key: cord-1004059-snyli53y
authors: Roebuck, Maryann; Aubry, Tim; Manoni-Millar, Stéphanie
title: A Qualitative Study of the Working Alliance in the Strengths Model of Case Management with People with Severe Mental Illness
date: 2021-10-20
journal: Community Ment Health J
DOI: 10.1007/s10597-021-00903-9
sha: d963b95478b68544062cece5b965ba2014011db8
doc_id: 1004059
cord_uid: snyli53y

The purpose of this study was to examine clients’ perceptions of the client-case manager working alliance in the context of receiving the Strengths Model of Case Management. Twenty people with severe mental illness, with a SMCM case manager, participated in semi-structured, qualitative interviews. Using first and second cycle coding, data were analyzed thematically. People in the study attributed personal life changes to their relationship with their case manager. They valued their case managers’ flexibility and highlighted their work on a wide range of goals of their choosing. Case managers approached the SMCM intervention responsive to their clients’ preferences and choices. The working alliance serves as a key element of the SMCM intervention. Clients describe the working alliance as helping to improve their lives. This study supports the implementation of SMCM with people with severe mental illness due to its focus on fostering a strong working alliance.

Researchers studying the working alliance in psychotherapy and case management explore what characteristics and actions of a support worker lead to a trusting bond with a client, and ultimately improvements in the lives of people with severe mental illness (De Leeuw et al., 2012; Farrelly & Lester, 2014; Fluckiger et al., 2018; Kidd et al., 2017; Webb et al., 2010) . The definition of the working alliance is conceptualized as the bond between a client and mental health service provider (e.g., psychotherapist, case manager) and the degree to which the client and worker agree on the goals of the intervention and the tasks needed to work towards those goals (Bordin, 1979; Horvath, 2018) .

While the working alliance in psychotherapy (usually referred to as the "therapeutic alliance") has been thoroughly researched with consistent positive results (Fluckiger et al., 2012 (Fluckiger et al., , 2018 Horvath, 2018; Wampold, 2015) , the evidence base of the working alliance in mental health case management interventions is small with more variable research methods than psychotherapy research (De Leeuw et al., 2012; Kidd et al., 2017; McCabe & Priebe, 2004) . Overall, mental health case management studies show a relationship between the working alliance and client outcomes, such as better functioning, lower depression, overall life satisfaction, and improved quality of life (Ashford et al., 2010; De Leeuw et al., 2012; Howgego et al., 2003; Kidd et al., 2017; Kondrat, 2012; Kondrat & Early, 2010; Latimer & Rabouin, 2011; McCabe & Priebe, 2004; Sandu et al., 2021; Tsai et al., 2013) . Some proposed underlying mechanisms of change within the working alliance include having clear goals, having small caseloads, affirming a person, mutual respect, adopting structured interventions, and being a responsive case manager (Baldwin et al., 2007; De Leeuw et al., 2012; Farrelly & Lester, 2014; Fluckiger et al., 2018; Kidd et al., 2017; Wampold, 2015) .

Research also shows that the working alliance in mental health case management may be different than the therapeutic alliance in psychotherapy. The community-based setting of mental health case management makes the practice more task-focused, and involves providing access to services and helping people to remain in the community (McCabe & Priebe, 2004) . Mental health case management also consists of several different approaches (e.g., Assertive Community Treatment, intensive case management [ICM] , standard case management, brokerage model, clinical case management) (Kidd et al., 2017; Latimer & Rabouin, 2011; McCabe & Priebe, 2004) . The working alliance is conceptualized differently (or not at all) under each approach. In a review of mental health case management research, Ponka et al. (2020) noted that few studies described the roles of case managers or mechanisms of success.

The Strengths Model of Case Management (SMCM) is a type of ICM for people with severe mental illness that is described in detail by its developers, unlike many other case management interventions (Latimer & Rabouin, 2011; Ponka et al., 2020; Rapp & Goscha, 2012) . When compared to broader ICM, SMCM is somewhat unique in that it focuses less on deficits and symptoms than other types of ICM, while leveraging strengths to accomplish clients' goals. SMCM has a low client-to-case manager ratio (15:1) and prioritizes connecting people with natural community resources rather than resources in the formal mental health system (Rapp & Goscha, 2012; Rapp & Sullivan, 2014) .

