocial rehabilitation program. The ten participants for the qualitative study
were purposefully sampled from the parent sample on the basis of race, gender, and
ability to articulate their experiences.
Findings revealed a statistically significant association between working alliance
and hope as well as among hope and psychosocial functioning. The second critical
finding from this study was the statistically significant one-tailed mediation results that
indicated a trend for hope to be the mechanism through which working alliance affects
psychosocial functioning. This trend was substantiated in the qualitative phase as
participants emphasized that the relationship between consumer working alliance and
psychosocial functioning was driven by hope, which was influenced by spiritual and
religious beliefs, encouragement from others, improvement of self-concept, and
successful attainment of goals. The hypothesis that the mediation relationship from
consumer working alliance to hope to psychosocial functioning may be moderated by
length of attendance (less / more than three months) was not demonstrated.
Implications from the study findings for clinical practice, policy resolutions, and future
directions were also discussed.
1
Chapter I: Introduction
Approximately twenty years ago, researchers were impelled to demarcate the
treatment process variables related to improved psychosocial outcomes for persons with
schizophrenia (Brekke & Test, 1992; Mueser et al., 1998; Olfson, 1990; Scott & Dixon,
1995; Solomon, 1992; Taube et al., 1990). Despite progressive documentation of the
effectiveness of community-based psychosocial rehabilitation programs, relatively little
progress was made during the subsequent decades (Peer et al., 2007; Stanhope &
Solomon, 2008).
Community-based psychosocial rehabilitation programs encompass a variety of
interventions such as assertive community treatment, family intervention, supported
employment, skills training, illness self-management, cognitive interventions, and
integrated treatment for co-morbid substance use disorders (Mueser et al., 2001).
These programs were instituted to reduce disability and promote community
reintegration, as well as assist individuals to pursue independence, self-management,
engage in personally meaningful activities, and enhance their quality of life (Drake et al.,
2003; Mowbray et al., 2005; Silverstein, 2000).
However, two research problems have persisted in this area. First, even though
these programs have generally been found to reduce relapse and hospitalization
(Dobson et al., 1995; Moller & Murphy, 1997), psychosocial functioning outcomes have
not been consistent (Brekke & Test, 1992; Bustillo et al., 2001; Mueser et al., 1998;
Scott & Dixon, 1995) and improvements in different areas of psychosocial functioning
vary between groups, across individuals, and within any given individual during and
upon termination of the intervention (Ciompi, 1980; Harding, 1988). Second, there is a
dearth of information about the effective treatment process variables that have an impact
on successful outcomes (Brekke & Test, 1992; Bustillo et al., 2001; Mueser et al., 1998;
2
Solomon, 1992; Taube et al., 1990; Olfson et al., 1999). Some studies have found
service delivery factors such as intensity, continuity, and longitudinality of services to
enhance consumer outcomes (Brekke et al., 1997; Brekke et al., 1999; Greenberg &
Rosenheck, 2005; Sosin, 2001). Clearly, much more remains to be understood and it is
therefore essential to ascertain the critical treatment processes that lead to improved
consumer outcomes.
One of the key features distinguishing the rehabilitation and recovery models of
community-based psychosocial programs is the emphasis on including the consumer’s
preference in treatment planning and goals through a joint venture between the
consumer and the mental health provider focused on the ultimate goal of instilling “hope,
choice, normalization, engagement in meaningful activity, self-determination, building
supports and relationships, and the need for systems change” (Mowbray et al., 2005,
p.8). This joint venture, referred to as a “working alliance,” arises from a “collaborative
and affective bond between the consumer and provider” (Martin et al., 2000)
characterized by compassion, collaboration, and respect (Liberman, 2008; Sowers,
2005). Three decades of psychotherapy research including narratives demonstrate that
working alliance is the sine qua non of treatment regardless of the type of therapy
(Horvath, 1994; Martin et al., 2000; Solomon et al., 1995). Studies on a variety of
populations have verified that a strong working alliance is a key factor in preventing
premature treatment termination and influencing positive outcomes for individuals with
schizophrenia (Chinman et al. 2000; Donnell et al., 2004; Horvath & Greenberg, 1989;
Howgego et al., 2003; Johansson & Eklund, 2003; Martin et al., 2000; Solomon et al.,
1995; Torgalsboen, 2001). Likewise, the hope that individuals with schizophrenia derive
through the consumer-provider relationship appears has been underscored as a critical
3
component towards achieving successful outcomes (Corrigan et al., 2004; Donnell et al.,
2004; Russinova et al., 2002; Snyder et al., 2002; Torgalsboen, 2001; Yip, 2004).
Working alliance and hope are two concepts that are frequently highlighted in the
current recovery and empowerment literature for persons with schizophrenia (Corrigan
et al., 2004; Jenkins et al., 2005; Liberman & Kopelowicz, 2002; Resnick et al., 2004).
Studies have considered working alliance and hope separately in their relationship to
various outcome variables but not in concert or alongside psychosocial functioning
outcomes consisting of work, independent living, and social relationships. Outcome
studies for individuals with schizophrenia have also lacked examination of mediating
variables.
Treatment outcome research for persons with schizophrenia has leaned towards
the technical facets of treatment and disregarded nonspecific aspects such as the
working alliance between providers and consumers (Bentall et al., 2003). Treatment
processes may be under-examined due to the difficulty in assessment with current
research tools, nevertheless, “studying process is a vital part of building an evidence
base from both a research and a practice perspective” (Stanhope & Solomon, 2008, p.
886).
Given that little is understood regarding the treatment process variables that
effectively influence outcomes, this study will investigate the relationship between
consumer working alliance, hope, and psychosocial functioning outcomes, and explore
the causal ordering of these constructs. This study responds to the major reports by the
National Institute of Mental Health, the President’s Commission on Mental Health, the
Institute of Medicine, the Surgeon General’s Report on Mental Health, and the World
Health Organization which urge all mental health services to be effective, equitable, and
consumer-centered, while improving the continuity of care, moving beyond symptom
4
reduction and focusing on promoting recovery and empowerment through meaningful
collaborations between providers and consumers (Department of Health and Human
Services, 1999, 2003; Institute of Medicine, 2001; National Advisory Mental Health
Council,1998, 2000; World Health Organization, 2006).
5
Chapter II: Background and Significance
Working Alliance
Working alliance is a concept that originated in psychoanalysis and has been
recognized by others who hold diverse array of theoretical perspectives. Considered the
“quintessential integrative variable” (Wolfe & Goldfried, 1988, p.449), working alliance is
studied in a range of populations because it is believed to represent the active
ingredients in the therapist-client relationship and because of the strength of the alliance
is predictive of outcome irrespective of the therapeutic technique (Martin et al., 2000).
In the mental health literature, the term “working alliance” is often used
synonymously with “working relationship,” “therapeutic relationship,” “therapeutic
alliance,” and “helping alliance,” (Catty et al., 2007). Horvath (2001) broadly defines
working alliance as the “quality and strength of the collaborative relationship between
client and therapist” (p.365).
Building rapport is the basic ingredient and a common factor across therapeutic
fields regardless of the type of treatment (Martin et al., 2000). Individuals with
schizophrenia appreciate and connect with providers who are kind, empathic,
committed, trustworthy, and respectful (Bjoerkman et al., 1995; Martin et al., 2000; Ware
et al., 2004), who listen to their needs, concerns, and values, as well as those who focus
on how consumers make sense of their experience (Donnell et al., 2004; Ware et al.,
2004).
Bordin’s (1976) three conceptual elements consisting of tasks (i.e. the within-
therapy behaviors that form the basis of the intervention), bonds (i.e. mutual trust and
personal attachment within the therapeutic relationship) and goals (i.e. mutually agreed-
on targets for treatment) are measured with the Working Alliance Inventory (WAI;
Horvath & Greenberg, 1989), one of the most widely used measures of the working
6
alliance for individuals with schizophrenia. Although findings are inconsistent as to
whether consumers’ evaluations (Calsyn et al., 1999l; Horvath, 1994; Horvath &
Luborsky, 1993) or providers’ evaluations (Gehrs & Goering, 1994; Neale & Rosenheck,
1995) are better predictors of outcomes, there is agreement that assessment of working
alliance early rather than later in treatment better predicts consumer outcomes
(Klinkenberg et al., 1998).
Establishing and maintaining a strong working alliance should be a goal for any
therapeutic interaction but it is particularly important for persons with schizophrenia.
Consumers and providers often hold differing opinions on the values and aims of
psychiatric treatment (Fischer et al., 2002; Goldberg et al., 2004; Kravetz, et al., 2002).
Providers tend to be placed in the expert role (Ware et al., 2004), consequently
creating a power and role imbalance (McCubbin, 1994; Sullivan, 1991; Ware et al.,
2004). Tarrier and Barrowclough (2003) affirm that “without an equality and
collaboration between those who provide and those who use professional mental health
services there is always a risk of paternalism, stigmatization, and coercion” (p.240).
Additionally, hierarchical relationships may lead to dehumanization and promote
dependency, passivity, and learned helplessness (Seligman, 1975).
The power imbalance is over and above the prevalent stereotypes and verbal
and nonverbal demoralization, infantilization, discrimination, and stigmatization that
individuals with schizophrenia face from providers as well as the general public
(Corrigan et al., 2004; McReynolds & Garske, 2003; Wahl, 1999). These negative
beliefs, perceptions, and attitudes can lead providers to commit confirmation bias
(Rosenhan, 1973), lower their standards, limit the potential of persons with
schizophrenia, and weaken the therapeutic relationship (Thorne et al., 2000). Providers’
negative beliefs and attitudes also tend to exacerbate consumers’ negative expectations
7
of outcomes, intensify their sense of hopelessness, discouragement (Beck et al., 1974;
Clarke & Kissane, 2002; Hill et al., 1988), and low self-esteem (Wahl, 1999), and
consequently cause them to withdraw, avoid, and resist social interactions as a way to
protect themselves (Corin & Lauzon, 1992), thus ultimately reducing their rehabilitation
progress.
On the other hand, developing a working alliance may kindle a variety of feelings
for persons with schizophrenia such as regard, respect, acceptance, encouragement,
and trust which may be indispensable in cultivating feelings of support and encourage
hesitant or indifferent consumers to continue with treatment (McCabe & Priebe, 2004).
Like the vulnerability-stress-protective factor theory, a positive working alliance may
safeguard the negative impact of stress and facilitate feelings of stability, self-efficacy,
and self-worth, as well as promote consumers to transfer the rehabilitation successes
outside of the treatment setting during and upon termination of the program (Donnell et
al., 2004; Howgego et al., 2003; Krupnick et al., 1996; Penn et al., 2004).
A strong working alliance “is a precondition to the development of motivation, and
motivation is a precondition for action” (Miller & Rollnick, 1991 in Noordsey et al., 2002,
p. 319). Due to the large numbers of individuals who drop out of treatment, developing a
relationship is crucial in order to encourage them to remain in treatment at the very least,
and further support and motivate them to engage and participate in treatment (Donnell et
al., 2004). Thus, developing a successful working alliance has promising implications on
the subjective experience and perceptions together with the outcome of the illness for
individuals with schizophrenia (Liberman & Kopelowicz, 2002).
For persons with schizophrenia, a strong alliance is associated with enhanced
feelings of support (Chinman et al., 2000), higher goal attainment (Gehrs & Goering,
1994), greater medication and treatment collaboration (Fenton et al., 1997; Frank &
8
Gunderson, 1990; Olfson et al., 2000; Solomon et al., 1995; Weiden & Havens, 1994),
fewer days of homelessness (Chinman et al., 2000), higher social functioning (Howgego
et al., 2003; Neale & Rosenheck, 1995), increased vocational outcomes (Donnell, 2004,
Ferdinandi et al., 1998; Neale & Rosenheck, 1995), global functioning (Neale &
Rosenheck, 1995), better life satisfaction (Chinman et al., 2000), quality of life (McCabe
& Priebe, 2004; Solomon et al., 1995), and quality of care (Ware et al., 2004). While
studies have found that a stronger alliance is associated with lower symptom severity
(Howgego et al., 2003; Klinkenberg et al., 1998; Lacro et al., 2002; Neale & Rosenheck,
1995; Tattan & Tarrier, 2000), there have been other investigations that have not found a
relationship between alliance rating and symptom ratings (Joyce & Piper, 1998; Paivio &
Bahr, 1998).
Conversely, the absence of a positive relationship is related to worse symptom
levels and a lower quality of life (Tattan & Tarrier, 2000), violent behavior (McCabe &
Priebe, 2004), noncompliance with treatment, premature termination, as well as general
poor rehabilitation outcomes (Frank & Gunderson, 1990; Howgego et al., 2003).
Svensson and Hansson (1999), in their study of the working alliance between inpatients
with schizophrenia and their therapists, discovered that 72% of inpatients with
schizophrenia with a lower level of working alliance dropped out of the treatment
program.
Davis and Lysaker (2004) found conflicting results between neurocognition and
working alliance; poorer performance on verbal memory was significantly related to
consumer appraisal of stronger alliance while higher performance on spatial reasoning
was significantly related to provider evaluation of stronger alliance. Neurocognitive
impairment may lead to difficulties in interpersonal relationships (Addington & Addington,
1998; Brekke et al., 1997), and thereby impair formation of a therapeutic alliance.
9
Studies have examined the period needed to develop an alliance along with the
predictive ability of the working alliance at different time points. Frank and Gundersen
(1990) found that few persons with schizophrenia in their study had a difficult time
forming an alliance. However, those who were unable to create a positive relationship in
the first six months had a hard time developing an alliance during the remaining
treatment period. Similarly, Howgego and his colleagues (2003) demonstrated that the
majority of individuals with schizophrenia in their study with poor alliances after the first
six months withdrew from services within the subsequent three months. Establishment
of an alliance between persons with schizophrenia and their case manager by the third
month of treatment was related to a reduction in homelessness at 12 months and a
greater decrease on the number of days spent homeless among those with a higher
alliance (Chinman et al., 2000).
Evaluation of the working alliance at the fourth session moderately predicts
improvement scores (Busseri & Tyler, 2003; Horvath, 1994; Horvath & Symonds, 1991;
Martin et al., 2000), but not symptom severity. This suggests that WAI scores are
related to general global improvement scores of therapy change rather than symptom
ratings (Busseri & Tyler, 2003). However, Klinkenberg et al. (1998) found that a strong
alliance after two months was marginally associated with lower global symptom ratings.
They also discovered that low hostility, more perceived needs, more program contacts,
and being African American predicted a better alliance at the second month (Klinkenberg
et al., 1998).
Several factors have been demonstrated to positively influence the working
alliance, including older age (Draine & Solomon, 1996) more service contacts
(Klinkenberg et al., 1998), and less severe symptoms (Clarkin et al., 1987; Frank &
Gunderson, 1990; Neale & Rosenheck, 1995). The type of therapy does not appear to
10
have any affect (Salvio et al., 1992). Klinkenberg et al. (1998) found that African
American clients formed a more positive alliance than other race groups.
Along with degree of comfort and trust, factors such as denial of illness, stigma
along with more severe symptoms such as hostility (Klinkenberg et al., 1998), paranoia
and other psychotic symptoms (Constantino et al., 2002; Gunderson et al., 1997; Raue
et al., 1993; Weiden & Havens, 1994) have been found to interfere with a positive
development of therapeutic alliance (Mallinckrodt, 1991; Kokotovic & Tracey, 1990;
Satterfield & Lyddon, 1995). Other factors that have been suggested to affect the
therapeutic relationship in research outside of schizophrenia are the gender of the
therapist (Lazaratou et al., 2006; Thomas et al., 2005), the therapists’ experience level,
and length of therapy (Dunkle & Friedlander, 1996; Thomson et al., 2008).
Investigators have reviewed the techniques that effectively promote and sustain
a positive therapeutic alliance. The ability of the professional to be present non-
judgmental, warm, supportive (Barker, 2001; Repper, 2002; Watkins, 2001), trustworthy
(Barkham, 2002; Horvath & Greenberg, 1989), approachable, human (Gamble, 2000),
and challenging (Bordin, 1994; Egan, 2002; Frank & Gunderson, 1990) is appreciated by
the consumer. Commitment is demonstrated by the manner in which providers speak
and listen to consumers with genuine interest, respect, empathy, warmth, and sensitivity
(Anthony et al., 2003; Barkham, 2002; Barker, 2001; Bordin, 1994; Dennis, 2000;
Paulson et al., 1999; Repper, 2002; Rogers & Pilgrim, 1994; Watkins, 2001). Providers’
efforts to educate the consumer about their diagnosis, medication, and resources (Read,
1996), collaborative task and goal-setting (Barkham, 2002), as well as provide them with
choices (Read, 1996) have also been highly regarded.
Clinical experience and studies with nonclinical population have found that
therapists by their actions can get through initially poor alliances and actively engage
11
even highly resistant clients in treatment (Frank & Gunderson, 1990). The initial goal of
therapy must be to promote, establish and maintain a positive working alliance with the
consumer. It is imperative that consumers sincerely commit to the treatment process
and believe it is beneficial so as to have them remain in treatment (Donnell, 2004).
Despite the contributions of existing studies, the abovementioned have been
limited as the service settings from which participants were gathered have been
dissimilar, making the findings difficult to generalize to those participating in community-
based psychosocial rehabilitation programs. The first aim of this study will treat working
alliance as the main exogenous construct and examine its direct association with hope
and psychosocial functioning outcome, respectively.
Hope
Hope is a concept that is frequently cited in personal accounts within research on
the phenomenological aspects of schizophrenia (Deegan, 1996; Lovejoy, 1984;
Schmook, 1996) and is deemed by mental health professionals and scholars to be a
critical factor in the rehabilitation process (Anthony et al., 1990; Landeen et al., 1996;
Russinova, 1999). Definitions of hope vary depending on the theoretical perspectives
(Flemming, 1997; Herth, 1996; Miller, 1989; Morse & Doberneck, 1995; Parse, 1990).
Health care researchers tend to embrace the oft-cited work by Dufault and Martocchio
(Dufault & Martocchio, 1985) which defines hope as a multidimensional, complex,
process-oriented, “dynamic life force characterized by a confident yet uncertain
expectation of achieving a future good which, to the hoping person, is realistically
possible and personally significant” (Dufault & Martocchio, 1985; p. 380). This definition
along with the Herth Hope Index (HHI; Herth, 1992), a frequently used measure to
assess hope based on Dufault and Martocchio’s (1985) definition, will be used in this
study.
12
Dufault and Martocchio (1985) theorized hope to have two spheres: generalized
and particularized. The former is a general outlook which gives an “overall motivation to
carry on with life’s responsibilities” (p.380). The latter is “concerned with a particularly
valued outcome, good, or state of being, in other words, a hope object” (p. 380) and
demonstrated by a wish and anticipation. Dufault and Martocchio (1985) further
theorized hope to have six dimensions consisting of affective, spiritual, relational,
cognitive, behavioral, and contextual aspects. These elements are shared by other
investigators (Cutliffe, 2004; Farran et al., 1995; Haase et al., 1992; Herth, 1996;
Kirkpatrick et al., 1995; Miller, 1989; McCann, 2002; Oades et al., 2004).
The affective dimension comprises a myriad of emotions from joy and strength to
fear, anger, and despair. The spiritual aspect contains organized religion as well as a
broader holistic notion of spirituality (Burkhardt, 1989; Emblen, 1992) that focuses on “a
connectedness with something greater than self, for some a belief in a higher being or
force…and involves finding meaning and purpose in one’s life” (Farran et al., 1995; p.6).
Positive relationships with family, friends, and mental health professionals are also an
important source of hope. The cognitive factor consists of intellectual strategies, for
instance encouraging individuals to review previous achievements and revise goals
based on the current circumstances. The behavioral element is analogous to the
problem-focused coping strategies including goal-focused thoughts and activities that
cultivate hope. The contextual dimensions are the present life situations and capabilities
that affect hope such as physical, cognitive, emotional, functional abilities and financial
stability (Dufault & Martocchio, 1985; Farran et al., 1995). Nearly all definitions of hope
include the idea of a positive future orientation (Farran et al., 1995; Haase et al., 1992;
Herth, 1996; Kirkpatrick et al., 2001; Landeen et al., 2000; Miller, 1989; Salerno, 2002;
Woodside et al., 1994).
13
Snyder and his colleagues (1991) conceptualized hope to have two components
consisting of an individual’s goal-directed agency, determination, or efficacy together
with the individual’s pathways or plans to achieve the goals (p.571) (see also Snyder,
2000). Hope is conceptualized to exist only when an individual has the motivation to
stay involved with a future outcome and can expect a way to reach that outcome
(Snyder, 2000). Genuine hope differs from false hope as the latter occurs when
expectations are based on illusions rather than reality (Beavers & Kaslow, 1981; Callan,
1989, Tomko, 1985), when inappropriate goals are pursued (Murrell & Norris, 1983), and
when poor strategies are used in an attempt to reach desired goals (Kwon, 2002).
Hope is related to, and has been compared with, five other positive psychology
constructs, including: optimism (Gottschalk, 1974; Maier et al., 2000; Scheier & Carver,
1985), learned optimism (Seligman, 1991), self-efficacy (Bandura, 1997), problem-
solving (Heppner & Hillerbrand, 1991), self-esteem (Hewitt, 1998), and wishing
(Bruininks & Malle, 2006). While both hope and optimism share a positive expectation
that the future will be positive (Scheier & Carver, 1985), hope is an emotion (Averill et
