Clinical implications

The clinical implications mostly arise out of the complex links found between

compliance and alliance. A key question is whether case managers should put more

emphasis on improving the alliance, or on improving compliance. The study does

not allow conclusions to be drawn about any causal links between these concepts.

However, the study does reinforce the idea that the working alliance is an important

concept in the case management of clients with psychosis, and it may be that it

would be most productive to work on the alliance, rather than on trying to increase

compliance directly. Perkins and Repper (1999) point to two potential difficulties in

interventions aimed directly at improving compliance. Firstly, the goals of the client

and the clinician may differ, which can raise ethical problems in that the client may

not be giving informed consent for the treatment. The second issue, perhaps even

more serious, is that interventions aimed at compliance are often associated with

forced treatment, which can worsen the relationship between the client and clinician,

as clients may avoid services (Perkins & Repper, 1999). Thus it may be more

helpful to aim interventions at the alliance, on the assumption that an improved

alliance may bring improved compliance, along with other benefits. It is important

to think about variables that can be manipulated, as suggestions about issues that

study highlights some areas which might be useful to focus on for the development

and maintenance of a therapeutic alliance.

The first area is the weaknesses of the alliance itself. Research in psychotherapy

suggests that discussing a poor alliance, in particular problematic feelings towards

the therapist, can improve an alliance (Foreman & Manner, 1985). In particular,

case managers could consider resentments that might be based on negative

experiences of treatment. A second area which may give rise to problematic feelings

is compulsory treatment. It is possible that the presence of the opportunity for

compulsion distorts the therapeutic relationship, and while some degree of

compulsion may or may not be necessary, its impact on the alliance needs to be

better understood. A recent survey by the National Schizophrenia Fellowship

found that 48% of users of mental health services supported the introduction of

compulsory treatment in the community (The Guardian, 16/4/99). This could be

interpreted as indicating that some clients are aware that they may become reluctant

to take medication, but that in itself does not mean that compulsion is the best way

to ensure adherence. Such concerns are reflected in the continuing debate over the

use of the terms ‘compliance’, ‘adherence’ and ‘concordance’ (Perkins & Repper,

1999).

Another possible focus for improving the alliance concerns beliefs about treatment.

Although the link between causal belief congruence and other variables was not

established, the possibility was raised that differences over the unhelpful aspects of

treatment may contribute to difficulties in the relationship, or with compliance.

problems they experience with their treatments, and try to be aware of potential

disagreements with clients, and if possible discuss them. Also making their own

beliefs more explicit may be helpful. However, such suggestions are tentative, and

would require more investigation.

The above suggestions are aimed at improving the working alliance, which may be

clinically useful directly, as the relationship may beneficial in its own right, and

indirectly, by improving improved adherence. Improving adherence, as stated

before, has benefits in terms of reducing relapse and hospitalisation. It may also be

of benefit by reducing the frustration and hopelessness that case mangers may be

subject to, as they experience both clients repeatedly returning to hospital, and

clients who do not adhere to a treatment which the case manager thinks is important.

If staff felt that they were able to intervene in some way to increase compliance, then

frustration, hopelessness, and ultimately staff turnover might conceivably be

reduced. There is some tentative evidence from this study that the alliance does

continue to develop, and thus reducing turnover in itself might serve to increase

compliance. One client commented that one of the problems he experienced was

that as soon as a relationship developed, the case manager left. While the study was

in progress, a case manger left, and one of her clients was hospitalised shortly

afterwards. Although in the context of this study, one cannot make claims about any

link between the two events, it is important to bear in mind the idea that staff

turnover may have a serious impact on clients.

It is useful to consider the clinical implications of this study for clinical

multi-disciplinary settings have been recently considered by Gelsthorpe (1999). One

difficulty is that of presenting a different, psychological viewpoint, in an

environment in which other paradigms may take precedence. One suggested

solution was to gather research evidence, and the findings of the present study could

help in this regard, by pointing to the importance of a psychological construct, the

working alliance, in case management.

Another difficulty for psychologists in CMHT’s is a sense that their professional

identity can be subsumed within the team (Weaver, Renton & Tyrer, unpublished

paper). The findings of the present study suggest that a way that psychologists can

be of use is in helping other case managers to understand the psychological

processes that underlie the building and maintenance of an alliance, and fluctuations

in adherence. The use of psychological principles in the day-to-day care of

psychotic clients has been termed “psychotherapeutic management” (Weiden &

Havens, 1994), and the importance of both teaching and supervising mental health

workers with regard to psychological processes has been highlighted (Weiden &

Havens, ibid.) Thus imparting psychological principles to fellow staff members may

be clinically useful, by both improving case managers’ understanding of their

relationship with clients and by giving psychologists a sense of their role within a

multi-disciplinary team. In both of these ways, staff morale might possibly be