Strengths model case managers base their practice around six principles: (1) There is an overall focus on individual strengths rather than pathology or deficits; (2) The community is viewed as an oasis of resources; (3) Interventions are based on client self-determination; (4) The case managerclient relationship is primary and essential; (5) The primary setting for the work is in the community, not in an office; (6) People can recover, reclaim and transform their lives (Rapp & Goscha, 2012) . While other forms of case management may outline similar principles in their programs, SMCM has developed tools and a fidelity scale to organize the intervention, apply the principles to practice, and determine how closely local implementations follow the model.

The principles are implemented through the use of the SMCM tools: a Strengths Assessment, a Personal Recovery Plan (i.e. goal worksheet), structured group supervision, and individual supervision (Rapp & Goscha, 2012) . The Strengths Assessment is used to identify clients' personal attributes, goals, concrete skills and talents, and environmental resources (Rapp & Goscha, 2012) . Using the Personal Recovery Plan, the client and case manager break down goals into small, specific, measurable steps (Rapp & Goscha, 2012 ). The strengths model theory suggests that using SMCM principles and tools lead to client achievement of meaningful, individual goals.

The case manager's role is clearly defined in SMCM as being purposeful, reciprocal, and hope-inducing (Rapp & Goscha, 2012) . While the relationship is central, it is not intended to be long-term or to act as a permanent anchor in a person's life. The relationship is a "medium to achievement" (Rapp & Goscha, 2012, p. 71) . Within the strengths model, the case manager learns about the person's individual set of experiences through an openness to understanding and by laying aside their assumptions about specific diagnoses (Rapp & Goscha, 2012) . Every client-case manager meeting is framed around strengths, goals, and purpose (Rapp & Goscha, 2012) . According to the model framework, these interactions increase a person's self-efficacy, their perceptions of being able to move forward in life, and their confidence to act on options (Rapp & Goscha, 2012) .

This research is part of a larger study that examined the implementation of SMCM in seven community mental health organizations, located in three Canadian provinces (Ontario, Newfoundland, and Quebec) . From 2014 to 2017, the participating organizations implemented SMCM. Prior to implementation of SMCM, six of the organizations delivered other types of ICM. The seventh organization was already delivering SMCM. After 2017, six of seven organizations continued to implement SMCM but without measures of fidelity to the model. As part of the larger study, we found that higher fidelity to SMCM predicted stronger client-case manager working alliance, and stronger working alliance predicted improvements in clients' quality of life and hope outcomes (Roebuck, 2021) .

The purpose of this current study was to examine clients' perceptions of the client-case manager working alliance in SMCM. This study was intended to examine underlying mechanisms in the SMCM working alliance that might facilitate change in people's lives. The study also builds on the growing body of research on the working alliance in case management and previous SMCM research.

The following research questions were examined to further understand the working alliance in SMCM practice:

1. How do SMCM clients describe the working alliance with their SMCM case managers? 2. What are the underlying characteristics or key elements that comprise clients' descriptions of the working alliance with their SMCM case managers? 3. How do SMCM clients describe the role of the working alliance in leading to change in their own lives?

In the interviews conducted for this study, people were asked to describe the relationship they had with their case manager and what makes a good connection with them. For this reason, sometimes the terms "relationship" or "connection" are used in addition to "alliance" when reporting the results.

Study participants were from one of the organizations that participated in the larger SMCM study. As part of this study, the organization began to implement the SMCM intervention in 2014, under the guidance of University of Kansas SMCM trainers. The organization serves people with severe mental illness, with histories of homelessness and vulnerable housing. It provides a portfolio of programs, including ICM (using SMCM), housing supports based on the Housing First philosophy and practices, court outreach, and groups and supports for people with dual diagnoses (developmental disabilities) and comorbidity with substance use. Twenty SMCM clients were recruited for this study. Inclusion criteria for the study were that clients had been receiving SMCM at the organization for at least six months. To be eligible for case management services at the organization, people had to have been diagnosed with a severe and persistent mental illness (e.g., schizophrenia, major affective disorder) or display behaviours that would suggest a severe or persistent mental illness. They also had a history of vulnerable housing or homelessness and were 18 years of age or older.