al., 1990; Seligman, 1991) that is aligned toward personal agency and goals (Snyder,
1994) and can be maintained it even if the outcome is unlikely. In contrast, optimism
involves: (i) planning, (ii) having confidence in the outcome, and (iii) a foundation of
rational and tangible facts, and is contingent upon a considerable plausibility of the
outcome occurring (Snyder et al., 1999). As the probability of the outcome increases,
the amount of personal control increases and engagement in the outcome decreases,
which tends to make individuals more optimistic than hopeful (Averill et al., 1990).
Magaletta and Oliver (1999) found that hope produced unique variance beyond optimism
in predicting numerous variables and the two factor structures differ.
14
Self-efficacy differs from hope as it focuses on the situation-specific agency that
is needed to initiate a goal-directed action. Hope theory presumes that both agency and
pathway thoughts are required to pursue a goal. It persists across circumstances and is
not situation-specific (Snyder et al., 1991). Hope theory also posits that emotions are
the result of goal-directed thoughts (Bandura, 1997). In Magaletta and Oliver’s (1999)
investigation, hope a generated a variance separate from self-efficacy in predicting well-
being.
Hope influences self-esteem, but self-esteem does not influence hope. Further,
the goal pursuit must be valued to implicate self-esteem (Hewitt, 1998). In problem-
solving theory, when an individual explicitly identifies a desired goal (a problem solution)
it is implicitly assumed that it involves an important goal (Heppner & Hillerbrand, 1991).
The difference between hope and wishing is that individuals invest in the outcome when
they hope while they fantasize about an outcome that is unfeasible and not viable when
they wish (Bruininks & Malle, 2006).
In the continuum of hope and hopelessness (McGee, 1984), optimists have
sometimes been considered to be “hopeful” toward the future (Affleck & Tennen, 1996)
whereas pessimists said to exhibit “hopelessness” (Beck et al., 1974). Hopelessness
and despair have been illustrated synonymously (Cutliffe, 1997).
Hope is a potentially powerful factor in healing, buffering stress, adaptive coping,
and physical and mental well-being (Herth, 1993; Hinds & Martin, 1988; Farran et al.,
1995; Miller, 2007; Rustoen, 1995; Stephenson, 1991). This construct has been found to
predict outcome in many areas such as academics (Snyder et al., 2002), athletics (Curry
et al., 1997), as well as interpersonal relations (Snyder et al., 1997), and found to be a
vital ingredient to enhance the quality of life (Farran & Popovich, 1990; Owen, 1989),
functional and health status (Popovich, 1991), the survival rate for individuals with
15
cancer (Greer et al., 1979) and AIDS (Kylma et al., 2001), the life expectancy in the
elderly (Herth, 1993; Zorn, 1997), as well as mediate between stress and well-being
(Irvin & Acton, 1997). Hope also appears to be a crucial element for motivation and
subsequent behavior (Averill et al., 1990; Noordsy et al., 2002; Snyder et al., 2003).
For persons with schizophrenia, hope has been found to relate to coping
(Kanwal, 1997) as well as subjective well-being, insight, perception of self, and quality of
life (Landeen et al., 2000; Lysaker et al., 2005). Hope also mediates the relationship
between involvement in consumer-run services and recovery (Yanos, 2001). Salerno
(2002) found statistically significant relations between hope, power, and perception of
self for individuals with schizophrenia. However, no statistically significant correlation
has been found between hope and symptom severity (Landeen et al., 2000).
In contrast, hopelessness, utilizing the Beck Hopelessness Scale (BHS), has
been linked to social and vocational dysfunction (Davis & Lysaker, 2004; Hoffman et al.,
2000; Renegold et al., 1999), suicide risk (Drake et al., 1995), avoidant coping (Clemens
et al., 2001; Ventura et al., 1999), and stigma (Mechanic et al., 1994; Wright et al.,
2000). Hopelessness has also been found to correlate better with suicidal intent and
subsequent suicide than severity of depression (Beck et al., 1974; Drake & Cotton,
1986). Kirkpatrick and his colleagues (1995) described several obstacles of hope
including stigma from society and mental health professionals along with illness-related
factors such as interpersonal difficulties and consequences of their symptoms. Hoffman
et al. (2000) posit that hopelessness may contribute to the chronicity of the illness.
The power and value of the medical professionals’ ability to bestow hope in their
patients has been substantiated (Groopman, 2003; Hinds, 1984; Warr, 1999). Akin to
the medical literature, infusing and sustaining hope for individuals with schizophrenia via
the consumer-provider relationship has been highlighted as a crucial factor towards an
16
optimistic rehabilitation process and favorable outcomes (Corrigan et al., 2004; Donnell
et al., 2004; Russinova, 1999; Snyder et al., 2002; Torgalsboen, 2001; Yip, 2004).
“Hope is at the heart of psychiatric nursing practice” (Moore, 2005; p. 100) and an
“essential ingredient in recovery from schizophrenia” (Kelly & Gamble, 2005; p. 248).
Several clinical techniques have been found to encourage hope in studies
involving persons with schizophrenia as well as for nonclinical population. Positive
relationships with family, friends, and mental health professionals who are present,
supportive, positive, encouraging, and tolerant (Cutcliffe, 2004; Edey and Jevne, 2003;
Farran et al., 1995; Herth, 2000; Holt, 2001; Kirkpatrick et al., 1995; McCann, 2002;
Miller, 1991; Oades et al., 2004; Turner & Stokes, 2006) are vital to fostering and
maintaining hope. Individuals also appreciate information and education about their
diagnosis and medication (Johnson & Roberts, 1996; Kirkpatrick et al., 1995) help with
cognitive reframing and other cognitive strategies (Herth, 1993, 2000; Holt, 2001;
McCaan, 2002), help in managing (Kirkpatrick et al., 1995) and coping (Herth, 1989;
Kim, 1989) with illness, finding meaning, purpose (Coleman, 1999; Kelly & Gamble,
2005; McCann, 2002; Davidson & Strauss, 1995) and a reason to live (Nowotny, 1989).
Involving individuals in treatment planning, decision-making, and realistic goal-setting
(Stanhope & Solomon, 2008; Wake & Miller, 1992), giving them choices, control, and
autonomy (Kelly & Gamble, 2005; Kirkpatrick et al., 1995; McCann, 2002; Oades et al.,
2005) motivates and invigorates people (Kruger, 2000), which likely increases self-
efficacy and hope. Parallel to the recovery model, individuals want to move beyond the
illness (Repper & Perkins, 2003), have equal opportunities and integrate into the greater
society (Kelly & Gamble, 2005). Religious and spiritual practices including a belief in a
higher power (Farfan, 1997; Hall, 1999; Herth, 1989, 1993, 2000; Kylma & Vehvilainen-
17
Julkunen, 1997; Mickley et al., 1992; Miller, 1989, 2007; Moadel, 1999; O’Neill & Kenny,
1998) also cultivate hope.
On the contrary, just as a strong working alliance encourages one’s sense of
self-worth, self-confidence, and self-respect, positive or negative schemas that are
shaped by interpersonal interactions act as a self-fulfilling prophecy where the individual
behaves in a way that is congruent with how s/he expects to be treated by others along
with the estimation of his/her capability to achieve the intended objective (Bowlby, 1982;
Byrne, 1994; Herth, 2000; Groopman, 2003; Shorey et al., 2003; Snyder, 1991, 2000).
A paternalistic and hierarchical relationship with the provider may potentially lead the
consumer to become passive and/or dependent. The consumer may withdraw, and
his/her self-esteem may decrease (Deegan, 1990; Seligman, 1975). On the other hand,
as hope is stimulated in the context of supportive relationships (Edey & Jevne, 2003;
Cutcliffe, 2004), mental health professionals who initiate relationships with consumers
are in a prime position to nurture, inspire, and maintain hope with their consumers.
Psychosocial Functioning
The recovery paradigm is characterized by the assistance of individuals with
severe and persistent mental illness not only with managing their symptoms, but also in
building on their strengths in order to participate fully in the community and pursue
positive activities of interest such as education, employment, hobbies, family life,
parenting , intimate partnerships, community involvement, and other meaningful
activities (Harding, 1994; Mead & Copeland, 2000; Department of Health and Human
Services, 2003; Onken et al., 2002; Townsend et al., 1999). Community-based
psychosocial rehabilitation programs help individuals with schizophrenia develop the
skills necessary to live a satisfying and meaningful life (Brekke & Long, 2000; Brekke et
al., 1997; Phillips et al., 2001) as well as reintegrate into the community through various
18
interventions such as assertive community treatment, supported employment, illness
self-management and skills training, and case management (Mueser et al., 2001).
Investigators have proposed various models to measure functioning outcomes
(Brekke et al., 2002). Some concentrate specifically on vocational functioning (Griffiths,
1973), while others concentrate on social adjustment (Smith et al., 1999), community
functioning (Norman et al., 1999), independent living (Rempfer et al., 2003), or social
functioning (Birchwood et al., 1990). This study focused on the functional outcomes of
work, independent living, and social functioning as measured by the Role Functioning
Scale (RFS; Goodman et al., 1993), a subcomponent of the Community Adjustment
Form (CAF; Test et al., 1991), which has been shown to be one component of a model
of psychosocial functioning in schizophrenia (Brekke & Long, 2000) and has been used
successfully in several studies of psychosocial rehabilitation outcomes for schizophrenia
(Bae et al., 2004; Brekke et al., 1997, 1999; Brekke & Long, 2000).
Increasing evidence demonstrates that individuals with schizophrenia are
capable of improving and developing a meaningful life separate from their illness
(Bellack, 2006; Davidson et al., 2008; Glynn et al., 2006; Hoffman & Kupper, 2002). In
fact, studies have found that symptom severity is typically only mildly correlated to
consumer psychosocial functioning (Brekke & Long, 2000; Brekke et al., 1997; Phillips et
al., 2001). Consumers want to work (McQuilken et al., 2003; Mueser et al., 2001;
Rogers et al., 1991), and are able to succeed in competitive jobs (Bond et al., 2001; see
also Mueser et al., 2001). They prefer to live independently (Browne & Courtney, 2005;
Forchuk et al., 2006; Ogilvie, 1997; Tanzman, 1993) and long for interconnected
relationships (Penn et al., 2004).
Consumers’ opportunity for success in work is positively impacted by adherence
to expressed work preferences (Becker et al., 1996). This finding is consistent with
19
behavior of individuals without schizophrenia (Gagne & Deci, 2005). The recovery
framework has therefore expanded treatment outcomes to include personally defined
goals (Anthony et al., 2003; Gingerich & Mueser, 2005).
20
Chapter III: Specific Aims and Hypotheses
The recovery framework emphasizes the importance of collaboration in care,
goal setting, hope, empowerment, autonomy, self-determination, and choice for
individuals with schizophrenia who are engaging in meaningful ambitions and interests
(Department of Health and Human Services, 2003; Oades et al., 2005; Onken et al.,
2002; Townsend et al., 1999). Despite the contributions made by existing studies, such
studies have been limited in that the service settings from which participants were
gathered have been dissimilar, making the findings difficult to generalize to individuals
with schizophrenia participating in community-based psychosocial rehabilitation
programs.
Investigators have noted that the value of the working alliance rests on its
function as an independent predictor of outcome and second as a mediating factor that
captures significant variance in the treatment outcome (Ferdinandi et al., 1998, Frank,
2000; Gaston, 1990; Priebe, 2000). Although a few studies have been conducted to
evaluate if alliance is a mediator (Calsyn et al., 2004; Kenny et al., 2004), no
examination has been made to identify and elucidate the mechanism underlying the
established relationship between working alliance and functioning outcome.
Ascertaining the treatment process variables that influence successful psychosocial
functioning outcomes among and within individuals throughout the course of treatment
will enhance the theoretical and empirical knowledge base, thereby improving treatment
models that promote better outcomes towards recovery as well as enhancing the quality
of life for individuals with schizophrenia. Although often discussed singularly or in pairs,
to date researchers have not examined the confluence of working alliance, hope, and
psychosocial functioning with respect to persons with schizophrenia who are involved in
community-based psychosocial rehabilitation programs.
21
This study will examine the relationship and causal ordering between consumer
working alliance, hope, and psychosocial functioning outcomes of individuals with
schizophrenia participating in community-based psychosocial rehabilitation services.
The study uses mixed methods sequential explanatory design, which is characterized by
a collection and analysis of quantitative data followed by the collection and analysis of
qualitative data, which are subsequently integrated and interpreted collectively. The
specific aims and hypotheses of this study are discussed below.
Aim 1
The first aim is to examine the empirical relationship between consumer working
alliance, consumer hope, and consumer psychosocial functioning for a sample of 100
individuals diagnosed with schizophrenia. It is hypothesized that Working Alliance will
have a positive relationship with Hope and Psychosocial Functioning, respectively.
Aim 2
The second aim is to evaluate whether consumer hope mediates the relationship
between consumer working alliance and psychosocial functioning (Figure 1).
22
Figure 1.
Aim 2. To evaluate whether consumer hope mediates the relationship between consumer’s working alliance
and psychosocial functioning.
Note
1
. Working Alliance Inventory (WAI): WAI 1 = Task, WAI 2 = Bond, WAI 3 = Goals. Consumer Hope;
Hope 1 = Temporality & Future, Hope 2 = Readiness & Expectancy, Hope 3 = Interconnectedness ,
Psychosocial Functioning: RFS 1 = Independent Living, RFS 2 = Work, RFS 3 = Social. BPRS = Brief
Psychiatric Rating Scale.
It is hypothesized that consumer hope will mediate the relationship between working
alliance and psychosocial functioning.
Aim 3
The third aim is to investigate if the abovementioned mediation relationship is
moderated by the study participants’ length of attendance (less / more than three
months) at the community-based psychosocial rehabilitation program. It is hypothesized
that the participants who have been in the program for more than three months will
demonstrate a stronger mediation relationship than those who have been enrolled in the
program for less than three months.
Hope
Psychosocial
Functioning
Working
Alliance
WAI 1
HHI 3
HHI 2
RFS 1
RFS 2
HHI 1
RFS 3 WAI 3
WAI 2
23
A multiple-group approach (Pentz & Chou, 1994) will be used to evaluate if the
length of attendance (less / more than three months) moderates (i.e. strengthens or
weakens) the relationship between consumer working alliance, consumer hope, and
psychosocial functioning. Factor intercepts are freely estimated in the less than three
months group while in the more than three months group, they are constrained to be
equal to zero. The fit of the two models are compared using the 
2
difference test
(Santorra & Bentler, 2001) and moderation is substantiated with the more parsimonious
model.
Aim 4
Qualitative semi-structured interviews will be conducted on ten subjects obtained
through purposeful sampling from the parent sample to gain insight into issues and
contexts related to consumers’ working alliance, hope, and psychosocial functioning. A
total of ten subjects will be purposively sampled and stratified equally by their length of
attendance (less / more than three months) at the community-based psychosocial
rehabilitation program.
Aim 5
A mixed method sequential explanatory design will be utilized to explore and
explain the quantitative results with the qualitative results. This design will be employed
to better understand the relationship and causal ordering between consumer working
alliance, consumer hope, and consumer psychosocial functioning.
The qualitative analysis will parallel the multiple-group approach. Textual coding
and thematic analysis of the interviews will first be analyzed. Analyses will be further
enhanced by determining the most common themes by constructs (i.e. working alliance,
hope, psychosocial functioning) as well as by groups (i.e. enrolled in program less /
more than three months). Thematic analyses will also be conducted between individual
24
cases and across groups. Conceptual models will be developed inductively in the end
from the analyses of similar and dissimilar topics from the quantitative and qualitative
data to indicate the important elements that are associated with the study aims and
hypotheses.
25
Chapter IV: Method
Design
The present study used a mixed-methods sequential explanatory design where
the results of the primary quantitative phase guided the data collection in the second
phase and the two methods were integrated during the interpretation stage (Creswell et
al., 2003). The sequential explanatory design was selected for this study as the
quantitative data alone would not be able to explain the relationship and causal order of
the study constructs. The qualitative phase is therefore used to explore, expand,
interpret and corroborate the mainly quantitative investigation. The quantitative data for
this study came from 100 individuals diagnosed with schizophrenia randomly selected
from the active de-identified caseload roster at Portals, stratified by how long they have
been enrolled at Portals (Group 1 = less than three months; Group 2 = more than three
months). Research has not yet definitively established the exact time point at which
working alliance is established. Davis and Lysaker (2004) demonstrated that the
presence of a working alliance at the third month of treatment correlated with a decrease
in homelessness one year after. Frank and Gunderson (1990) also found that treatment
adherence was predicted by a strong alliance during the first six months of treatment
despite controlling for a number of pretreatment characteristics such as social and
vocational adjustment and level of cognitive disorganization. Therefore, this study used
the three months as the dividing point between groups to examine if length of
attendance moderates the mediation analysis.
After the quantitative data were collected and analyzed, ten individuals divided
evenly by their length of attendance (less / more than three months) were purposefully
sampled for subsequent open-ended interviews. The purpose of these interviews were
to further investigate the results from the quantitative data to gain a thorough
26
understanding of the relationships and causal ordering of the working alliance, consumer
hope, and consumer psychosocial functioning. In the final stage, the quantitative and
qualitative data were integrated and inferences were made. In this study, inference
denotes “both the process of interpreting the findings AND the outcome of this
interpretation (i.e. the process of interpreting, as well as the emerging conclusions) to
provide answers to the original research questions” (Tashakkori & Teddlie, 2008, p.103).
Study Site
This study gathered research participants from Portals, a community-based
psychosocial rehabilitation program composed of three Wellness and Recovery Centers
all located in the Los Angeles County. Each adult day service program offers a range of
services including assertive community treatment, case management, dual diagnosis
residential treatment units, psychiatric consultations, medication management, along
with psychosocial rehabilitation services that consists of educational groups, money
managing, various socialization, recreational and community activities, recovery
meetings, and health groups that assist consumers to restore their abilities in social,
vocational, and independent-living functioning through on-going intensive services.
Upon intake, the average consumer (also identified as a member) engages in a
rehabilitation activity three to four days a week for approximately five hours a day. Each
site operates according to an identical service philosophy and service profile, and each
admits approximately six consumers a month. Portals carries about 1300 active clients
at any one time and there are approximately 30 new admissions per month at Portals.
Portals has been the site of two previous and one ongoing R-01 study headed by
Dr. John Brekke, as well as a newly funded IP-RISP entitled “Biosocial Factors in
Rehabilitation for Schizophrenia”(R24 MH071794-01A1, Brekke, PI). Brekke and Test
(1992) determined that the frequency of staff to client contact in the first three months of
27
rehabilitation is 18 contacts (14 hours) in the first month, 28 contacts (14 hours) in the
second month, and 26 contacts (ten hours) in the third month. From the aforementioned
total contact hours, the following describes the average distribution of the time spent on
various activities; 27% on vocational, 25% on activities of daily living, 12% on social /
recreational,14% on one-to-one support, and the remaining 16% are distributed among
six other service areas (Brekke & Test, 1992). Two studies further demonstrated that
psychosocial rehabilitation services at Portals were better than a low intensity case
management practice in improving social, vocational, and independent living outcomes,
along with self-esteem, indicating the effectiveness of the combined approach (Brekke et
al., 1997; Brekke & Long, 2000). In view of these findings and these previous studies,
Portals afforded a tenable site for this study.
Study Design
There is still no one set of language to discuss mixed methods (Bryman, 2008)
but in this study, mixed methods is defined as “the collection or analysis of both
quantitative and qualitative data in a single study in which the data are collected
concurrently or sequentially, are given a priority, and involve the integration of the data
at one or more stages in the process of research” (Creswell et al., 2003, p. 212). On the
one hand, quantitative methodology grants a researcher to collect a large sample of
people, distinguish and illustrate the relationships between constructs and control for
other factors using statistical methods as well as provide evidence of reliability, validity,
and generalize findings to a population. On the other hand, qualitative techniques
progress inductively through open-ended interviews and fieldnotes “to seek, to discover,
to explore a process, or describe experiences (Onwuegbuzie & Leech, 2006; p. 482),
and allows researchers to elaborate and inform the quantitative data as well as amend
the theoretical models based on what is uncovered in the qualitative interviews (Beck,
28
2005; Creswell et al., 2003; Goodyear et al., 2005). The combination of quantitative and
qualitative data collection and analysis in a single study enhances the results over and
above what can be obtained with a single method (Brewer & Hunger, 1989; Tashakkori
& Teddlie, 1998).
Investigators have delineated several purposes for employing mixed methods
(Tashakkori & Teddlie, 2008) which are summarized in Table 1.
Table 1. Purposes for Mixed Methods
Purpose Description
Complementarity To increase a study’s validity and interpretability, complementarity
elaborates, improves, and elucidates the results from one method with the
results from the other method and assesses “overlapping, but also different
facets of a phenomenon” (Greene e tal.,1989, p. 258).
Triangulation To strengthen a study’s validity, triangulation seeks convergence and
corroboration of the same phenomenon from different methods.
Completeness To obtain a complete picture of the phenomenon.
Development Questions from one method develop and inform questions for the
subsequent method.
Initiation Analyzes inconsistent results from the two phases to increase the “depth
and breadth” (Johnson et al., 2007) of knowledge using different methods