The study was approved by the Health Sciences and Science Research Ethics Board at the University of Ottawa. Participants were recruited through case managers. Case managers were told that the researchers were hoping to recruit clients with whom they had weak or strong working relationships; however, we primarily received referrals of participants who had strong working relationships with their case managers. The primary researcher met with clients to explain the study, reviewed the consent form, and invited them to participate in an interview.

Each client participated in a qualitative, semi-structured interview that ranged in length from 30 min to 1 h. The interviews were conducted from February 2020 to August 2020. The first six interviews were completed in-person and the remaining 14 were conducted by phone, due to COVID-19 pandemic restrictions. Participants received an honorarium of $20 for participating. Interviews were audio recorded and transcribed verbatim.

The semi-structured interview protocol was developed based on a review of the working alliance, therapeutic alliance and SMCM literature, the research questions, and components of fidelity to receiving SMCM (Rapp & Goscha, 2012) . As an example question, clients were asked, "Thinking back over your relationship with your case worker, how would you describe the relationship?" And "When you meet, what kinds of things do you talk about?" As an example of a more specific follow-up question, if they did not mention strengths related to the broader interview questions, they were asked specifically, "Do you ever talk about strengths? It's okay if you don't. By strengths I mean talents, skills, or resources."

At the beginning of the interview, participants also responded to the 24-item Recovery-Promoting Relationships Scale (RPRS), a quantitative measure of the relationship between clients and their case managers (Russinova et al., 2006) . Clients respond to statements about their current mental health provider (i.e., case manager) on a 4-point agree/disagree Likert scale, such as "My provider helps me feel hopeful about the future" and "My provider helps me learn from challenging experiences." Total scores range from 24 to 96. Cronbach's alpha was 0.96 for this study. The scale has shown good test-retest reliability with coefficients of stability ranging from 0.61 to 0.72. Regarding convergent validity, total RPRS scores have been shown to have a high correlation with the Working Alliance Inventory (WAI) (r = 0.79; Russinova et al., 2006) .

In addition to the semi-structured interviews, the 20 participating clients allowed the organization to share their administrative information with the researchers, particularly their age, sex, gender, diagnoses, housing status, ethno-cultural identities, and length of time in case management.

The interview transcripts were analyzed thematically according to methods outlined by Miles et al. (2014) . The primary researcher developed a case summary matrix for each interview (Miles et al., 2014) , summarizing participants' responses to each interview question. Following development of the case summary matrices, a provisional first cycle coding scheme was developed, which included descriptive codes, emotion codes, and hypothesis codes based on the research questions and working alliance and SMCM literature (Miles et al., 2014) . The interview transcripts were coded using NVivo 12 qualitative analysis software. Two researchers coded the first two transcripts separately, using the coding list. They then compared the different versions of coded manuscripts, resolved discrepancies, and adjusted the coding list. In vivo codes and identity codes were added to the coding list to further examine concepts as they arose throughout coding (Miles et al., 2014) .

Following the first cycle coding, a cross-case matrix was developed for second-cycle coding, using the evaluation matrix tool in NVivo 12. In the resulting matrix, each row represented one client interview and each column represented a code. The primary researcher grouped participants by gender in the cross-case matrix to compare findings associated with gender, considering that there might be different perceptions of the alliance by gender (Nevid et al., 2016) . Throughout analysis, findings related to each theme were examined to identify any potential differences associated with gender.

The researchers identified patterns and connections across codes and cases, collapsed columns with similar codes, and tested new themes to see if patterns reflected the data accurately. During the second cycle of coding, the primary researcher drafted a conceptual diagram of the qualitative analysis themes (see Fig. 1 ). In addition to validation by a second researcher, the final evaluation matrix and diagram were also verified by referring to the case summary matrices and the coded transcripts.

The analysis was validated by a second researcher at each stage of the analysis, including when developing the case summary matrices, during the NVivo coding, when interpreting the cross-case matrix, and in the interpretation of the themes and findings based on the analysis. Both researchers referred to the case summary matrices and transcripts throughout the coding process in order to verify findings. Analysis decisions were also documented as an audit trail. An external audit of the data collection methods, analysis and results were performed by three researchers external to the study. Table 1 presents the demographic characteristics of the 20 study participants. While participants ranged in age from 22 to 61 years, the subgroup of men was older (M = 51.6, SD = 11.7) than the subgroup of women plus the person who was transgender (M = 33.2, SD = 11.2). Clients had been in case management at the time of the interview for an average of two and a half years. Length of time receiving case management for study participants ranged from six months to more than eight years. Sixteen clients (80%) had had at least one previous case manager. Based on the length of time in case management and the timeline that SMCM was implemented in the organization, most, if not all, past case managers would have also been trained in SMCM. All of the clients' current case managers were trained in SMCM. The most recent SMCM fidelity assessment was conducted in December 2017 with five of the organization's ICM teams, more than two years prior to data collection for this study. At the time, teams were determined to have a medium to high level of SMCM fidelity.

See Table 2 for a summary of the final categories, themes, subthemes, and codes from the thematic analysis. Figure 1 is the conceptual diagram of the study's broad categories and themes. The following results are presented according to this conceptual diagram, first describing key elements of the working alliance, then highlighting SMCM elements, followed by participants' descriptions of their life changes and how they connected the working alliance and SMCM elements to these life changes.

Eighteen people perceived their relationship with their current case manager positively, indicated by statements like, Less than high school diploma 7 (35%) High school diploma 10 (50%) College/University degree 2 (10%) Homeless (living in an emergency shelter) 2 (10%) "I like him," or, "It's a good dynamic." The remaining two clients expressed that the relationship was either both good and bad or mediocre. These strong alliances were confirmed further in the RPRS ratings. The mean total score was 91.0 (SD = 8.1 [out of 96]). While connections with current case managers were highly positive, participants compared current case managers with past ones and often discussed areas of dissatisfaction with past working relationships, which were included in the thematic analysis and are reported in these study results. 

When asked to describe their relationship, 17 participants referred positively to task-oriented activities they do with case managers, usually involving connecting with services, resources, or activities. Examples included: finding housing, buying groceries, obtaining ID, and attending medical appointments. One client referred to his case manager by saying, "He's been really helpful in terms of getting things done that I need to get done." In contrast to practical tasks, only five people spoke about working on improving their mental health or well-being with their case manager. Two clients said they intentionally chose not to share personal details with their case manager but were still satisfied with the work on practical tasks. For example, while talking about his case manager's help with accessing housing, one person said, "I don't really get into my personal life… I'm a private person so you wouldn't get me just telling her openly about it."

Flexibility was a theme in 13 descriptions of clients' case management relationships. People described case managers' flexibility in their professional roles, use of time, and use of paperwork. One client contrasted her current case management relationship, which she said was "more like a friendship," with a past case management relationship, saying:

One of them was… very professional. I'm not saying [current case manager] is unprofessional, but she's… more laid back. The other one was really, like, to the T, and there was nothing fun. They were just about mental health and how I was doing and stuff. Never, like, taking a break and just talking.

Eight people valued that their workers went above and beyond what they viewed as a case worker's job description. One said, "When I needed help with my son, she, like, gave me advice with that-where to go and who to connect with. So, she, like, expands her role a bit, you know?" (she/her). Another said, "I don't even think it was in her job to have to do that" (he/him). Finally, eight people framed flexibility in how workers used their time. For example, "And it wasn't, like, okay, I could give you an hour of my time and after that I'm going to go to another no matter how stressed out I am" (he/him).

To balance the view of flexibility, however, one person identified a past worker who was not structured enough, describing her as laidback, unstructured, and missing appointments. Speaking of her current worker, the client said, "It's kind of good to have that stability in my life right now, like, the structure again, 'cause I was going downhill again." Another person said, "I hate it when she puts boundaries up." However, she expanded by describing how her worker was teaching her how to have boundaries, indicating that this was a skill and a positive focus of their relationship.