for different goals.
Expansion To expand or explain the understanding obtained in a previous strand of a
study.
Corroboration /
Confirmation
To evaluate the credibility of inferences obtained from one method.
Compensation To compensate for the weaknesses of one method by using the other
method.
Diversity To gain different depictions of the same phenomenon, which are then
compared and contrasted.
Note. This table was combined and created using the following sources; Creswell, 2003; Greene et al.,
1989; Johnson et al., 2007; Patton, 2002; Tashakkori & Teddlie, 2003; Rossman & Wilson, 1985.
Given that the purpose of this study was to explore, expand, interpret, and
corroborate the quantitative data, sequential explanatory design was selected because it
used the qualitative interviews to further illuminate the mainly quantitative investigation.
In this design, data analysis is commonly connected and integration typically occurs at
the data analyses and interpretation stage as well as in the discussion section (Johnson
et al., 2007; Morgan, 1998) but integration may occur at various stages in a particular
study at the researcher’s discretion and the aim of the study (Caracelli & Greene, 1993;
29
Creswell et al. 2003; Greene et al., 1989; Onwuegbuzie & Teddlie, 2003; Tashakkori &
Teddlie 1998). In this study, the quantitative and qualitative data were analyzed
separately and the findings were compared and contrasted in the results and discussion
sections. Integration or mixing seeks to increase understanding about the research
topic while preserving the integrity of each method.
A visual illustration of the present study’s design is demonstrated below (Figure
2).
30
Figure 2. Sequential Explanatory Design
Determine the Goal of the Study
To understand the relationship and causal ordering between
Working Alliance, Hope, and Psychosocial Functioning
Decide on Study Design
Sequential Explanatory Design
Formulate Research Questions & Hypotheses
1) To examine the relationship between Consumer Working Alliance, Consumer Hope, and Consumer
Psychosocial Functioning.
2) To evaluate whether Consumer Hope mediates the relationship between Consumer Working
Alliance and Consumer Psychosocial Functioning.
3) To assess if the above relationship (#2) differs by length of attendance at rehabilitation program.
4) Qualitative semi-structured interviews will be conducted on ten subjects obtained through
purposeful sampling from the parent sample to gain insight into issues and contexts related to
consumers’ working alliance, hope, and psychosocial functioning.
5) A mixed method sequential explanatory design will be utilized to explore and explain the
quantitative results with the qualitative results.
Collect Quantitative Data
100 individuals diagnosed with Schizophrenia (incl & excl criteria)
Analyze and Interpret Quantitative Data
Structural Equation Modeling with Latent Variables
Re-Evaluate Research Questions
Collect Qualitative Data
Purposeful Sampling
10 participants stratified equally by length of attendance at rehabilitation program
Analyze and Interpret Qualitative Data
Coding & Thematic Analysis
Within-case, across-case, and cross-thematic analysis
Interpret and Explain the Quantitative & Qualitative Results
Interpretation and Explanation of the Quantitative & Qualitative Results
Quantitative Results Qualitative Results
Compare and Contrast Results
Integration of
Quan & Qual
Data
31
Sampling for Quantitative Study
To ascertain the sample for the quantitative study, a de-identified list of all
existing clients were obtained from the Information Services Division at Portals.
Selection criteria included the following: (1) diagnosis of schizophrenia or schizoaffective
disorder, (2) residence in Los Angeles for at least three months before study admission,
(3) adults age 18 and over, and (4) no primary diagnosis of alcohol or drug dependence
in the previous six months, no mental retardation diagnosis, and no identifiable
neurological disorder. Diagnoses of schizophrenia or schizoaffective disorder were
determined by a Portals staff member who was partially supported by the IP-RISP using
clinical records and the Structured Clinical Interview for DSM-IV-TR (SCID; Steinberg,
1994). Upon selection, the aforementioned Portals staff member contacted the selected
consumers, briefly described the study, and asked if they were willing to be contacted by
this researcher who described the study in more detail. After providing consent to be
approached by the research staff, this author contacted the potential study participant,
discuss, and reviewed the treatment protocol as well as reviewed the informed consent
with the participant to ensure that individuals with limited reading and/or cognitive-
attention skills fully understood their rights and any potential risks before agreeing to
participate in the study. After they agreed to participate in the study, consent was
obtained in accordance with the guidelines approved by the University of Southern
California Review Board and Ethics Committee (USC UP-06-00034-AM003) to
participate in the study. A total of 100 study participants were recruited for the
quantitative portion of the study. To reduce a social desirability bias, this investigator
clearly informed each study participant that their responses from both the quantitative
and qualitative interviews would not be shared with any of the professionals that work at
32
Portals and would only be available to members of the research staff who are staffed at
the University of Southern California and do not work at Portals.
Sampling for Qualitative Study
After the quantitative data were collected, five individuals who have been
enrolled at Portals for less than three months and five individuals who have been
enrolled at Portals for more than three months were purposefully sampled for the
qualitative interview. Participants for this phase of the study were selected on the basis
of race, gender, and their ability to articulate their experiences. Following informed
consent, ten participants engage in open-ended interviews to clarify and detail the
quantitative findings to understand factors that determine the development of a working
alliance, strategies and sources that facilitate hope, as well as the factors that influence
psychosocial functioning outcomes.
Data Collection for Quantitative Study
After providing consent to participate in the study, this author conducted face-to-
face interviews at a place of the participant's choosing, typically a program site or their
residence. The Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) and the
Herth Hope Scale (HHI; Herth, 1992), and the Role Functioning Scale (RFS; Goodman
et al., 1993) took approximately 30 minutes to complete. The PI was trained in the
administration of the RFS (Goodman et al., 1993) by Brekke’s previous project manager
who also specializes in instrument training using a method devised over the last 15
years of community-based research. Training comprised of live and taped interviews
until this investigator reached a reliability criterion of intra-class correlation of greater
than .8 with expert and consensus ratings. Interviewer training is not needed for the WAI
and HHI because they are self-report instrument but if a study participant did not appear
to understand the instrument or responds without reading the items. Demographic data
33
(age, gender, ethnicity) were gathered on a face sheet and confirmed during the
interview. Participants were compensated for participating in the study.
Measures for the Quantitative Data
Working Alliance measure. The Working Alliance Inventory (WAI; Horvath &
Greenberg, 1989) is a 36-item self-report measure that assesses the three
subcomponents of the working alliance as defined by Bordin (1979): (a) agreement on
tasks, (b) bond between client and therapists, and (c) agreement on goals. Each item is
rated on a seven-point Likert scale (1 = “never,” 7 = “always”), and scores range from 36
to 252 with higher scores indicating a stronger alliance. Two versions of the WAI have
been developed to measure both therapist and client perceptions of the working alliance.
For the present study, only the client form will be used and the overall WAI score will be
used (i.e., the sum of all 36 items). The overall score is appropriate because a
confirmatory factor analysis by this study and Tracey and Kokotovic (1989)
demonstrated a three-dimensional structure that corresponds to the three sub-scales.
Examples of these items include: “My counselor and I agree about the things I will need
to do in therapy to help improve my situation” (task); “My therapist and I trust one
another” (bond); and “We agree on what is important for me to work on” (goal).
Several other alliance scales exist and they have been shown to be highly
correlated (Hatcher & Barends, 1996; Safran & Wallner, 1991; Tichenor & Hill, 1989).
Horvath and Greenberg (1986) applied a multitrait-multimethod analysis to examine the
construct validity of the WAI and concluded that their instrument adequately met the
criteria outlined by Campbell and Fiske (1959). Validity for the WAI has also been
established through significant correlations between WAI ratings and counseling
outcome (Horvath & Greenberg, 1986) as well as WAI ratings and client characteristics
(Kokotovic & Tracey, 1990). Moreover, reliability and validity of the instrument have
34
been established with various populations and diagnoses (Horvath & Greenberg, 1989;
Tichenor & Hill, 1989) including persons with severe mental illness in psychiatric settings
(McCabe & Priebe, 2004; Ralph & Clary, 1992). McCabe & Priebe (2004) reviewed
measures of the therapeutic relationship used for the severely and persistently mentally
ill and found that although the subscales of the WAI are highly inter-correlated, the full
scale has high inter-rater reliability and internal consistency. Stylianos and Goering
(1989) administered the instrument to 22 practitioners providing supportive or
rehabilitative counseling to 50 clients with a chronic psychotic disorder, stabilized in the
community. The investigators did not find evidence of discriminant validity in their
sample as they did not differentiate among the three subscales (Stylianos & Goering,
1989 in Catty et al. 2007). Internal consistency (Cronbach's alpha) for the WAI is
estimated with coefficient alphas ranging from .85 to .88 (Horvath & Greenberg, 1989) to
.98 (Tryon & Kane, 1993). For the present study, the internal consistencies for the
subscales of task, bond, and goal are .90, .90, and .88, respectively.
Hope measure. The Herth Hope Index (HHI; Herth, 1992) is an abbreviated
version of the Herth Hope Scale (1992) designed for use specifically to assess adults in
clinical setting. The parent tool is based upon the conceptualization of hope represented
in Dufault and Martocchio’s Model of Hope (Dufault & Martocchio, 1985). HHI consists
of 12-items measuring on a four-point Likert scale (1 = “strongly disagree,” 4 = “strongly
agree”) and scores range from 12 to 48 with a higher score indicating a higher level of
hope. The 12 statements are grouped into three factors: 1) inner sense of temporality
and future (the perception that a positive desired outcome is realistically probable in the
near or distant future); 2) inner positive readiness and expectancy (a feeling of
confidence with initiation of plans to affect the desired outcome); 3) interconnectedness
with self and others (significant, shared, and meaningful personal relationship with
35
another person, a spiritual being, or nature). The three-dimensional structure of the HHI
has been supported through factor analysis (Herth, 1992). The total score is used to
measure hope in the current study. The HHI is designed to facilitate the examination of
hope at various intervals so that changes in hope can be identified. The scale has been
demonstrated to be especially useful in the chronically and terminally ill because it is
short and easy to administer and good for respondents with limited concentration skills
(Herth, 1992). Internal consistency and face, content, and construct validity of the HHI
has been demonstrated (Herth, 1992). Cronbach’s alpha coefficient of .97 and a 2-week
test-retest reliability of .91 have been reported (Herth, 1992). Criterion-related validity
has been established by correlating the HHI with the parent HHS (r = .92), the Existential
Well-Being Scale (r = .84), and the Nowotny Hope Scale (r = .81) (Beckie et al. 2001).
Divergent validity has also been established with the Hopelessness Scale (r = –0.73).
The internal consistency alpha coefficient for this sample was .81.
Psychosocial functioning measure. Functional outcome will be measured using
the Role Functioning Scale (RFS; Goodman et al., 1993), a scale of choice for this
population (Green & Gracely, 1987). RFS consists of several probes that assesses
work, independent living, and social functioning, that are administered through a semi-
structured interview in accordance with procedures described in (Brekke et al., 2002).
The RFS provides anchored descriptions of each level of functioning for each of the
three items, and they capture both quantity and quality of functioning in each domain.
After interview training, the intraclass correlations among three interviewers on the RFS
items were >.80 (Brekke et al., 1993). This study will use the global score or the sum of
the three items. A principal components factor analysis of the three items found that
there is a single factor with an eigen value greater than one that explained 55% of the
item variance, lending credence to the use of the global score.
36
Data Collection for Qualitative Study
As mentioned above, this study employed a sequential explanatory design
characterized by the collection and analysis of quantitative measures followed by the
collection and analysis of qualitative measures which were then integrated and
interpreted in concert (Creswell et al., 2003). Therefore, following the quantitative data
collection and analysis to complete the first two aims of the study, ten semi-structured
open-ended interviews were conducted to accomplish the third aim of the study. Semi-
structured interviews were used to complement and enrich the quantitative results,
thereby increasing understanding and knowledge of consumers’ perspectives on the
factors influencing development of the working alliance and sources of hope, as well as
motives that shape psychosocial functioning outcomes.
The decision to sample ten participants for the qualitative study was determined
by the principle of “saturation” (Morse, 1995). Saturation of data occurs when additional
sampling provides no new information, only redundancy of previous collected data. Ten
participants were anticipated to be adequate to achieve saturation and explore the study
constructs and hypotheses. If saturation was not achieved with ten participants, more
participants were prepared to be sampled to reach saturation.
The interviews were free-flowing conversations during which explored (1) the
factors that determine the development of a working alliance, (2) strategies and sources
that facilitate hope, and (3) the factors that influence psychosocial functioning outcomes.
A preliminary interview guide was developed (Table 2) that includes the following issues:
1) consumers’ perspectives and evaluations of their alliance with their providers, 2) their
expectations of their provider as well as from the psychosocial rehabilitation program in
general, 3) personal conceptualization and source of hope, 4) their values, beliefs, and
goals regarding rehabilitation, together with 5) their source of motivation to accomplish
37
their goals. The interview guide ensures efficient, focused, and systematic use of limited
interview time. Since this interview guide had never been used, two pilot interviews
were conducted to make sure it meets the objective of the interviews and is also
agreeable to the study participants.
Table 2. Interview Questions
1 How would you describe your relationship with your provider?
2 What makes your relationship good / bad?
3 Why do you think your relationship with your provider is good / bad?
4 How do you define hope?
5 What give you hope?
6 Does your relationship with your provider make you more / less hopeful?
7 How does your relationship with your provider affect your goals?
Data Analyses
Quantitative Data Analyses
Structural equation modeling (SEM) with latent variables (Bentler, 1995; Kline,
2005; Loehlin, 1992; Roseman, 1984) was used to test the first two hypotheses for this
study. SEM is a more powerful statistical technique than multiple regression, path
analysis, or factor analysis because it can simultaneously explain several interactional
relationships among variables rather than individual coefficients, handle nonlinearities,
correlated independents and error terms, measurement error, multiple latent
independents as well as latent dependents measured by several indicators (Francis,
1988; Garson, 2005; Grimm & Yarnold, 2000; Hoyle & Panter, 1995; Kline, 1998;
Loehlin, 1992). It can also model mediating variables and pathways (Loehlin, 1992).
This method of analysis has become popular in recent years with an increasing number
of studies testing theoretical models with cross-sectional (Barnett et al., 2007; Sergi et
al., 2007) and longitudinal data (Bellack et al., 2007; Brekke et al., 2005; Drake et al.,
2004; Green et al., 2004; Sergi et al., 2006; Xie et al., 2005). Variable distributions were
checked before modeling to make sure it met the multivariate normality assumption.
38
SEM combines confirmatory factor analysis with path analysis and allows one to
construct, analyze, and assess extensive causal structural path models as well as
compare the goodness of fit of models and their adequacy over multiple groups of
individuals. The objective was to examine interrelationships among a set of observable
variables by studying causal relationships between a set of theoretically developed
constructs (Bentler, 1995; Kline, 1998; Loehlin, 1992). SEM consists of two main sets of
equations; measurement equations and structural equations. The measurement part of
the model corresponds to factor analysis and illustrates the relationship between the
measured variables and the theoretical constructs that presume to underlie them and
this set of equations permits one to evaluate the accuracy of the proposed
measurements. The structural equation part corresponds to path analysis and
demonstrates the hypothesized relationships, the direct, total, and total indirect effects of
the latent variables, between the theoretical constructs which allows for the examination
of the proposed theory (Loehlin, 1992).
In ordinary path analysis one models the relationship between observed
variables, whereas in SEM, one models relationships between factors. The
hypothesized model is compared for its “goodness of fit” with the actual observations in
the sample data. The parameters are estimated by comparing the actual covariance
matrices representing the relationships between variables and the estimated covariance
matrices of the best fitting model, which is obtained through the maximum likelihood
estimation method (Bentler, 1989).
Methods of assessing model fit in the present study were selected based on
established criteria (Bentler, 1990; Browne & Cudeck, 1993; Kelloway, 1998; Kline,
2005). The 
2
test is the fit measure most often used to denote whether the
hypothesized model is significantly different from one that fits the data perfectly; thus, a
39
non-significant test statistic is desired to support the model (Pedhazur, 1997). The
Comparative Fit Index (CFI) varies between zero and one and provides an assessment
of comparative fit without being affected by the sample size. Values > .95 are considered
excellent and >0.90 adequate fit (Bentler, 1990). A fit index that is based on trying to
estimate the match of the model to the reality in the population using degrees of freedom
and the noncentral 
2
distribution is Steiger’s Root Mean Square Error of Approximation
(RMSEA). The RMSEA is fairly insensitive to sample size, adjusts for parsimony, and
provides a confidence interval for the fit statistic, which ranges from zero (perfect fit) to
one; a statistic no greater than .08 is desirable (Loehlin, 1998).
Analyses for this study was carried out using the software programs SPSS
version 11.5 (SPSS Inc., 2002) and Mplus version 4 (Muthén & Muthén, 2006). Several
SEM programs can obtain the estimates of direct, total, and total indirect effects and
conduct hypothesis tests and construct confidence intervals for indirect effects in both
simple and multiple mediator models using either the product of coefficients strategy or
bootstrapping in some form (Bentler, 1995; Byrne, 1994; Muthen & Muthen, 1998).
Mediation and moderation models are best estimated in a SEM context because of the
greater flexibility SEM programs provides in model specification and estimation options.
Mediation Analysis
Mediation analysis was performed based on the four-step guideline to test for
mediation proposed by Baron and Kenny (1986). As demonstrated in Figure 3, the
overall total effect of the independent variable, consumer working alliance, on the
dependent variable, psychosocial functioning, path c, was estimated in the first step.
Then, the effect of independent variable, consumer working alliance, on the mediator,
consumer hope, path a, was estimated. In the third step path b, the direct effect of
consumer hope on psychosocial functioning controlling for consumer working alliance,
40
was estimated. Finally in the fourth step, the significance of the mediation effect is
calculated using the product of path coefficients, a and b, and is tested with the Sobel
test (Sobel, 1982). Mplus (Muthen & Muthen, 2006) uses the Sobel equation for testing
mediation-based indirect effects and is also able to conduct bootstrapping, one of a
number of re-sampling techniques to assess the variability of estimates of indirect effects
in mediation analysis (Shrout & Bolger, 2002).
Baron and Kenny’s (1986) method is an exploratory method, similar to a
stepwise regression where the subsequent steps are dependent upon that which
precedes it. In an exploratory study, limited theory or an unspecified model drives the
analysis and the likelihood of a Type I error, the chances of finding a significant
mediator, increases owing to the number of statistical tests. Baron and Kenny’s (1986)
steps have also been noted for their limitations especially when there is low power due
to sample size, larger standard errors, restriction of range, and sample distributions that
are not normal (MacKinnon et al., 2007). “A recent study using empirical approaches to
determine required sample size for 0.8 power to detect a mediated effect with small
effect size values of the a and b path required approximately 21,000 subjects for the
causal steps test” (Fritz & MacKinnon 2007).
Despite the abovementioned limitations this study was based on Baron and
Kenny’s (1986) method because it is still regarded to guide the general steps to conduct
mediation analyses (MacKinnon, 2008; MacKinnon et al., 2007). However, the following
issues must be noted. First, this study was driven by substantial theory and previous
empirical research. Second, structural equation modeling uses latent constructs to
simultaneously estimate the parameter estimates and mediation analysis. Lastly, the
requirement that the first step (e.g. relationship between the IV and DV be significant) in
the causal analysis may be relaxed as it has been found to severely reduce power to
41
detect mediation (MacKinnon, 2008, MacKinnon et al., 2007). This test has been noted
to be “controversial because it is possible that the relation between the independent
variable and dependent variable may be nonsignificant, yet there can still be substantial
mediation” (MacKinnon, 2008, p. 68). MacKinnon and his colleagues (2002) suggest
that the most important conditions for mediation are that the path from IV to the mediator
and the path from the mediator to DV are significant. Therefore, this study will not strictly
require the first step to be significant.
Figure 3. Steps for Mediation Analysis
Moderation Analysis
A moderator is a variable that modifies the direction or strength of the
relationship between the IV and DV (Baron & Kenny, 1986; Holmbeck, 1997; James &
Brett, 1984). A number of researchers (Baron & Kenny, 1986; Holmbeck, 1997; Marsch,