The concept of fit was also a prevalent theme, related to clients' personal characteristics and whether or not they felt a bond with their case managers. Four clients (across genders) mentioned an age match that helped them relate to their case manager. One client noted a match in culture, and another mentioned an intellectual match. Incompatibility was raised when people felt their case managers did not understand or accept them, often related to their diagnoses. One client said, "Yeah, one of the challenges is that she didn't understand me… There's a lot of, like, my diagnosis she didn't know about and I still think she doesn't know about."

The most common theme in the interviews was the clientcase manager focus on goals. All participants identified a goals focus and it came across as central to case management. While some goals were related to mental health, like "being happy," most were linked with the practical tasks clients and case managers did together. One client described her goals process with her case manager:

We always explore ideas about school or going back to work or changing cities… She kind of breaks it down with me. And then, you know, there's a lot of options that we point out and we talk about… So, it really helps.

Within the goals conversation, one client connected goals and the working alliance with his case manager, saying, "I think that because I'm achieving those goals it's a stronger connection." Hope Through Goals. Six people described hope, particularly as seeing a way through a crisis or challenge. Identifying hope through the goals process, one client said, "When you have goals, you think forward." Another person described his case manager by saying:

She gave me some hopes…about, she's gonna be here to help me find an apartment and try to get out of this really unstable environment that I'm in, because it weighs heavily on my outlook and my day.

Choice. Fifteen people identified the importance of choice and autonomy in the goals process with their case manager. When describing what makes a good connection with his case managers, a client said, "They don't say, like, what you need to do. They ask you what you want, what you would like to do. And in terms of a healthier life, how you wanna move forward."

There were also examples of people lacking choice, such as a client who described his past case manager by saying:

He kind of pressures things… he assumes too much… If I don't want to do certain things and he assumes I do… He used to drive me to a lunch and, well, I don't really want to go too often but he just assumes I want to go.

Another client emphasized her lack of autonomy in the client-case manager relationship but in a positive way, saying:

Obviously, I'm a client. It's not a mutual thing. I needed help and I would like that. So, I want her around… I respect her for being my worker. And if I don't feel like meeting her one day, I always meet her. I never not meet her.

When asked about goals and choice, two clients highlighted their personal autonomy, independent of their case manager. While goals were important, they could achieve them on their own. While their case managers were helpful, they as clients were capable.

The strengths focus was not as salient a theme as the goals focus in the interviews -it did not come up spontaneously and some participants said it was not an important focus of their case management. At the same time when specifically asked about them, fifteen people said their case manager highlighted their strengths and reminded them of their accomplishments and skills, usually when they were facing a challenge. Describing strengths conversations, one client said: Several clients also identified challenges they had with strengths conversations. Two people said they did not like the term "strengths," and one said that if she was asked to identify her strengths, she would say, "I don't have any, go away." However, she was open to more general conversations about her abilities, indicating that "abilities" was an alternative to the term "strengths."

Clients described many diverse ways their lives had changed during the time that they had their case managers. Twelve people said their mental health had improved (i.e., happier, decreased suicidal ideation and self-harm, decreased hospitalizations, better coping) and nine mentioned improved well-being, such as increased independence, and feeling good about themselves. Six people described improved relationships and decreased isolation. One person described her life change as follows:

What changed is the way I cope with my mental health… And I've mastered that. I'm really happy… Because I've been in a place, right, I was locked up for five years, so I just got off six years of probation. Me and my kids are so happy. I didn't think I was ever gonna get here. So that's a lot that's changed.

Ten people described moves to more stable housing or improvements within their housing, such as addressing bed bug situations or major cleaning needs. Five said that they had better connections with services and resources. Additional life changes mentioned were improved money management, improved children's well-being, post-secondary education participation, employment, and physical health improvements.

Across genders, four people said that goals were helpful in improving their lives and four people connected strengths to life changes. People's descriptions of goals linked to life changes came up more naturally in the interviews than the connection between strengths and life changes. When discussing strengths, one person said talking about strengths helped with his self-esteem and confidence. Another said the focus on strengths helped her to be positive and was healing.

Regarding goals, one client linked improvements in practical areas of her life with the practical goals she was setting with her case manager. Another client described how setting goals with her case manager led to life successes each week. Finally, when talking about her goals, one client said:

It gives me a purpose in life, like, it gives me the confidence that I am productive, I am adding to my community, I am adding to the society. I am doing something right so that would boost my self-confidence, level of comfort. I start loving myself.

Working Alliance Related to Life Changes. The most prevalent linking theme in the data was the connection between the working alliance and life changes. Eighteen of the people in the study linked the client-case manager relationship to life changes. People framed their life changes as a result of the working alliance. For example, one client said, "She helped me through it." Another described her life changes, then said, "I've done that with [case manager]'s help." Some people recognized that life changes started at the beginning of their relationship with their case manager. For example, one client said, "Before her I wouldn't go to groups. Before her, I was too afraid to get help." Again, referring to the change beginning with her relationship with her case manager and her growth from that point onwards, another client said:

Before it was just me. And my own actions were not good. And now I have someone to bounce it off. I've done so much practice with her and I'm able to do it by myself now.

Finally, the following quote highlights the key role a case manager has had related to life changes. A client said:

You feel like you don't belong in the world and you don't see the light. And, when [Case manager] came… she spoke to me and it was just like, she could just see through me, and she could just see the potential, but I couldn't. And, the way she pursued her work with me, and went through the crisis with me… it was very remarkable, and I would say, it is a wonderful experience that I've had with her.

The findings of this qualitative study provide insight into perceptions of the SMCM working alliance and its key elements, from the perspective of twenty people with severe mental illness. The study conceptual diagram (Fig. 1) highlights key themes that were described by participants, within the working alliance concept and the SMCM intervention, and how these concepts may be connected to life improvements for people with severe mental illness. While we noted when a theme was identified "across genders" in the Results, we did not find gender differences in the major study themes.

Study participants placed a high level of importance on a working alliance, particularly shown in their expressions of the connection between the alliance and life changes, as well as their positive descriptions of the relationship itself. The focus of the alliance was moving forward to accomplish practical goals and tasks. This prominence of the goals focus reflected both the theory behind SMCM and Bordin's (1979) definition of the therapeutic alliance. As such, the goals focus connects the broad concepts of this study.

In the theory guiding SMCM, by achieving a goal in one life area, a person becomes more hopeful and motivated to move towards goal achievement in other areas. The increase of hope and motivation leads to overall improved quality of life (Rapp & Goscha, 2012) . Redko et al. (2007) also found that people with substance abuse issues receiving SMCM highlighted goals as an important focus of the client-case manager relationship. In Tsoi et al.'s (2019) SMCM study, one of the only differences between their SMCM group and a comparison group (case management without SMCM) was higher goal achievement of the SMCM group. Movement on practical goals is identified as a key element in building the alliance and fostering hope in both community mental health literature (Farrelly & Lester, 2014; Kidd et al., 2017; Redko et al., 2007; Tsoi et al., 2019) and psychotherapy research (Baldwin et al., 2007; Fluckiger et al., 2018; Wampold, 2015) .

The finding that clients' descriptions of the goals focus fits with SMCM theory is notable given the research considerations that case management "style" and individual case manager differences are associated with the quality of the working alliance (De Leeuw et al., 2012; Farrelly & Lester, 2014; Kondrat & Early, 2010) . These findings support the use of the SMCM, with the rationale that the intervention equips case managers in building strong working alliances with their clients through a focus on practical goals.

Agreement on goals and the tasks to achieve those goals are two of the three main components of Bordin's (1979) definition of the working alliance. According to Horvath (2018) , there is much work to be done to clarify the concept of the alliance, both in psychotherapy and in related psychosocial interventions. Study participants' descriptions of client-case manager relationships aligned well with Bordin's (1979) definition. Participants described the centrality of the goals process, and many described the tasks they engaged in to work towards goals. To a lesser degree, participants also referred to the degree of fit or compatibility they had with case managers.