2002) recommend SEM to study moderator effects. SEM can examine interactions
involving both categorical and continuous variables (Holmbeck, 1997; Kenny & Judd,
1984). In the former, a multiple-group approach is used in which the relationship
c
Hope
Working
Alliance
Psychosocial
Functioning
Working
Alliance
a
b
Psychosocial
Functioning
c’
42
between the IV and DV is estimated separately for the multiple groups, while in the latter
continuous variable approach, an interaction term is created by multiplying the IV and
the moderator.
This study used a multiple-group approach (Pentz & Chou, 1994) to investigate if
the length of attendance (less / more than three months) moderates the relationship
between consumer working alliance, consumer hope, and psychosocial functioning. In
testing this model, both CFA and SEM models were developed separately for the less
than and more than three months groups. Latent mean structure was stipulated in the
multiple group models to test invariance of the latent factor means across the two
groups. Before assessing the moderator hypothesis, the two groups were compared on
demographic and relevant study variables to evaluate for sample characteristics that
may confound any moderating effect. Baseline models of two groups were initially
combined as the basic model with equal constraints set on all factor loadings, regression
pathways, and all intercepts for the observed measures. The factor intercepts were
freely estimated in the less than three months group and constrained equal to zero in the
more than three months group, which is regarded as the “reference” group.
The fit of the two models were compared using the 
2
difference test (Santorra &
Bentler, 2001); TRd = (T0 - T1)/cd, where T0 and T1 are the 
2
values while cd are the
degrees of freedom. Parsimonious models are favored as the purpose is to not
decompose the models by constraining parameters across the two groups. If there is
significant difference in chi-square values between models, the less constrained model
is considered to fit significantly better than the more constrained model and moderation
is confirmed.
43
Qualitative Data Analyses
Qualitative research involves an “integrative deductive – inductive process using
qualitative data to inform and transform existing theory and research” (Nastasia &
Schensul, 2005, p. 183). All ten interviews from the current qualitative phase of the
study were audiotaped and transcribed verbatim within one week of the interview.
Transcripts were then reviewed against the audiotapes for responses that were not clear
and to check for accuracy. Analyses of transcripts for the current study were managed
in the following manner concurrent with most qualitative investigators (Strauss & Corbin,
2007).
Initial analysis was obtained to get a general sense of common experiences and
concerns. During this process, concepts and themes that were derived inductively
coded at a very general level to condense the data into more manageable units for
detailed analysis. Segments of the interview transcripts, ranging from single phrases to
several grouped paragraphs, were then assigned general codes based on their content.
These open codes were based on existing themes obtained from the study inquiry or
from the items in the qualitative interview guide, along with the themes that emerged
through the course of the analyses. At times, some segments were assigned multiple or
overlapping codes. The contents of each coding category were reviewed to remove,
combine, or subdivide coding categories (Glaser & Strauss, 1967; Ryan & Bernard,
2003; Strauss & Corbin, 1990). Passages that diverge from the common responses
were also noted. Textual coding and thematic analysis of the interviews were analyzed
following the standard procedures of qualitative research using Atlas. ti version 5.0.
(Muhr, 1997), a qualitative data analysis program based on grounded theory (Miles &
Huberman, 1994).
44
Common and repeated ideas and themes were further grouped into what Atlas. ti
(Muhr, 1997) calls families, larger themes that organizes conceptual categories.
Analyses were further refined by identifying the most common themes by constructs (i.e.
working alliance, hope, psychosocial functioning) as well as by groups (i.e. enrolled in
program less / more than 3 months). Frequency tables were created for each family on
the various codes and compared and contrasted to explore the salience of different
codes for different concepts and groups of participants. Thematic analysis were also
performed on two levels, individual cases and across groups, comparing the themes and
categories to answer the following question: “To what extent are the perceptions and
experiences regarding the quality of the working alliance, extent and sources of hope, as
well as the causes of their psychosocial functioning level similar or dissimilar between
those who have been enrolled at Portals less than three months to those who have been
there more than three months?” Finally, conceptual models were developed inductively
from the analyses of similar and dissimilar topics from the two data sources to highlight
the meaningful materials that were associated with the questions addressed in the
research aims.
Mixed methods research has had to deal with what Onwuegbuzie and Johnson
(2006) call “the problem of legitimation,” or “the difficulty in obtaining findings and / or
making inferences that are credible, trustworthy, dependable, transferable, and / or
confirmable” (p. 52). Tashakkori and Teddlie (2003) offered a standard to assess the
quality of inferences (Table 3) which was followed in this study.
45
Table 3. Criteria for design quality and interpretive rigor
Features of
Inference Quality
Research Criteria Indicator or Audit
Design Quality 1. Design Suitability Are the methods of study appropriate
for answering the research
question(s)? Does the design match
the research questions?
2. Design Adequacy / Fidelity 2a) Are the procedures implemented
with quality and rigor?
2b) Are the methods capable of
capturing the meanings, effects, or
relationships?
2c) Are the components of the design
(e.g. sampling, data collection
procedures, data analysis procedures)
implemented satisfactorily?
3. Within Design Consistency Do the components of the design fit
together in a seamless manner? Is
there “within design consistency”
across all aspects of the study?
4. Analytic Adequacy Are the data analysis procedures /
strategies appropriate and adequate to
provide possible answers to research
questions?
Interpretive Rigor 5. Interpretive consistency 5a) Do the inferences closely follow the
relevant findings in terms of type,
scope, and intensity?
6. Theoretical Consistency Are the inferences consistent with
theory and state of knowledge in the
field?
7. Interpretive Agreement 7a) Do other scholars reach the same
conclusions on the basis of the same
results. Is there peer agreement?
7b) Do the investigator’s inferences
match participants’ constructions? (Is
there a researcher – participant match?
8. Interpretive Distinctiveness Is each inference distinctively more
plausible than other possible
conclusions that can be made on the
basis of the same results?
9. Integrative Efficacy Does the meta-inference adequately
incorporate the inferences made from
QUAL and QUAN strands of the study?
Note. This table was adapted from Tashakkori & Teddlie (2008)
Additionally, this author kept memos, fieldnotes, and reflexive journals to record
informal observations, contacts, conversations, and impressions throughout the course
of the study. Reflective journals were kept to make clear the assumptions, knowledge,
and biases related to the research topic as well as to assure data quality and assess the
46
adequacy and quality of inferences (Jasper, 2005; Natasia & Schensul, 2005;
Tashakkori & Teddlie, 2008).
47
Chapter IV: Results
Description of the Sample
The sample consisted of 100 individuals diagnosed with schizophrenia or
schizoaffective disorder who met the inclusion and exclusion criteria mentioned earlier
and completed the measures for this study including working alliance, hope,
psychosocial functioning, and symptoms. Of the 100 subjects, 35 (35%) were female
and 65 (65%) were males. The racial breakdown was: 29 (29%) Caucasian, 29 (29%)
Black, 16 (16%) Latino, and 1 (1%) Asian. The average age of the consumer was 43.54
(10.84) years-old (age range of 19 – 63 years of age).
T-tests were performed to compare scores of the study variables between the
two groups (Group 1 = less than three months; Group 2 = more than three months).
There were significant differences between the groups on the three subcomponents and
total working alliance scores. Group 1 scored significantly higher on the three
subcomponents – task, t (81.66) = 2.37, p = 0.02, bond, t (80.24) = 2.33, p = 0.02, and
goal, t (71.59) = 3.44, p = 0.00 – as well as the total working alliance measure, t (75.53)
= 2.90, p = 0.01. Group 2 scored significantly higher on the amount of days on
antipsychotic medications in the previous 180 days t(53.19) = - 4.55 as well as on work t
(82.44) = -1.83, p = 0.01 than Group 1, Detailed sample characteristics are presented in
Table 4.
48
Table 4. Sample Characteristics (n=100)
Less than
3 months
More than
3 months
Entire Sample
Gender Male 33 32 65
Female 17 18 35
Ethnicity White 11 18 29
African-American 32 22 54
Latino 6 10 16
Asian 1 0 1
Total 50 50 100
Less than
3 months
More than
3 months
Entire Sample p
d
Age 40.96 (10.42) 45.68 (11.15) 43.32 (10.99) 0.31
Education 12.34 (2.62) 12.16 (2.23) 12.25 (2.43) 0.71
Days on Anti-Psychotic
Medication in Previous 180 days
144.82 (51.26) 178.50 (10.61) 161.66 (40.53) 0.00
WAI
a
Task 81.14 (3.87) 78.68 (6.25) 79.91 (5.32) 0.02
WAI
a
Bond 81.10 (3.66) 78.76 (6.10) 79.93 (5.14) 0.02
WAI
a
Goal 80.84 (3.75) 76.72 (7.59) 78.78 (6.30) 0.00
WAI
a
Total 243.08 (10.37) 234.16 (19.12) 238.62 (15.94) 0.01
HHI
b
Temporality & Future 12.22 (2.04) 11.58 (2.07) 11.90 (2.07) 0.12
HHI
b
Positive Relatedness &
Expectancy
12.52 (2.41) 12.30 (2.00) 12.41 (2.21) 0.62
HHI
b
Interconnectedness 12.08 (2.12) 11.66 (1.72) 11.87 (1.93) 0.28
HHI
b
Total 36.84 (5.77) 35.56 (4.90) 36.20 (5.36) 0.23
RFS
c
Work 1.44 (1.11) 1.98 (1.77) 1.71 (1.49) 0.01
RFS
c
Independent Living 4.06 (1.11) 4.78 (1.57) 4.42 (1.40) 0.07
RFS
c
Social Relationships 3.56 (1.86) 3.36 (2.05) 3.46 (1.95) 0.61
RFS
c
Total 9.06 (2.79) 10.12 (4.19) 9.59 (3.58) 0.14
a
Working Alliance Inventory (WAI; Horvath & Greenberg, 1986)
b
Herth Hope Index (HHI; Herth, 1992)
c
Role Functioning Scale (RFS; Goodman et al., 1993; McPheeters, 1984)
d
p = 0.05
The first aim of this study was to consider the empirical association between
consumer working alliance, consumer hope, and psychosocial functioning. The bivariate
Pearson correlations among the latent constructs were -.043 for consumer working
alliance with psychosocial functioning, .271 for consumer working alliance with
consumer hope, and .062 for consumer hope with psychosocial functioning. The
correlation between consumer working alliance and consumer hope was the only
correlation from the above that was significant at the 0.01 level. The negative
relationship between consumer working alliance and psychosocial functioning
corroborates a small body of existing literature (Krupnick et al., 1996; Raue et al., 1993)
49
that stronger working alliance is related to worse psychosocial functioning at about a
medium effect size level using Cohen’s (1988) criterion. This study also provides the
first data on the relationships between consumer working alliance and consumer hope,
and between consumer hope and psychosocial functioning. Consumer hope had a
positive association with both consumer working alliance and psychosocial functioning.
The first step in Baron and Kenny’s (1986) test of mediation is for the path
between the independent variable and dependent variable to be significant. In this
study, the path from consumer working alliance to psychosocial functioning was not
significant. However, the requirement of this first step was relaxed in this study due to
the controversies mentioned above in the Methods section and because the hypotheses
for this study were driven by substantial theory and previous empirical research.
Therefore, hypotheses two and three were tested.
Mediation Hypothesis
Consumer hope was hypothesized to mediate the relationship between
consumer working alliance and psychosocial functioning. Zero-order correlations
among the study variables are shown in Table 5. Data were checked for normality,
which is a critical assumption underlying the maximum-likelihood procedure used in this
study.
50
Table 5. Means, Standard Deviations, and Zero-Order Correlations Among
10 Observed Variables
M 1 2 3 4 5 6 7 8 9
1 WAI 1 79.91 1 .82** .92** .16 .32** .20* .06 .02 -.09
2 WAI 2 79.93 1 .83** .08 .27** .24* .03 .01 -.11
3 WAI 3 78.78 1 .17 .31* .22* -.00 -.00 -.11
4 HHI 1 11.90 1 .62** .54** -.06 .01 -.04
5 HHI 2 12.41 1 .65** .14 .10 -.00
6 HHI 3 11.87 1 .21* .06 -.03
7 RFS 1 1.71 1 .44** .27**
8 RFS 2 4.42 1 .27**
9 RFS 3 3.46 1
Note. N = 120. Working Alliance Inventory (WAI): WAI 1 = Task, WAI 2 = Bond, WAI 3 = Goals.
Consumer Hope; Hope 1 = Temporality & Future, Hope 2 = Readiness & Expectancy, Hope 3 =
Interconnectedness , Psychosocial Functioning: RFS 1 = Independent Living, RFS 2 = Work,
RFS 3 = Social.
As can be seen from Table 5, the three subscale scores of the Working Alliance
Inventory (WAI; Horvath & Greenberg, 1989) correlated significantly. The dimensions of
readiness and expectancy as well as interconnectedness of the hope scale correlated
significantly well with the working alliance measure. Furthermore, the social functioning
component of the Role Functioning Scale (RFS; Goodman et al., 1993) correlated with
the independent living and work element.
Table 6 and 7 demonstrate the zero-order correlations among the study variables
for Group 1 and 2, respectively. The three subscores of the WAI were significant for
both groups. For Group 1, the Readiness and Expectancy subscore of the Herth Hope
Index (HHI; Herth, 1992) was correlated with all three subscores of the WAI.
Furthermore, the Independent Living subscore of the RFS was correlated with the
Interconnectedness subscore of HHI. The Work subscore of the RFS was correlated
with Independent Living subscore of the RFS and Social subscore of the RFS was
correlated with the Temporality and Future as well as Readiness and Expectancy
subscores from the HHI.
For Group 2, the Readiness and Expectancy (HHI) was the only subscore that
correlated with the Goal subscore of the WAI but not with the other two WAI subscores.
51
However, like Group 1, the Readiness and Expectancy (HHI) subscore was correlated
with the two other subscores of the HHI. Finally, the Interconnectedness (HHI) subscore
was correlated with the Goals subscore of the WAI.
Table 6. Means, Standard Deviations, and Zero-Order Correlations Among
10 Observed Variables for Group 1 (less than three months)
M 1 2 3 4 5 6 7 8 9
1 WAI 1 81.14 1 .84** .93** .18 .41** .17 .10 .04 -.23
2 WAI 2 81.10 1 .86** .16 .38** .28 .06 .06 -.21
3 WAI 3 80.84 1 .15 .36* .16 .04 .03 -.22
4 HHI 1 12.22 1 .60** .46* -.17 -.07 -.28*
5 HHI 2 12.52 1 .60** .07 .01 -.15
6 HHI 3 12.08 1 .29* .12 -.10
7 RFS 1 1.44 1 .55** .32*
8 RFS 2 4.06 1 .37**
9 RFS 3 3.56 1
Note. N = 120. Working Alliance Inventory (WAI): WAI 1 = Task, WAI 2 = Bond, WAI 3 = Goals.
Consumer Hope; Hope 1 = Temporality & Future, Hope 2 = Readiness & Expectancy, Hope 3 =
Interconnectedness , Psychosocial Functioning: RFS 1 = Independent Living, RFS 2 = Work,
RFS 3 = Social.
Table 7. Means, Standard Deviations, and Zero-Order Correlations Among
10 Observed Variables for Group 2 (more than three months)
M 1 2 3 4 5 6 7 8 9
1 WAI 1 78.68 1 .74** .87** .06 .22 .23 .20 .15 .13
2 WAI 2 78.76 1 .70** -.14 .15 .18 .18 .04 .03
3 WAI 3 76.72 1 .11 .32* .29* .23 .16 .05
4 HHI 1 11.58 1 .64** .60** .20 .21 .22
5 HHI 2 12.30 1 .68** .27 .27 .13
6 HHI 3 11.66 1 .21 .05 .03
7 RFS 1 1.98 1 .09 .26
8 RFS 2 4.78 1 .13
9 RFS 3 3.36 1
Note. N = 120. Working Alliance Inventory (WAI): WAI 1 = Task, WAI 2 = Bond, WAI 3 = Goals.
Consumer Hope; Hope 1 = Temporality & Future, Hope 2 = Readiness & Expectancy, Hope 3 =
Interconnectedness , Psychosocial Functioning: RFS 1 = Independent Living, RFS 2 = Work,
RFS 3 = Social.
Measurement model
The two-step model-building approach (Anderson & Gerbing, 1988) was used to
examine the mediation and moderation hypotheses. The measurement model was
initially tested to evaluate the empirical viability of all latent variables in the hypothesized
model. The first measurement model included the entire 100 study participants. Tests
52
of this measurement model resulted in a good fit to the data, 
2
(24, N = 100) = 21.97, p
= 0.58, CFI = 1.00, and RMSEA = .00 (90% confidence interval CI: .00, .07). The
loadings of the measured variables on the latent variables were all statistically significant
(p < .001). The subsequent measurement model was a multi-group model where the
sample was divided by length of enrollment (Group 1 = less than three months; Group 2
= more than three months). Results of this measurement model showed a better fit to
the data, 
2
(54, N = 100) = 60.95, p =0.24, CFI = 0.98, and RMSEA = .05 (90%
confidence interval CI: .00, .11). These findings support the use of the latent variables
multiple-group approach to test the study hypotheses.
Structural model
The multiple-group structural model was carried out to test the mediation
hypothesis. The results revealed a good fit, 
2
(57, N = 100) = 63.51, p = 0.26, CFI =
.98, RMSEA = .05 (CI: .00, .10). The direct paths from consumer working alliance to
consumer hope (unstandardized  =0.091, p=0.002) and from consumer hope to
psychosocial functioning (unstandardized  = 0.149, p= 0.049) were statistically
significant. The direct path from consumer working alliance to psychosocial functioning
was not statistically significant (unstandardized = 0.015, p = 0.542). The mediation
effect was not statistically significant at the two-tail level,  = 0.014, p=0.087 but
statistically significant at the one-tail level, p = 0.04. The unstandardized coefficients of
the direct effects with standard error estimates are presented in Figure 4.
There are two things to note about these findings. First, unlike the nonsignificant
bivariate correlations between hope and functional outcome, the parameter estimate
between hope and functional outcome was statistically significant. Second, the majority
of the study sample had a high working alliance, which created a ceiling effect and
restriction of range. The mediation analysis may have been statistically significant at the
53
two-tail level had there been more variation in the working alliance rating. The one-tail
results suggest that there is a trend towards consumer hope mediating the relationship
between consumer working alliance and psychosocial functioning.
Figure 4.
Note
1
. Working Alliance Inventory (WAI): WAI 1 = Task, WAI 2 = Bond, WAI 3 = Goals. Consumer Hope;
Hope 1 = Temporality & Future, Hope 2 = Readiness & Expectancy, Hope 3 = Interconnectedness ,
Psychosocial Functioning: RFS 1 = Independent Living, RFS 2 = Work, RFS 3 = Social.
Note2. Factor loadings are unstandardized with standard error estimates. Researchers indicate that
unstandardized regression coefficients should be used for interpretation and substantive inference in cross-
group analysis (Bollen, 1989; Singh, 1995).
Moderation Hypotheses
To evaluate if length of attendance moderated the above mediation relationship,
multiple-group meditational analysis was used. Results of the multi group meditational
model without equal constraints was, 
2
(60, N = 100) = 72.93, p=0.12, CFI = .97,
RMSEA = .07 (CI: .00, .11) while the model with equal constraints was, 
2
(63, N = 100)
1.00 (0.00)
1.16 (0.06)
0.87 (0.07)
1.14 (0.36)*
0.84 (0.30)*
1.00 (0.00)
0.02 (0.12)
0.09 (0.03)* 0.15 (0.08)*
1.00 (0.00)
0.99 (0.16)
1.43 (0.22)
Consumer
Hope
Working
Alliance
(Consumer
)
Psychosocial
Functioning
WAI 3
WAI 2
WAI 1
RFS 3 RFS 1
HHI 1 HHI 3
HHI 2
RFS 2
54
= 75.31, p=0.14, CFI = .97, RMSEA = .06 (CI: .00, .11). The 
2
difference test was not
significant ( 
2
Difference
(3) = 2.38, p = 0.497) and moderation was not demonstrated.
There were no significant difference between the constrained and the non-constrained
models indicating that the constrained model is considered superior and there were no
differences between those who have been enrolled at Portals for less than three months
versus those who have been enrolled for more than three months.
Results of the quantitative analysis demonstrated a trend for hope to mediate the
association between working alliance and psychosocial functioning. The parameters
from working alliance to hope and hope to psychosocial functioning were statistically
significant in the predicted direction, establishing a critical relationship that has not been
examined for individuals with schizophrenia participating in a community-based
psychosocial rehabilitation program.
Qualitative Results
The final portion of the analysis focused on the data collected through the ten
open-ended interviews. This qualitative phase was used to supplement and illuminate
the abovementioned quantitative results. Preliminary analyses were conducted to
determine whether or not significant differences existed between the selected ten
participants and the entire sample as well as between the two groups (less / more than 3
months) selected for the qualitative phase on demographic variables along with the
scores on the relevant study variables.
Similar to the quantitative sample, t-tests to compare Group 1 and Group 2 in the
qualitative sample revealed significant differences between these groups on the three
dimensions – task, t (8) = 2.29, p = 0.05, bond, t (8) = 2.36, p = 0.05, and goal, t (8) =
3.85, p = 0.01 - and total working alliance scores, t (8) = 2.96, p = 0.02. The more than
three months group rated significantly higher on the work, t (8) = -3.31, p = 0.01,
55
independent living, t (8) = -2.50, p = 0.04, and total scores t (8) = -5.46, p = 0.00 of the
role functioning scale. The characteristics of the qualitative sample are presented in
Table 8.
Table 8. Sample Characteristics (n=10)
Less than
3 months
More than
3 months
Entire Sample
Gender Male 3 2 5
Female 2 3 5
Ethnicity White 0 2 2
African-American 2 2 4
Latino 2 1 3
Asian 1 0 1
Total 5 5 10
Less than
3 months
More than
3 months
Entire Sample p
d
Age 42.60 (4.56) 42.60 (11.24) 42.60 (8.09) 1.00
Education 12.60 (2.41) 13.40 (2.79) 13.00 (2.49) 0.64
Days on Anti-Psychotic Medication
in Previous 180 days
130 (68.56) 180 (0.00) 155.00 (52.76) 0.18
WAI
a
Task 82.60 (2.61) 75.40 (6.54) 79.00 (6.04) 0.05
WAI
a
Bond 82.60 (1.95) 75.60 (6.35) 79.10 (5.76) 0.05
WAI
a
Goal 82.80 (1.79) 72.40 (5.77) 77.60 (6.80) 0.01
WAI
a
Total 248.00 (5.87) 223.40 (17.64) 235.60 (17.94) 0.02
HHI
b
Temporality & Future 13.40 (1.82) 11.80 (2.28) 12.60 (2.12) 0.26
HHI
b
Positive Relatedness &
Expectancy
13.80 (1.30) 12.40 (2.79) 13.10 (2.18) 0.35
HHI
b
Interconnectedness 12.60 (0.55) 11.80 (1.64) 12.20 (1.23) 0.33
HHI
b
Total 39.80 (3.27) 36.20 (6.50) 38.00 (5.21) 0.30
RFS
c
Work 4.60 (1.34) 6.40 (0.89) 5.50 (1.43) 0.04
RFS
c
Independent Living 2.20 (2.17) 5.80 (1.10) 4.00 (2.49) 0.01
RFS
c
Social Relationships 4.20 (2.05) 5.40 (1.82) 4.80 (1.93) 0.36
RFS
c
Total 11.00 (1.41) 17.60 (2.30) 14.30 (3.92) 0.00
a
Working Alliance Inventory (WAI; Horvath & Greenberg, 1986)
b
Herth Hope Index (HHI; Herth, 1992)
c
Role Functioning Scale (RFS; Goodman et al., 1993; McPheeters, 1984)
d
p = 0.05
Qualitative research is a continual “reflexive process” (Nastasia & Schensul,
2005, p. 183) between theoretical deductive logic and empirical inductive reasoning. As
elaborated in the method section, qualitative interviews were first analyzed deductively
with the major themes from the interview guide and the literature. These were
subsequently investigated inductively to examine the unanticipated themes that emerged
from the data. The final list of codes and families consisted of themes and subthemes
related to the research questions under investigation including the factors influencing
56
working alliance, hope, and psychosocial functioning, and the relationships among the
three constructs.
Evaluation of participants’ accounts in the open-ended interviews discovered
themes that resonate with the recovery literature and narratives of individuals with
schizophrenia. Interviews revealed that a positive working alliance between a consumer
and provider consisting of qualities such as trust, respect, and compassion laid the
foundation for a collaborative consumer-driven goal-setting process and ultimately a
positive psychosocial outcome. This association between alliance and outcome was
found to be powerfully influenced by hope, which was driven by spirituality and the
positive encouragement consumers receive from others. Although study participants did
not use the term “psychosocial functioning,” they spoke at length about their short and
long-term goals. The qualitative interviews found that achieving goals stimulated a
consumer’s self-esteem, self-efficacy, self-confidence, and motivation, which in turn
stimulates their hope and leads them to pursue more challenging goals.
Shared and distinct themes regarding the importance of working alliance,
sources of hope, and consideration of goals emerged in the two groups (Group 1 = less
than three months; Group 2 = more than three months); they are summarized in Table 9.
Quotes are used to exemplify the themes revealed in the analyses. Pseudonyms have
been used to maintain confidentiality.
57
Table 9. Shared and Distinct Themes Between the Two Groups
< 3 months < 3 months
Importance of the
Working Alliance
Setting Basic Goals
(ADL, Treatment / Med
collaboration
Maintaining Basic Goals
Trust Trust
Sense of Connection Sense of Connection
Self-Schema (self-esteem, self-
confidence)
Setting / Accomplishing more
Challenging Goals
Medication Collaboration Medication Collaboration
Comfortable approaching providers
about medication
Comfortable approaching providers
about medication
Sources of Hope Spirituality / Religion Spirituality / Religion
Encouragement from Providers,
Members, and Family
Encouragement from Providers,
Members, and Family
Witnessing other Members and
Casemanagers Successfully
Pursuing Goals
Accomplishing Goals
Noticing the Positive
Effects of Medication
Self-Esteem / Self-Confidence
Goals Desire to go to school, get a job,
and get independent housing
Desire to go to school, get a job,
and get independent housing
Work with CM to set goals Members learn to be self-directive
and assertive in pursuing goals
Desire to pursue more challenging
goals after they accomplish
previous goals
Some mismatch between CM and
members on various goals
Importance of the Working Alliance
Participants in the qualitative study rated their working alliance with their
providers highly, which was comparable to the quantitative sample. During the
qualitative interview, consumers in Groups 1 and 2 identified common themes including
appreciation for services, trust, sense of connection, and the providers’ approachability
and flexibility in changing medication.
Appreciation for Services
All ten qualitative study participants expressed their sincere appreciation for the
services they received from their respective providers. Participants were grateful for the
providers who demonstrated genuine care and interest by being present; taking the time
to acknowledge them; spending extra time when needed; making direct eye contact and
58
actively listening; providing encouragement, hope, and reassurance; working with them
on their difficulties and goals; and most importantly treating them with respect and
kindness. For example, though Lauren had encountered providers in other rehabilitation
programs, her providers at Portals were the first to utilize several techniques that she felt
authentically conveyed concern. “Just…the fact that they took the time out…that they
made conscious effort to keep eye contact with me…uhm…to engage in conversation
with me, to get me to talk about how I was feeling, and then, you know, not to, they were
very nonjudging, and extremely attentive and encouraging.”
Donna particularly appreciated how her case managers remembered the various
things she had told them and took the time to follow up on those matters. “You can tell
them something and instead of them just listening, and lettin’ it go, they follow-up and
ask you, you know, ‘Is it any better?’…[They] just acknowledge you whenever they see
you even if they’re busy…[T]hey ask you, ‘How do you feel about this?’ or ‘What would
work for you?’…Everything is about you….[They] make me feel worthwhile.…They have
like an open door policy, where you can talk to them about anything….Their service
coordinators really cared.… It's not just a job to them, you know? It's that they really care
and they really are trying to help them.”
Trust
Frank noted that the techniques used by his providers fostered trust between
them. “I think it's the way they helped me. They care a lot. They take the time now and
listen to you. And I feel they are very interested in me. About what happens to me. And
that's very nice. I look forward to coming here. Because they want you to be happy and
do good….I trust them to be there, I trust them with my personal issues, and I trust that
they are looking out for me. And that feels good.” Melissa also stated, “I can count on
them…they have my best interest in mind. I can also tell them anything and don’t have
59
to worry about my private information going anywhere.”
Sense of Connection
A common sentiment found among almost all of the participants was the sense of
connection they felt with the providers and members. Olivia stated, “I mean, Portals…I
have found a wonderful place! That’s the way I really feel about it. I really feel like I
found a place for me. For the first time, I feel like I really fit in…and I really belong…to
some part…to something!...to have a place…people to relate to.” In spite of some
disappointing experiences Eric and Hannah experienced with their providers, they
acknowledged their appreciation for the manner in which their respective providers made
them feel regarded and cherished. When Eric disclosed to his providers that he had
been depressed and suicidal, his providers seemed surprised and asked, “‘Why didn't
you call?’ He goes, ‘Why didn't you pick up the phone and call everybody. We're your
family. We are your lifeline.’ And I didn't even think about that until they told me, until
the staff told me…That made me feel good.” Similarly, Hannah recalled an incident
when she told one of her providers about how she woke up after she fainted and
collapsed in her room due to a bad reaction with her psychiatric medication. Her
provider asked why she hadn’t called, and encouraged her to call if something similar
happens in the future. Melissa had a difficult time containing her emotions as she
expressed how her providers did not reject her when she had a setback and instead
made her feel unconditionally valued. “The service coordinators have really given me an
opportunity to learn…They invested in me. And they gave me a job back. And uhm…
they want me here as a staff as well as a client.”
Melissa briefly dropped out of treatment in between the quantitative and
qualitative portions of the current study due to life circumstances. During her qualitative
interview, she spoke about how astonished and touched she was when one of her
60
providers “took the time to go up and down the street and look for me” while she was
absent from the program.
Medication
Participants in Group 1 asserted that this was the first time they had taken
psychiatric medication consistently on a daily basis, and that the change was due to the
providers and other members who encouraged them to see the positive effects of
medications. Olivia stated, “I was in denial that I needed the medications… but I know
now, if I take my medicine, I don't have to self medicate…you know, I don’t have to, you
know, put nothin’ in me to make me feel better, that's what my medicine is for, so
basically, what I'm learning here, is how to be med compliant and to take my medicine
on a daily basis.” Eric noted, “occasionally, I think I don’t need my medications but I
know that if I don’t take them, I’ll be in bad shape, in the hospital or my symptoms will
get worse…so I know to take it every day and not skip it.”
Except for Melissa, who dropped out of treatment for a period of time, the
participants in the qualitative study stated that they had taken their medication
consistently since they enrolled at Portals. The study participants felt comfortable
voicing their concerns and discomfort regarding the side effects of their psychiatric
medications, but none of the participants had received any education about their
diagnoses or their medications from their case managers, therapists, or their
psychiatrist. Frank stated, “I was told I have schizophrenia but I’m not sure what that
means…And no…they haven’t told me what each medication is for…I just take it
because it works.”
Hannah was the only person in the sample who indicated that she did not speak
up when she was having an issue with her medication. She explained that although she
trusted her doctor and felt comfortable talking to him, she was hesitant to express her
61
concerns for fear that she may be perceived as complaining and annoying. “I thought
that maybe the doctor sees something wrong or something… I don't know.” She spoke
to her providers after she got dizzy and collapsed in her apartment room. Her providers
were shocked and helped her communicate this scary outcome to her psychiatrist and
continually urged her to not wait that long and tell them at the first sign when something
is not going correctly.
Critical Importance of the Working Alliance for Recent Enrollees
Self-concept
Providers were critical in helping consumers in Group 1 to develop a positive
self-concept or self-identity, defined as "the totality of a complex, organized, and
dynamic system of learned beliefs, attitudes and opinions that each person holds to be
true about his or her personal existence" (Purkey, 1988). These views organize and
process self-related information. They vary from person to person because each
individual has diverse social and cultural life experiences, but in any case the views are
important to a person’s evaluation of his/her own worth. Self-esteem, self-efficacy, and
self-confidence are subsumed within self-concept. Self-esteem pertains to a person’s
sense of self-worth while self-efficacy relates to a person’s perception of their capability
to be effective and successful in attaining a goal. Self-confidence refers to both self-
esteem and self-efficacy (Neill, 2005).
Positive self-concept not only helped consumers in Group 1 feel better about
themselves, but also instilled confidence, hope, and motivation to pursue various goals.
Olivia used to isolate herself because of her low self-worth but her providers helped her
come of out her shell and improve how she views herself. “They take a personal interest
in what I'm interested in.… They give me the guidance that I need if I have any questions
or if I'm feeling a certain way, you know, they're able to help me as much as they
62
possibly can, and direct me, you know, on a better way of thinking and acting, you know,
with behavior change and cognitive thinking, so, they’re good for me and my self-
esteem…and they re-instill confidence in me, ‘cause I was a person lacking confidence
in myself, so, they helped me a lot.” Lauren stated, “the people here including my
casemanagers, therapist, and the other members have made me believe in
myself…made me believe that being homeless is my past life and I can do better for
myself. They made me realize that I can go back to school and get a degree so I can
help others who may be in a situation I was in the past.”
Sources of Hope
Parallel to many studies on hope, the participants in this study emphasized the
importance of spirituality. Not all of the consumers belonged to an organized religion,
however, all held some sort of spiritual belief or transcendent reality. Positive
encouragement from various people in their lives – fellow members, family, providers,
church members, and friends - was also influential towards increasing hope. Support
from members, casemanagers, and family were noted most frequently throughout the
entire sample.
Spirituality
Nearly all of the participants emphasized the importance of spirituality through
involvement in organized religion, praying, reading the bible, or believing in a higher
being or power to foster and maintain hope and attain goals. Olivia believes that her
spirituality corresponds with the philosophy that guides Portals. “My faith and my beliefs,
it just coincides and aligns with what Portals tries to teach me to be self-sufficient, you
know, self-supporting, you know, and responsible! …When I seek God through prayer,
that’s what I pray for! So it kinda go[es] hand in hand….To seek spirituality because
that’s a part of recovery as well.” Lauren grew up and continues to be fairly religious.
63
She regularly prays and believes that her prayers are often answered when individuals
around her comfort and assist her. Thus, spirituality brings her “a sense of calm, a
sense of calm, yeah, yeah…peace…that I was able to find even in the midst of
my…struggle. It’s a release…and…it’s a way to make a conscious contact with
something that’s greater than myself, that’s bigger than me, and that I feel I can depend
on, that I can trust….I think God works through people.” Eric reflected the way his
feeling about God changed over time: “It fills me up when I read the word of God…. It
gives you more hope, it gives me more as strength, more faith in God where I didn't have
before… I was so angry at him before...and blamin’ him for, ‘Why did he do that? Why
did he let this happen to me? Why am I like this?’…I hated him! …To find out he was
there all along, and it was just me that really didn't put that much faith into him. Even
from staff members that are religious, you know I talk to them about that and…you know,
they always tell me, ‘You know what, you're still loved.’…so it helped me both ways.
Mentally…with my physical health, and spiritually.”
Support from providers
All of the participants had a handful of supportive and significant people in their
lives including mental health providers, other members at Portals, family members, and
other friends who bolstered them as they journeyed through treatment. Eric affirmed,
“the encouragement and confidence that providers had in me has given me so much
hope….that has helped me a lot.”
Support from members
Support from other members particularly encouraged consumers in Group 1 to
follow their treatment and medication regimen. For example, Frank truly valued the
other members as he stated, “the other members have helped me by sharing their
experiences when I’m having a hard time. It’s nice to know you’re not alone.” Lauren
64
noted, “I do get support from the members…because…we’re all trying to save our
lives…so we have a common bond, you know?…We all go through our struggles and it’s
nice to know, you know, you’re not the only one…And we lift each other up…because
they don’t really have all the answers. We’re trying to find different coping skills,
together…and…just supporting each other…There’s…an element of camaraderie.”
James and Chris, both of whom have been enrolled at Portals for a couple of
years, inspire other members to work and go back to school. “The part of the fact that
I’m maintained a job and I’ve influenced other people to go into the work force….I got uh
three people now that’s supposed to come into employment that I referred to,” noted
James. Chris stated, “Like my friend, always encouraged him to go to school, at least
take one class…Hopefully he will…I encourage him to work, work on something he
really wants to do. Instead of just the average… stayin’ around, sittin’ around the house
all day.” This insight and support from members who are struggling with their own
illness hearten consumers to work towards their own goals.
Support from family
Lauren stated that thinking about her children helps her to put things in
perspective and have hope especially when she is having a bad time. “They definitely
bring me hope…They’ve been times when I’ve been suicidal and the first thing that I
think about are my children… There have been times that I really felt like ending it, but
because they’re here…there’s no way! They encourage me to not give up hope. They
are my hope. My children are my hope and my joy.” James shook his head in
admiration as he stated, “my stepmother has been there for me through all the difficulty
and headache I put her through…she’s amazing!” For Chris, his family’s
encouragement and praise lifted his mood and hope for the future. “They call me, they
65
say they love me.… They're always behind me doing somethin’ good… They
commemorate me when I do something good.”
Distinct Sources of Hope for Each Group
Spirituality and encouragement from others were common elements that inspired
hope for participants in both groups. However, there were also different sources of hope
for each group.
Positive results of medication and new adaptive coping skills
Noticing the positive effects of psychiatric medication and learning various coping
skills from other members, particularly those who have been enrolled for a longer period,
was an incentive to keep taking the medication, which in turn was a source of hope and
pursue goals for participants in Group 1. Consumers in both groups generally appeared
to eventually learn, through therapy and discussions with their providers as well as from
other long-term members, about how to cope with the occasional dips in moods and
engage in self-talk to reinforce the importance of continuing to take their medication.
Lauren stated, “I tell myself that…it’s working, you know, things may not be rosy but in
comparison to the way I was feeling before prior to taking the medication, I know that
there’s a definite change…in my mood, in my…it’s gradual, but it’s consistent.”
Similarly, Eric noted, “I know that nothing bad is gonna last forever. And it's gonna pass.
Before I used to say, ‘Why the hell are you telling me that?’ Staff would tell me, ‘It's
gonna pass.’ Even for variety they say ‘One day at a time. Take little baby steps.’
That's what I do. You know, I'm learning a lot. I'm in recovery. I know a lot of those
things are true. And I just try to say, ‘It’s gonna pass. It’s gonna pass.’ So, you know, I'm
getting there.” Donna stated, “if my symptoms act up, I will either remind myself that it’s
temporary and think about the good days I’ve had….I also talk with my casemanagers or
talk about it with the other members or call my family to get support.”
66
Although Steven, also a participant in Group 1, continues to have symptoms, his
medications and the cognitive behavioral therapy have helped him to direct his attention
elsewhere. “Yeah, I still got them but I don’t focus… I don’t focus to the voice. I listen.
But sometimes…I try to ignore them. But right now, I do much better. Because if I take
the medication… I don’t got that kinda delusional thinking.” These new coping skills
have allowed him to have a different perspective on his illness so that he can engage in
other important activities such as work and relationships. Chris stated that on the days
he hears voices, “if distracting myself doesn’t work, I will shift gears and pace myself. It
used to frustrate me that I have to slow down but I know that slowing down is good in the
long-term…luckily, I don’t have to do it often.”
Other members’ success
Individuals in Group 1 stated that seeing other members successfully pursuing
goals gave them hope for the prospect of achieving their own goals. “I know that they’ve
been there…a lot of them have. And I can see that they are no longer in the place that
I’m in so it gives me hope…Second of all, I believe that whatever tools that are working
from them, maybe not all of them, but some of them could work for me. So it’s important
to me that I take their suggestions.” The possibility of change and of an optimistic future
was demonstrated to be important for these participants.
Accomplish goals
Successfully achieving goals was a source for hope for Group 2. All five were
either working or in school, and all either had independent housing or were in the
process of obtaining such housing. For these consumers, simply engaging in their
pursuits gave them hope. Donna works part-time as a receptionist at Portals and states,
“having a regular job that I enjoy gives me something to look forward to and makes me
feel good about myself and how I help other people.” James was a medical radiation
67
therapist several years before his illness worsened and was hospitalized a number of
times. He recalled being fairly hopeless when he enrolled at Portals but “but with my
job, it’s really built up my self-confidence and I’m more outgoing now…I’ve got more of a
positive attitude….I became a lot more hopeful after I got my job.” Melissa recalled
feeling ashamed of herself for dropping out of the program but “when they gave me my
job back and allowed me to participate in the different groups, that was somethin’! I
wouldn’t have been surprised if they kicked me out but instead, they gave me my job
back…that instilled a lot of confidence in me!”
These distinct sources of hope, along with the aforementioned influence of
spirituality and positive encouragement from others, were vital in consumers’ desires to
pursue goals.
Goals
All participants indicated similar goals, which included ongoing medication
regimen, using adaptive coping skills, living independently, going to school to gain
additional skills or earn a college degree, obtaining and maintaining a satisfying job,
having intimate relationships, and finding meaning and purpose in life.
Maintaining medication treatment
Continuing to take their medication was a goal for many participants in both
groups. As Olivia mentioned, “learning how to take care of myself and be responsible
for myself, [and being] medication compliant is one of my goals…I have to remember to
take my medicine. No matter how good I feel.” Hannah stated, “my medication, my
life…but I have to take the medication” and James noted, “It’s really working for me…I’ve
been stabilized for the past four years on this medication” about their respective
medication. Lauren asserted, “I tell myself that…it’s working, you know, things may not
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be rosy but in comparison to the way I was feeling before prior to taking the medication, I
know that there’s a definite change…in my mood, in my…it’s gradual, but it’s consistent.”
Work, school, and live independently
Instead of focusing primarily on ways to reduce their symptoms, participants
across the board wanted providers to assist them in finding a job, going back to school,
living independently and having close relationships. For example, James stated, “I’ve
been working part-time at The Clubhouse but my casemanager helped me get into
school.” Chris, who had been enrolled at Portals for three years, has been living
independently and taking classes at the local community college towards obtaining a
career that incorporates computers and music. He also yearns “to get married and have
a kid of my own.”
Find meaning and purpose
Common to all of the participants was their wish to have meaning in their lives
and participate in society. Lauren stated, “My long-term goals would be to… become
self-supporting, through my own contributions…and to find meaning and purpose in my
life, and…to have some independent living…experience, so I’m going to try to get into
school… and I’m gonna be majoring in psychology.” Chris added, “I want to do
something that’s important not just for me but for other people…I want to make a
difference.”
Another meaningful aspiration that many participants voiced was their wish to
“give back” to Portals by volunteering or working in some capacity at the program. As
Eric noted, “I want to give back what Portals gave to me. It’s like the saying, ‘What was
freely given to me is to give back to others.’…I plan on working in this organization.”
Lauren also wanted to use her experience to support other members. “I’d like to
advocate that there is hope and that it’s possible.”
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Acceptance of illness
Acceptance of the reality of their illness, including the necessity of long-term
medication use, and learning how to cope with the lingering symptoms and side effects
of their medications were essential in seeking and accomplishing goals. Olivia stated,
“You know, it's just something that I have, and I have to accept the fact that I have the