The therapeutic alliance literature raises questions around whether or not the definition of the alliance is applicable to settings outside of psychotherapy (Chinman et al., 2000; McCabe & Priebe, 2004; Rogers et al., 2008; Tsai et al., 2013) . Descriptions of client-case manager relationships in this study were community-based and focused on meeting basic needs and pursuing highly pragmatic goals, which are quite different than the tasks and goals of psychotherapy. The practical focus also resembles the lower levels of Maslow's Hierarchy of Needs (Maslow, 1943) , such as immediate physiological needs or safety needs, which must be met first in order for people to move forward in other areas of their lives.

Most clients valued both the bond with their case manager and having their practical needs met, as well as a clarity around the goals and tasks of their case management practice. Some participants described how they chose not to share personal information or connect in a more personal way but were still satisfied with the practical tasks their case managers helped them to do. This may have been an indication of a less important role of the bond in case management compared to the bond in psychotherapy, which is a consideration raised by alliance researchers (McCabe & Priebe, 2004; Nath et al., 2012) . Overall, though, while the practice of SMCM is different than psychotherapy, the concept of the working alliance fits with its focus.

The choice and autonomy themes necessitate an acknowledgement and analysis of power in the working alliance. There is a power imbalance in a relationship between a mental health professional and a client navigating marginalization. Individualized care, a focus on strengths rather than symptoms, and pursuing meaningful goals that vary greatly from one person to the next, are ways that power can shift towards a client within the case management context. At the same time, any relationship that promotes autonomy and strengths will be challenged when a case manager says no, effectively over-ruling this autonomy. Choice was an important theme in the study; however, the findings were mixed, indicating the complexity of client-case manager dynamics in this area. Some clients described times when they did not have choice in the case management relationship. Two clients highlighted their personal autonomy in the interviews, resisting the assumption that they may be dependent on their case manager, and protecting their power in the relationship.

These choice and autonomy considerations also underscore nuances in the strengths language in the model. While most study participants described a focus on strengths consistent with the SMCM intervention, and valued this focus, some were uncomfortable with the term "strengths." For example, clients described this strengths focus in many ways, such as with an emphasis on their accomplishments, abilities, future goals, or potential. The SMCM language may not be the language naturally used by clients. Brun and Rapp (2001) and Rapp and Sullivan (2014) described the strengths focus of SMCM as infused into all areas of the model, not solely through the use of one tool, such as the Strengths Assessment.

In their meta-analysis of psychotherapy literature, Webb et al. (2010) noted that therapists adjust their use of an intervention based on people's behaviours, responses, and preferences. In their review of community mental health practice, Kidd et al. (2017) mentioned that community mental health workers navigate taking the time to carefully foster strong working alliances in the midst of organizational responsibilities around paperwork and caseloads. The flexibility theme in this study demonstrated case managers' responsiveness to clients.

While study participants described a variety of positive outcomes in this SMCM context, they clearly attributed life changes to their case manager. The descriptions of life changes ranged from improved well-being to maintaining housing, developing stronger relationships, connecting to resources, caring for children and pets, and more. The range of different areas of life changes align with the SMCM approach, which focuses on personalized goals. These goals may not be typical of traditional mental health treatment (i.e., reduced symptoms of mental illness), although improved mental health was a life change mentioned by participants. Regardless of type of life change, we concluded that the working alliance played a central role in clients' accounts of life changes because of the prominent attribution of life changes to the case manager and the alliance.

We included the organizational context and broader community mental health context in the conceptual diagram of this study in order to acknowledge that interactions between people with severe mental illness and their case managers are influenced by these settings. While clients valued a flexibility in case management, organizational context influences the extent to which case managers can exercise flexibility and promote choice (Ungar, 2008) . The current community mental health field is recovery-oriented, client-centered, and strengths-focused. We can identify elements of the working alliance that clients value, but overall, the approach of a field -broad policies and funding frameworks -may facilitate or hinder client preferences.