disorder, I have a mental illness, and do something about it.” Chris’s symptoms have
made it difficult for him to work or go to school full-time. His limitations used to depress
him but over time, he came to accept his circumstance. “If I work around it, not rely on it,
or start becoming down about it, I just try to keep pushing to do everything I can...Just
always think positive things, even around negative people…I’ve just accepted it. I know
that, I'll recover it one day.”
Differences between Group 1 and Group 2 on Goals
Group 1 wanted their providers to take an active supportive role in setting tasks
and goals, and taking small steps towards completing tasks and attaining goals. Lauren
stated, “they hold your hand. I’ve had staff members go with me to the campus…I’ve had
staff members go to court with me.” Eric echoed Olivia’s comment asserting, “I’m
lucky…sometimes, when I have a bad day or I need help with something that may not
seem so hard, my providers are there to listen and help me.”
Conversely, Group 2 wanted to be independent and appreciated their providers’
support, positive attitude, and honest feedback, especially if they had concerns. Chris
stated, “If I have a goal, we’ll sit down and talk about it, like exactly how I should play
into my life….planning [it] out, and I go back and they see that I'm on that goal… and I'm
doing what I need to do… and they encourage me like, ‘Good job! Keep it up! Keep
going!’” Accomplishing several goals over time helped the long-term participants to be
self-directed and assertive without the active help of their providers. Chris stated, “I
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have the desire to succeed. I don’t want just be out there… I want to be doing
something productive that's good for my life so I could start a family.” James felt
empowered by the responsibility his provider on him. “He puts a lot of responsibility on
me like for outings and stuff because he says he knows I can do it. So his faith in me
encourages me.”
Criticisms
Therapeutic alliance
The qualitative and quantitative interviews as well as informal conversations this
investigator had with other consumers in the waiting room consistently indicated that
negative interactions consumers experienced or observed with other consumers and
providers also impacted how a consumer experienced hope.
Given that the quantitative results indicated that the individuals in Group 1 rated
the therapeutic alliance higher than Group 2, this topic was analyzed in the qualitative
data. Eric from Group 1 and Hannah and James from Group 2 spoke about their
disappointing experiences with their providers. Eric was frustrated when his providers
were switched several times and his new providers did not review his files before their
session. “That's what angers me…they keep switching me from therapist to therapist to
therapist. I’m gonna switch over again…That’s what bothers me… And if they are gonna
get me, read my files! Read my thing about therapy!”
Goals
Hannah, Chris, and James were let down with regard to their respective goals.
Hannah’s provider failed to complete her Section Eight housing application despite her
persistent request for help. “They kind of… ‘but you've been staying here for five years,’
they say.… They expect me to live like that.” One of Chris’ providers was blasé about
his pursuit of competitive employment with greater job satisfaction and upward mobility.
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“ I don’t want to bag groceries forever. I want to and I know I can do much more than
that!” He therefore took the initiative to further his goals by enrolling part-time at a
community college while working part-time at a music production office, which is one of
his passions. James stated that one of the providers at Portals did not think he could go
to school while he was working. He proved them wrong as he rearranged his schedule
to work in the morning and take a two-hour bus ride each way to attend school.
Although it was a demanding commitment, he was quite proud to report: “They didn’t
think I could do it but I’m making it happen!”
No education about diagnoses or medication
Participants in both groups stated that they could approach their casemanagers,
therapists, and psychiatrists about difficulties with their medications and to request
possible adjustments, however their providers did not educate them about their
diagnosis or medications. Members noticed the positive effects of the medications but
many speculated about why they were prescribed the particular medications. Hannah
stated, “I don’t know why he put me on those medications.” Consumers often denied
receiving information about their respective diagnosis or what specific symptoms their
medications relieved.
As mentioned above, thematic and transcript analysis of the qualitative interviews
revealed similar and different themes that resonate with the recovery literature. Open-
ended interviews discovered that providers who were trusting, respectful,
compassionate, and consumer-focused paved the way for a collaborative working
alliance with their consumers. All participants in the qualitative study expressed the
same goals: to go to school, get a job, and live independently. However, individuals who
had been enrolled in the community-based psychosocial rehabilitation program less than
three months had a more tenuous self-concept than the participants who had been
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enrolled more than three months. The longer-term participants also had a stronger
positive self-concept and were more self-directive with their goal pursuits.
Narratives also uncovered the importance of the working alliance in encouraging
hope. This hope was also promoted by spiritual beliefs and support from others
including consumers and family. Participants emphasized that the hope fostered
through hope was critical in inspiring them to increase their self-concept, which in turn
motivated them to pursue more challenging goals.
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Chapter V: Discussion
Substantial evidence exists regarding the positive relationship between working
alliance and outcomes (Chinman et al. 2000; Donnell et al., 2004; Horvath & Greenberg,
1989; Howgego et al., 2003; Johansson & Eklund, 2003; Martin et al., 2000; Solomon et
al., 1995; Torgalsboen, 2001) as well as among hope and outcomes (Corrigan et al.,
2004; Donnell et al., 2004; Russinova et al., 2002; Snyder et al., 2002; Torgalsboen,
2001; Yip, 2004) for persons with schizophrenia. Findings from the present study
extended this body of research by examining whether hope mediates the relationship
between working alliance and psychosocial functioning. The study also investigated if
the relationship from working alliance to hope to psychosocial functioning is moderated
by the length of attendance (less / more than three months) for individuals with
schizophrenia participating in a community-based psychosocial rehabilitation program in
Los Angeles. The study used a mixed methods sequential explanatory design
exemplified by the collection and analysis of quantitative data followed by the collection
and analysis of qualitative data, which were subsequently integrated and interpreted
collectively (Creswell et al., 2003). The statistical results from the primarily quantitative
phase was subsequently enhanced by the qualitative phase to understand the factors
that lead to the formation and continuation of a working alliance, the techniques and
resources that promote and sustain hope, and the factors that affect psychosocial
functioning (Creswell et al. 2003; Hanson et al., 2005).
Powerful multivariate statistical techniques like structural equation modeling allow
researchers to investigate the relationship between abstract constructs using a variety of
statistical methods. On the other hand, narratives and subjective experiences that
qualitative researchers consider are also important elements in developing theory and
recovery-oriented interventions. When quantitative and qualitative data are combined in
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a study, results are enhanced to counterbalance the limitations found in each method
and make interpretations that goes beyond what the quantitative and qualitative
components can explain alone (Brewer & Hunter, 1989; Greene et al., 1989; Hanson et
al., 2005; Office of Behavioral and Social Sciences Research, 2001; Tashakkori &
Teddlie, 1998).
Complementing quantitative studies with qualitative research concurs with the
National Institutes of Health: “Qualitative studies may ask broad, open-ended, and
interconnected questions that are not always specifiable as conventional hypotheses”
(Office of Behavioral and Social Sciences Research, 2001). Within the recovery
movement, narratives have complemented traditional quantitative research, allowing
clients to talk about the complex experiences with mental illness and recovery (Davidson
et al. 2005). As mentioned before, many individuals with schizophrenia experience
negative attitudes, bias, and stigma oftentimes by the general public and sometimes by
mental health providers. Giving them the undivided attention and opportunity to re-
author their experience in their own voice is a pivotal aspect of recovery and “perhaps
the primary mechanism of personal growth” (Onken et al., 2007, p. 13). The consumers’
meaningful participation as experts in this experiential process not only empowers
consumers but also makes sure the research project advances the recovery and
rehabilitation principles and the study aims and outcomes genuinely reflect client
perspectives (Linhorst, 2006; Stanhope & Solomon, 2008).
Findings from the Quantitative Study
Structural equation modeling (SEM) with latent variables (Bentler, 1995; Kline,
2005; Loehlin, 1992; Roseman, 1984) was used to examine the study hypotheses
including the empirical relationship between working alliance, hope, and psychosocial
functioning, along with the mediation and moderation hypotheses. The paths from
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working alliance to hope and from hope to psychosocial functioning were statistically
significant in the predicted direction, establishing a critical relationship that has not yet
been examined for individuals with schizophrenia participating in a community-based
psychosocial rehabilitation program. Results of the mediation analysis established a
trend for consumer hope as a mediator in the relationship between consumer working
alliance and psychosocial functioning. This trend towards mediation was evidenced by
the statistical significance at the one-tail level of the indirect path from working alliance
through hope to functional outcome. This suggests that working alliance influences
psychosocial functioning through its relationship with hope, and that hope is an important
mechanism for explaining the relationship between working alliance and psychosocial
functioning. Regarding the third hypothesized model, the length of attendance did not
moderate the relationship between working alliance, hope, and psychosocial functioning.
Thus, no difference was found between Group 1 and Group 2.
Findings from the Qualitative Study
All ten open-ended interviews were audiotaped and transcribed verbatim within
one week of the interview. Textual coding and thematic analysis of the interviews were
analyzed following the standard procedures of qualitative research that includes “coding,
consensus, co-occurrence, and comparison” (Willms et al., 1992) using Atlas ti (version
5.0., Muhr, 1997). The mediation trend located in the quantitative analysis was clarified
in the qualitative interviews, which unambiguously found that the power of hope was
generated by spirituality and positive encouragement from other people.
Historically, psychotherapeutic approaches have not been carefully studied with
individuals who have a severe and persistent mental illness because of the presumption
among mental health providers that these individuals are unable to collaborate in a
therapeutic relationship (Repper, 2002). Contrary to this assumption, participants in this
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study did not appear to have a difficult time forming an alliance with their providers
regardless of their demographic characteristics and symptom levels. This finding is
consistent with other, similar, research (Frank & Gunderson, 1990).
The results of the qualitative study were also consistent with recovery literature,
in that they emphasized the importance of the working alliance in fostering hope and
supporting collaboration between the consumer and provider towards success in
satisfying consumers’ personally meaningful goals (Anthony et al., 2003; Department of
Health and Human Services, 2003; Frank & Gunderson, 1990; Martin et al. 2000;
Stanhope & Solomon, 2008). Attainment of these goals inspired individuals to develop a
positive self-concept, which in turn motivated them to pursue more challenging goals.
Similarly, the hope fostered through working alliance is also strengthened and increased
though success.
Working Alliance
Recovery is best attained through an encouraging and positive relationship
focused on goal-setting (Townsend et al., 1999). Participants in this study expressed
great appreciation for the services they received. Interviewees trusted and felt a sense
of connection with providers who were present, non-judgmental, warm, supportive,
trustworthy, committed, dependable, approachable, and human. This reliance and
confidence also helped consumers to feel comfortable approaching their providers with
their concerns regarding the effects of their medication.
Self-Concept
Psychotherapy researchers (Bruck et al., 2006; Henry & Strupp, 1994) have
established how process factors such as alliance, relationship, and therapy influence an
individual’s self-concept. As mentioned in chapter two, individuals with severe and
persistent mental illness experience discrimination and stigmatization by the general
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public and providers alike (Corrigan et al., 2004; McReynolds & Garske, 2003; Wahl,
1999). These negative attitudes may: (i) prompt providers to commit confirmation bias,
(ii) give rise to the tendency by individuals to search for or interpret information in a way
that confirms that individual's biases and presumptions and/or (iii) cause a person to
ignore or avoid information and explanation inconsistent with that person’s beliefs
(Rosenhan, 1973). Actual and perceived stigma may also lead individuals with
schizophrenia to develop a negative self-concept (Camp et al., 2002). However, the
empathic attunement that providers have with their consumers can undo the negative
internalizations consumers have of themselves (Bradshaw, 1998; Seligman, 1995).
Consistent with other recovery research (Davidson, 2003), both study groups (Group 1 =
less than three months; Group 2 = more than three months) confirmed this finding as the
participants frequently noted that providers’ encouragement and involvement in
treatment planning increased their self-esteem, self-efficacy, and motivation to pursue
their goals.
Bandura (1994) theorized that perceived self-efficacy, defined as the belief that
one has the ability to perform a behavior or task, can affect choices, goals, level of
motivation, quality of functioning, resilience to difficulties, and vulnerability to stress.
When individuals are unsuccessful at attaining a goal, some become less certain of their
sense of self-efficacy and lower their personal standards and goals, whereas others
continue to be positive and persevere in spite of the setback. Those who are less self-
efficacious self-doubt and dwell on the risks and difficulties, while those who are highly
self-efficacious set challenging goals and maintain a strong commitment to them
(Bandura & Cervone, 1986; Krueger & Dickson, 1993, 1994). Highly self-efficacious
people tend to ascribe failures to insufficient effort, perseverance, knowledge, or skills,
each of which can be improved through additional effort. They are more likely to handle
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difficult circumstances with self-confidence and conviction. Such resiliency and efficacy
maintains the consumer’s self-assurance when pursuing subsequent goals and
promotes intrinsic motivation. Further, appraisal of what must be learned to accomplish
the next challenging goal motivates highly self-efficacious individuals to gather the
personal resources required for success (Bandura, 1994).
Group 1 continued to have a somewhat tenuous self-concept, but participants in
Group 2, who had been enrolled in the program for considerably longer than three
months, had developed and sustained a positive self-concept. Building a positive self-
schema is critical in the initial phase of treatment as it allows for other positive outcomes
to follow. Teaching low self-efficacious students to establish proximal goals increases
their self-efficacy, academic achievement, and intrinsic interest in the subject (Bandura &
Schunk, 1991). Participants in Group 1 noted feeling better about themselves and
having more confidence because of the encouragement they received from providers
and other members.
Bandura (1994) theorized four ways to increase an individual’s self-efficacy;
social persuasion, physiological feelings, modeling, and mastery experiences. Social
persuasion bolsters one’s beliefs in his/her ability to succeed and may enhance his/her
efforts to accomplish the goal and sustain the confidence. Correspondingly, praise
builds one’s self-esteem, confidence, and self-efficacy (Lucas, 1990). How a person
perceives the physiological feelings that arise when pursuing a goal (e.g. anxiety, fear)
can also affect his/her self-efficacy. Furthermore, seeing other people similar to oneself
persevere and achieve their own personal goals increases the belief that the observer
may also have the capacity to succeed. Individuals seek capable and successful
models as standards by which to compare their own abilities. The aforementioned
models transfer their knowledge and teach the observer effective ways to manage and
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cope with various problems related to their illness. Finally, mastery experiences,
considered to be critical aspects of recovery (Davidson, 2003), have been noted as the
most powerful source of self-efficacy (Bandura, 1994).
Group 1 and Group 2 both asserted that the encouragement and enthusiasm
they received from the various people in their lives was vital in building a positive self-
concept. Moreover, noticing the positive effects of medication, learning healthy coping
skills, and witnessing other members successfully pursuing and achieving goals inspired
prospects for the future and cultivated positive self-esteem, self-efficacy, self-confidence,
motivation, and hope especially for Group 1. Consumers valued the encouragement
they received from other members to continue taking the medication despite the difficult
side-effects and some lingering symptoms. Advice on different ways to cope and
manage the side-effects and/or persistent symptoms was also appreciated.
Coping skills allow one to function in different spheres despite various difficult
symptoms, medication side-effects, and other life hurdles. Recovering from a mental
illness involves the development of coping skills and the ability to realize when to access
various resources, including formal and informal services as well as engaging in
adaptive personal interests (Curtis, 1997; Williams & Collins, 1999). The accessibility of
support in eliciting and utilizing coping techniques demonstrates the vital role
environment plays in fostering recovery and rehabilitation (Onken et al., 2002).
Research has also demonstrated that students with high academic efficacy
demonstrate greater determination, effort, and intrinsic curiosity in their educational
learning and performance (Schunk, 1989a, 1989b). In addition, perception of self-
efficacy predicts work choices (Lent et al., 1987; Lent et al., 1993). For individuals in
Group 2, accomplishing goals increasingly strengthened their evaluations of themselves
and their belief in their efficacy. This study found that the development of a positive self-
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concept kindled their venture towards their goals and various activities including work
and relationships, which was propelled by hope.
Sources of Hope
Hope’s critical influence in the relationship of alliance and outcome was made
clear in the qualitative interviews. Participants in the qualitative study corroborated other
studies (Herth, 1993; Miller, 2007; O’Neill & Kenny, 1998; Kylma & Vehviläinen-
Julkunen, 1997; Mickley et al, 1992) that underscored the import of spiritual and religious
practices, including a belief in a higher power, in nurturing and maintaining hope.
Spirituality is central in recovery from mental illness and infusing meaning and purpose
(Corrigan & Ralph, 2004; Sullivan, 1994). Analogous to many investigations (Anthony,
1993; Cutcliffe, 2004; Deegan, 1996; Herth, 2000; Kikpatrick et al., 1995; Lord &
Hutchison, 1997; McCann, 2003; Oades et al., 2004; Shorey et al., 2003; Turner &
Stokes, 2006), positive, supportive, and trusting relationships with fellow members,
family, providers, and other people were also vital in fostering and maintaining hope.
Moreover, hope was stimulated when consumers were given autonomy and control
through treatment planning, decision-making, and goal-setting (Kelly & Gamble, 2005;
Kirkpatrick et al., 1995; McCann, 2002; Oades et al., 2005; Stanhope & Solomon, 2008).
Consistent with the recovery literature, Group 1 and Group 2 both regarded the
encouragement and support provided by the various people in their lives, not just their
providers, as invaluable (Corrigan et al., 2004; Donnell et al., 2004; Moore, 2005;
Russinova, 1999; Snyder et al., 2002; Torgalsboen, 2001; Yip, 2004). Particularly for
Group 1, fellow members’ and providers’ ability to be heartening, cheering, and active in
setting goals was crucial in promoting hope. Recovery advocates maintain that
consumers may rely on peer-based models or their own personal support in addition to
their mental health providers. Experienced consumers may serve as paraprofessionals
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by advocating and teaching other consumers through the recovery and rehabilitation
process (Mead & Copeland, 2000; Ralph, 2000).
Goals
Participants in both groups stated their annoyance regarding their medication’s
frequent unwanted side-effects and inability to completely eliminate difficult symptoms.
Each of the interviewees described many instances when the interviewee did not want to
take the medication or times when the interviewee discontinued or adjusted the dosage
on his/her own.
Mental health providers, especially psychiatrists who use the medical model,
usually focus on ameliorating consumers’ symptoms and underestimate other quality of
life and recovery realms such as work, independent living, and social relationships
(Kravetz et al., 2002). Reduction of symptoms was certainly an important priority for all
the participants in the initial treatment phase. However, participants noted that once
they accepted their illness and the reality of their daily medication regimen, they focused
more on the positive effects of the medications.
After their medication was adjusted, their condition stabilized, and their
symptoms decreased, all of the participants in the qualitative study, like individuals with
schizophrenia in other studies, yearned to have equal opportunities to pursue various
activities and reintegrate into the community. They held the same goals to engage in
meaningful activities; to live independently, to return to school to gain skills or a degree,
find employment, and have more companionship as persons without schizophrenia
(Corrigan, 2003; Deegan, 1992; Kelly & Gamble, 2005; Kravetz et al., 2002; Lehman,
1988; Department of Health and Human Services, 2003; Onken et al., 2002; Repper &
Perkins, 2003; Skantze et al., 1992; Townsend et al., 1999).
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The recovery paradigm encourages individuals with severe and persistent mental
illness to pursue and engage in activities of interest, such as going to school, working,
participating in hobbies, and having close companionships, in order to live a satisfying