The study had several limitations. Clients presented their case managers in a highly positive light, possibly partly due to a social desirability response bias. Participants were very isolated, particularly in light of COVID-19 pandemic restrictions. Some were describing their relationship with their case manager as the only one they had with a person at the time. We were also unable to determine level of SMCM fidelity in the context of services received by study participants.

The data analysis included a start list of codes based on SMCM theory and working alliance research. While in our coding we actively looked for instances of misalignment with past research and theory, and validated each step of the analysis, we still could have been influenced by personal bias. The findings were also based on a convenience sample located at one agency and cannot be generalized to a broader population of people with severe mental illness or other experiences of the SMCM model at a different agency.

Additional suggestions for further research are to continue to develop and test the working alliance definition in case management. Future studies could more actively recruit clients with weaker working alliances. This may be done by screening people with an alliance measure prior to an interview. Further examination of SMCM fidelity could consider how to incorporate the centrality of the working alliance into measures of fidelity to the model. When examining outcomes in case management practice, the study points to the need to consider various outcome measures and concepts of quality of life. The measurement of individualized goal achievement on a wide range of goals could be a particular focus of SMCM outcome measurement. Future research examining fidelity-outcome associations could incorporate the working alliance as a mediator of the relationship. Finally, future studies could also test the conceptual diagram, examining underlying mechanisms within a fidelityalliance-outcome mediation model.

The people with severe mental illness and histories of vulnerable housing in this study valued their case management working alliance, particularly its goals focus. A working alliance is necessary for an intervention to lead to improvements in people's lives, such as exiting homelessness, accessing needed services, and experiencing improved overall wellbeing. One strength of the SMCM intervention is that it focuses on fostering the client-case manager working alliance and the intervention's conceptualization of the alliance aligns with a common definition of the working alliance. Based on these findings, this study provides support for the use of the SMCM and describes how the intervention may lead to meaningful life changes for people with severe mental illness.

Case management relationships and a recovery orientation: A consumer survey of class members in the Arnold Case

Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance

The generalizability of the psychoanalytic concept of the working alliance

Strengths-based case management: Individuals' perspectives on strengths and the case manager relationship

The case management relationship and outcomes of homeless persons with serious mental illness

The quality of the working alliance between chronic psychiatric patients and their case managers: Process and outcomes. Journal of Psychiatric and Mental Health Nursing

Therapeutic relationships between mental health service users with psychotic disorders and their clinicians: A critical interpretive synthesis. Health and Social Care in the Community

The alliance in adult psychotherapy: A meta-analytic synthesis

How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis

Research on the alliance: Knowledge in search of a theory

The therapeutic alliance: The key to effective patient outcome? A descriptive review of the evidence in community mental health case management

Common factors in community mental health intervention: A scoping review

Do treatment processes matter more than stigma? The relative impacts of working alliance, provider effects, and self-stigma on consumers' perceived quality of life. Best Practices in Mental Health

An exploration of the working alliance in mental health case management

Soutien d'intensité variable (SIV) et rétablissement: Quenouse apprennent les études expérimentales et quasi expérimentales? Santé Mentale Au Québec

A theory of human motivation

The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings

Qualitative data analysis: A methods sourcebook

Case managers' perspective on the therapeutic alliance: A qualitative study

The role of gender as a moderator of the alliance-outcome link in acute inpatient treatment of severely disturbed youth

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

The strengths model

The strengths model: Birth to toddlerhood

Understanding the working alliance between persons with substance abuse problems and strengths-based case managers

Examining the working alliance as a mediator of the relationship between fidelity to the strengths model of case management and client outcomes

Therapeutic alliance and change in psychiatric symptoms in adolescent and young adults receiving drug treatment

RPRS Manual: Recovery-Promoting Relationship Scale

Housing first, connection second: The impact of professional helping relationships on the trajectories of housing stability for people facing severe and multiple disadvantage

Longitudinal association of therapeutic alliance and clinical outcomes in supported housing for chronically homeless adults

A nonrandomized controlled trial of strengths model case management in Hong Kong

Resilience across cultures

How important are the common factors in psychotherapy? An update

Therapist adherence/competence and treatment outcome: A meta-analytic review