and productive life in spite of their mental illness (Andreasen et al., 2003; Department of
Health and Human Services, 2005; Department of Health and Human Services, 2003;
Onken et al., 2002; Ridgway, 2001; Townsend et al., 1999; Young & Ensing, 1999). The
aim of recovery is to encourage individuals to fully reintegrate and participate in the
community by developing strengths (Harding, 1994; Department of Health and Human
Services, 2003; Mead & Copeland, 2000; Rowe, 1999; Onken et al., 2002).
The first step in the recovery process is acceptance of the illness. Accepting the
illness for persons with schizophrenia requires a redefinition of how they understand and
view their circumstances and difficulties rather than assuming the identity of a “mentally
ill person.” Accepting the illness is frequently mentioned as the first step in the recovery
framework (Anthony, 2003; Deegan, 1988). As Deegan (1988) noted, “in accepting what
we cannot do or be, we begin to discover who we can be and what we can do” (p.15).
Furthermore, individuals in recovery must also embrace the notion that they are capable
of changing their circumstances and achieving their aspirations by taking responsibility
and engaging in treatment planning (Andreasen et al., 2005; Cook & Jonikas, 2002;
Farkas et al., 2005; Jacobson & Greenley, 2001; Onken et al., 2002). However, the
course of recovery is different for each person and recovery is not a linear process; each
person moves at his/her own pace through the challenges that are brought on by their
illness and/or life circumstance (Bellack, 2006; Cook et al., 2005).
In this study, participants stated that they met with their providers regularly to
collaborate on goals. Individuals in Group 1 spoke about setting and attaining basic
goals such as continuing to take their medication, attending and participating in the
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therapy groups, and completing their activities of daily living. Participants in Group 2
stated that while their providers were always supportive and encouraging about their
goals, their providers were somewhat passive in this process. Group 2 noted that their
providers were not inclined to challenge them with more difficult tasks and goals or
strongly encourage consumers to further pursue challenging goals. Thus, participants
noted that they initiated and expressed their aspirations on their own and pursued them
regardless of their providers’ support. Mental health providers tend to restrain their
encouragement for consumers to work because of their concern that the resultant stress
may lead individuals with schizophrenia to relapse (Baron & Salzer, 2000; Gioia, 2006;
Rutman, 1994). Despite this apprehension, studies have found that individuals with
schizophrenia have the capacity to maintain competitive employment for an extended
period of time (Bond, 2004; Russinova et al., 2002; Russinova et al., 2007).
Self-determination theorists hypothesize that intrinsic motivation may be
promoted in rehabilitative milieus where an individuals’ basic psychological need for
autonomy (i.e., to have input in determining one’s own behavior), competence (i.e., to
experience productivity and to control outcomes), and relatedness (i.e., to be related to
or care for others) (Deci & Ryan, 1985; Vallerand, 1997 for a review) are met. Social
contexts and preexisting individual differences affect people’s intrinsic need for
satisfaction, motivation, and performance. One social-contextual factor that has been
researched extensively is autonomy support (Deci & Ryan, 1987). Employment and
educational research has demonstrated that autonomy-supportive contexts promote self-
motivation (Deci et al., 1981; Grolnick & Ryan, 1989), satisfaction (Deci et al., 1989), and
performance in various settings (Benware & Deci, 1984; Koestner et al., 1984).
Autonomy support requires the supervisor or teacher to understand and acknowledge
the supervisee or student’s perspective and provide meaningful information in a manner
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that is not exploitive or disrespectful by offering opportunities for choice, and
encouraging self-initiation (Deci et al., 1994). Research has also shown that a teacher's
expectations have a powerful impact on a student's performance. Such expectations
must be appropriate, however. So as to avoid overwhelming the student, teachers must
gradually increase the difficulty level as the student accomplishes various goals
(American Psychological Association, 1992; Forsyth and McMillan, 1991; Lowman,
1984). The same logic holds true for the relationship between a supervisor and an
employee (Baard et al., 2006; Gagne & Deci, 2005; Kuvaas, 2009; Morris, 2007). As
with supervisors and teachers, mental health providers are in a prime position to
enhance an individual’s intrinsic motivation to facilitate successful outcomes.
Recovery and rehabilitation advocates assert that successful services begin with
an assessment of consumers’ personally meaningful goals (Anthony & Liberman, 1992;
Bachrach, 1992; Gingerich & Mueser, 2005; Mosher & Burti, 1992). Providers must also
consider the individuals’ characteristics and interests that may motivate or discourage an
individual to pursue a particular goal (Anthony et al., 2003). Given that unexpected
events occur and treatment goals change over the course of treatment, providers must
re-evaluate goals and continually make certain the goals are challenging enough for the
individual, yet not overwhelming. Some consumers who are overwhelmed with their
psychotic symptoms or lack coping and social skills may not be ready to work. Providers
must assist these individuals to find other rehabilitative activities until they are ready to
work.
The recovery framework is a completely consumer-driven practice where the
provider assists the consumer in determining the goals that interest him/her and
considering the pros and cons of those goals (Davidson, 2003; Glynn et al., 2006).
Providers are in a powerful position to encourage and discourage consumers from
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pursuing their goals and therefore, they must be aware of their bias, judgments, and
presumptions so that the provider does not dishearten or impose their views onto a
consumer who is trying to attain a realistic yet challenging goal.
Alliance Varies Over Time
Investigators disagree about the pattern of alliance development. Some assert
that alliance is initially high, weakens in the middle phase of therapy, and increases
again to high levels after successful therapeutic outcomes (Gelso & Carter, 1994;
Horvath & Luborsky, 1993). Others suggest that the level of alliance increases or
remains stable over time (Horvath & Greenberg, 1994). Most researchers view the
alliance to be dynamic and expect it to vary to some extent throughout treatment,
possibly on a weekly basis, depending on the phase of therapy or what occurs during a
particular session (Bachelor & Salame, 2000; Luborsky, 1976; Martin et al., 2000).
Therefore, single assessments of participants’ alliance ratings will not represent their
perceptions throughout the course of treatment, although certain perceptions may
endure for a long time.
Participants in both study groups had uniformly high alliance ratings, although
Group 1 had higher alliance scores than Group 2. Group 1 may have rated alliance
higher because they had not yet been challenged on their maladaptive patterns or had
not experienced or observed any negative interactions with providers, events already
experienced by members of Group 2. Results of the interview also demonstrated that
perceptions of alliance can vary within individual narratives: participants in the qualitative
phase sometimes reported positive opinions about their providers moments after voicing
their negative experiences.
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Lack of Education about Diagnoses or Medications
Psychoeducation about diagnosis and medications, including the provision of
information about the benefits and side-effects of medication, is central to the notion of
informed consent and vital in the rehabilitation and recovery process. Knowledge of the
illness, medications, and coping skills inspires persons with schizophrenia to regain
control and create a less hierarchical relationship with their providers in order to be
involved and make informed decisions about their own treatment (Charles et al., 1997;
Hamann et al., 2003; Mueser et al., 2004; National Institute for Clinical Excellence,
2002). Mueser and his colleagues’ (2004) research on illness management found that
“psychoeducation improves people’s knowledge of mental illness, behavioral tailoring
helps people take medication as prescribed, relapse prevention programs reduce
symptom relapses and rehospitalization, and coping skills training using cognitive
behavioral techniques reduces the severity and distress of persistent symptoms” (p.34).
Refinement of the Mediation Model
The quantitative results for this study were the first to demonstrate a relationship
between working alliance and hope as well as between hope and psychosocial
functioning. The qualitative findings provide several directions toward the refinement of
the meditation model. Interviews revealed that a positive working alliance increases
self-esteem, particularly during the period upon initial enrollment to the program. The
mediation model may be re-specified to examine if self-esteem mediates the relationship
between alliance and hope, and if this is moderated by length of attendance (less / more
than three months).
Spirituality and the encouragement from various people in their lives to influence
and maintain hope were underscored in the interviews. Mediation models may be
improved to evaluate if spirituality or multidimensional social support that includes
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emotional, instrumental, tangible, and informational support mediates the relationship
between hope and functional outcome. A moderated meditation model may also be
hypothesized to assess if spirituality mediates the relationship between hope and
functional outcome, and if this relationship is moderated by the level of social support.
Another finding from the qualitative interviews was the complicated relationship
between hope, self-esteem, motivation and work. Refinement of the mediation model
may examine if self-esteem or motivation mediates the relationship between hope and
functional outcome. Alternatively, it is worth evaluating if work mediates the relationship
between hope and self-esteem or hope and motivation.
Conclusion
The present study has several implications for clinical practice, policy resolutions,
and future directions. This study is the first to examine the relationship between working
alliance, hope, and psychosocial functioning for individuals participating in a community-
based psychosocial rehabilitation program. The study’s findings revealed a statistically
significant association between working alliance and hope as well as among hope and
psychosocial functioning. This study demonstrated that trusting, encouraging, and
collaborative relationships are imperative for individuals with schizophrenia to build
hope, which subsequently fosters a positive self-concept. Furthermore, hope was found
to positively influence psychosocial functioning. The development of hope influenced
individuals to gradually accomplish various goals.
The second critical finding from this study was the statistically significant one-
tailed mediation results that indicated a trend for hope to be the mechanism through
which working alliance affects psychosocial functioning. This trend was substantiated in
the qualitative phase. Participants noted that the relationship between consumer
working alliance and psychosocial functioning was driven by hope, which was influenced
88
by spiritual and religious beliefs, encouragement from others, improvement of self-
concept, and successful attainment of goals. This suggests that treatment must be
modified towards enhancing an individual’s hope.
The hypothesis that the mediation relationship from consumer working alliance to
hope to psychosocial functioning may be moderated by length of attendance (less / more
than three months) was rejected for this sample of persons with schizophrenia. This is
another important finding from this study which implies that hope’s effect between
working alliance and psychosocial functioning does not depend on an individual’s level
of attendance at the community-based psychosocial rehabilitation program.
The path from relationship to self-concept to hope to outcome may be virtuous or
vicious. In other words, a solid working alliance has the potential to improve how an
individual feels about him/herself. The encouragement and support an individual
receives from others positively influences his/her self-concept and hope. This
subsequently affects the accomplishment of goals, which again inspires hope.
Alternatively, a poor working alliance may worsen or reinforce a consumer’s negative
self-perceptions. The absence of sufficient praise and reinforcements may have a
destructive impact on an individual’s self-concept and hope, which may deter a
consumer from setting and pursuing a challenging goal. This may potentially decrease
his/her hope and self-concept.
Mental health providers thus have the ability to influence whether the sequence
becomes virtuous or vicious. They may well enhance an individual’s hope using the
techniques identified and developed by occupational therapists and teachers. Since
several studies have shown that actual, perceived, or anticipated failure may lead to
decreased feelings of power and effectiveness (Doble, 1988), it has been suggested that
individuals be assisted in getting over the hurdle of risk and potential failure by restoring
89
their belief in their own ability and develop their expectancies for success (Barris et al.,
1983). Individuals must be given choices, structuring the demands of the environment to
match the client’s feelings of effectiveness, making sure that the environment is
meaningful for the individual, and ensuring the individual experiences feelings of
personal control and competence (Doble, 1988; Kielhoftner & Burke, 1980).
Goal-setting, a collaborative process whereby the individual, the individual’s
family, and/or the rehabilitation team negotiate a set of shared goals, is a fundamental
component of any sound rehabilitation program (McPherson et al. 2001). An individual’s
active participation in their treatment and goal-setting is a key to accomplishing
treatment goals (Arnsten, 1990; Burke, 1977; Florey, 1969; Wu et al., 2000). “Meaning
comes from involvement in personally fulfilling goals, the integration of these goals into a
coherent self-system, and the integration of these goals into a broader social system”
(Emmons, 1996, p.333). Some of the aforementioned clinical approaches to increasing
motivation are part of how mental health professionals build a good working alliance with
individuals with schizophrenia (Donnell, 2004; Howgego et al., 2003; Penn et al., 2004;
Oades et al., 2005). As this study demonstrated however, fellow consumers or other
important people in a consumer’s life also have the potential to increase a positive self-
concept and stimulate hope to successfully reach goals. Spirituality also inspired hope to
pursue goal for this study’s sample. Accomplishing goals in turn inspired hope, causing
a reflexive association.
The goal of recovery for individuals with schizophrenia is to encourage them to
engage in activities of their interest and participate in the community (Department of
Health and Human Services, 2003; Onken et al. 20002). An important question raised
by this study for rehabilitation programs is to identify "active ingredients" or treatment
process variables that may be targets of intervention to increase self-efficacy,
90
motivation, and hope, which may ultimately promote successful psychosocial
functioning. On the other hand, studies that ascertain moderators that may specify for
whom and under what conditions an intervention works and help parse the sample to
uncover mediators may possibly lead to the development of treatments that are more
effective, efficient, and tailored to meet the specific needs of the individual. At a time of
fiscal constraints and increasing demands for accountability of outcomes, it is critical to
disseminate and implement empirically supported interventions. Delineating treatment
process predictors of hope and psychosocial functioning could provide relevant
information for improving the efficiency of rehabilitation programs. Understanding the
factors that mediate and moderate the relationship between different variables and
psychosocial functioning outcomes will have valuable implications for clinical practice
and the course of policy decisions.
Limitations
This study is not without limitations. Despite a large sample size, the ability to
draw inferences from these findings is limited in a few ways. The results of this study
can only be generalized to individuals with schizophrenia participating in community-
based psychosocial rehabilitation programs. In addition, the composition of the study
participants was mostly Caucasian and African American males so the results may not
be deduced to women or other race groups. This study also did not investigate how
ethnicity, gender, or other cultural factors may influence working alliance, hope, or
psychosocial functioning outcome.
Moreover, the impact of similarities and differences in personality characteristics
between consumers and providers along with the providers’ experience level on the
strength of the working alliance were not examined. The study is also limited to
consumer reports of alliance and provider. Observer ratings of the alliance may
91
potentially clarify other aspects that are related to the development and strength of the
working alliance and outcome. Although this study stratified the sample based upon the
length of enrollment in the community-based psychosocial rehabilitation program, the
impact of the number of contacts on the study constructs was not evaluated.
The majority of the current sample had a high alliance rating which created
ceiling effects. Inferential statistics are based on the assumption of a normal distribution
in the variables involved. As a result, if there is a restriction of range in any one of the
main study variables, the magnitude of the correlation will be reduced. Restriction of
range also increases both the likelihood that treatment effects will not be identified and
the probability of rejecting the null hypotheses when it is actually true (Type II). The
relationship between WAI scores and RFS scores may have therefore been attenuated
by extreme ceiling effects and restriction of range in the WAI ratings.
The lack of follow-up assessment and cross-sectional design of this study cannot
confirm causality and associations may be due to another unmeasured factor.
Inferences about causality are often difficult to make in field research because of many
uncontrolled background sources of variance.
Future Direction
Additional studies may provide clearer explanations for the questions raised by
this study. The mediation model may be re-specified to examine if self-esteem mediates
the relationship between alliance and hope, and if this is moderated by length of
attendance. The mediation model may also be refined to evaluate if spirituality or social
support mediates the relationship between hope and functional outcome. A moderated
meditation model may also be hypothesized to assess if spirituality mediates the
relationship between hope and functional outcome, and if this relationship is moderated
by the level of social support. Another way the mediation model may be improved is to
92
examine if self-esteem or motivation mediates the relationship between hope and
functional outcome. Testing whether work mediates the relationship between hope and
self-esteem or hope and motivation will also provide valuable knowledge.
Future studies should include more diverse sub-samples to examine the effect of
gender, ethnicity, and other cultural factors. The providers’ gender has been
demonstrated to affect how providers respond to consumers (Lazaratou et al., 2006;
McCabe & Priebe, 2004; Thomas et al., 2005) and consequently outcomes (Stark et al.,
1992). Investigators should therefore attempt to investigate the influence of gender
matching between providers’ and consumers.
Empirical studies on ethnic matching are inconclusive and require advanced
research designs (Karlsson, 2005; Mramba & Hall, 2002). While some state that race is
associated with the strength of the alliance (Klinkenberg et al., 1998) and ethnic
matching makes consumers more comfortable (Casas et al., 2002; Coleman, Wampold,
Casali, 1995; Gelso & Mohr, 2001), others maintain that ethnic matching does not have
an effect on the working alliance (Erdur et al., 2000; Karlsson, 2005; Ricker, Nystul, &
Waldo, 1999; Vera, Speight, Mildner, & Carlson, 1999) and that ethnic minorities do not
achieve differential treatment outcomes when treated by Caucasian therapists (Sue,
1988). Rather than ethnicity in and of itself however, there is a stronger evidence in the
counseling literature which illustrates that clients place more emphasis on cultural
attitudes, values, self-identification, social class, cultural commitment, acculturation,
personality (e.g., Atkinson, Furlong, Poston, 1986), and the providers’ cultural sensitivity
or competence (Atkinson & Lowe, 1995; Constantine, 2002; Fuertes et al., 2001; Sue,
2003; Yamamoto et al., 1984). Nevertheless, it is not necessarily the case that
absolutely every patient belonging to an ethnic group would benefit from ethnically
matched psychotherapy.
93
Prospective work may also examine the length of therapy (Tryon et al., 2007),
the number of program contacts, and relationship history (Klinkenberg et al., 1998),
which have been found to be related to the strength of the alliance. Preexisting
characteristics of the consumer (Connolly Gibbons et al., 2003; Mallinckrodt, Coble, &
Grantt, 1995), pretreatment social adjustment (Marziali, 1984), pretreatment
symptomatology (Eatong et al., 1988) and pretreatment consumer defensiveness
(Gaston et al., 1988) have also been found to be partially related to alliance. The
therapists’ experience level (Tyron et al., 2007) and interactional styles during the
therapists’ treatment techniques (Frank et al., 1993) are also worth examining.
Investigators have demonstrated that less severe symptoms (Clarkin et al., 1987;
Frank & Gunderson, 1990; Neale & Rosenheck, 1995) and older age (Draine &
Solomon, 1996) positively influence the working alliance. Conversely, denial of illness,
stigma, degree of comfort in trusting others, hostility, paranoia, and other psychotic
symptoms (Constantino et al., 2002; Gunderson et al., 1997; Kokotovic & Tracey, 1990;
Mallinckrodt, 1991; Raue et al., 1993; Satterfield & Lyddon, 1995; Weiden & Havens,
1994) have been shown to impede the development of a positive working alliance.
In this qualitative study sample, Group 1 and Group 2 did not differ on symptom
levels and age. This suggests that findings were not related to levels of symptom and
age.
More examinations of how neurocognition associates with working alliance,
hope, and psychosocial functioning are also essential. Neurocognitive problems may
cause difficulties during interpersonal relationships (Addington & Addington, 1998;
Brekke et al., 1997) making it difficult to form a therapeutic alliance. Davis and Lysaker
(2004) also theorized that a consumer’s neurocognitive capabilities may have a distinct
effect on consumers’ and providers’ perceptions of the working alliance. Modeling the
94
longitudinal relationship between working alliance, hope, and psychosocial functioning
may produce clinically noteworthy insight into how to improve the alliance. The
examination of other potential mediators is critical. Factors such as motivation and
readiness to change (DiClemente et al., 2008; Hattema et al., 2005; Jones et al., 2005;
Zhang et al., 2006) as well as positive client expectancies (Calsyn et al., 2003; Joyce &
Piper, 1998) may possibly classify the mechanism through which working alliance leads
to psychosocial functioning outcome.
95
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Abstract (if available)

Abstract Despite progressive documentation of the effectiveness of community-based psychosocial rehabilitation programs, relatively little progress has been made during the past twenty years in delineating the treatment process variables related to successful psychosocial outcomes for persons with schizophrenia. Studies and narratives demonstrate that a strong working alliance is a prerequisite to treatment regardless of the type of therapy being provided. Moreover, the hope that individuals with schizophrenia derive through the consumer-provider relationship appears essential to achieving successful outcomes. Working alliance and hope are also highlighted as important elements in the current recovery and empowerment literature. Although often discussed singularly or in pairs, to date researchers have not examined the confluence of working alliance, hope, and psychosocial functioning with respect to persons with schizophrenia who are involved in community-based psychosocial rehabilitation programs.

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Asset Metadata

Creator Nakagami, Eri (author)

Core Title Working alliance, hope, and functional outcome for individuals with schizophrenia: mechanisms of influence

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/30/2010

Defense Date 03/04/2009

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag functional outcome,Hope,mixed methods,OAI-PMH Harvest,schizophrenia,treatment processes,working alliance

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Brekke, J. S. (committee chair), Neville-Jan, A. (committee member), Palinkas, L. A. (committee member)

Creator Email eri@nakagami.net,nakagami@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m2131

Unique identifier UC1235888

Identifier etd-Nakagami-2760 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-226690 (legacy record id),usctheses-m2131 (legacy record id)

Legacy Identifier etd-Nakagami-2760.pdf

Dmrecord 226690

Document Type Dissertation

Rights Nakagami, Eri

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu