The Relationship Between Working Alliance, Patient Activation, Hope, and Depression in Community Mental Health Care
Objectives: Previous research suggests an association between working alliance, the collaborative and affective bond between patient and therapist, and improved therapeutic treatment outcomes within treatment of severe mental illness (SMI). However, little is known about the mechanisms through which working alliance improves outcomes in this population. Through investigating key elements of recovery within SMI, two possible mediators—patient activation and hope—appear particularly relevant to the relationship between working alliance and improved treatment outcomes. The current study aimed to examine patient activation and hope as potential mediators in the relationship between working alliance and improved depression in individuals with SMI. Additionally, the current study investigated whether or not the patient’s evaluation of which provider is most important to their recovery significantly moderated the relationship between working alliance and patient activation/hope.
Methods: The current study was a secondary analysis of longitudinal (baseline, 6-month, and 12-month) data comparing two interventions aimed at reducing treatment provider burnout in community mental health settings primarily serving individuals with SMI. Participants (maximum N for analyses = 346) completed measures of working alliance with a linked provider on their treatment team, patient activation, hope, and depression at baseline, 6 months, and 12 months. Using moderated mediation analysis, 6-month patient activation and 6-month hope were examined as mediators in the relationship between baseline working alliance and 12-month improved depression (change score between 12-month and baseline depression). Additionally, whether or not the patient deemed their linked provider as most important to their recovery was tested as a moderator in the relationship between baseline working alliance and 6-month patient activation/hope.
Results: Overall, the current study’s hypothesized model was not supported. Baseline working alliance did not significantly predict improved depression 12 months later. Further, both patient activation and hope measured at month 6 in the study did not significantly mediate the relationship between working alliance quality at baseline and improved depression at month 12. Additionally, whether or not the patient believed their linked provider was most important to their recovery did not significantly moderate the relationship between baseline working alliance and 6-month patient activation or 6-month hope. However, results indicate that better quality working alliance at baseline did significantly predict higher patient activation at 6 months. Lastly, the current study found a significant positive correlation between importance of provider and baseline working alliance.
Discussion: Results suggest that improvement in depression may not be a key SMI treatment outcome that relates to working alliance, patient activation, and hope. Further, fostering a positive working alliance (e.g., collaboratively developing goals/tasks in-session) may increase patient’s ability, willingness, and confidence in managing their own mental health care. Additionally, a positive working alliance may also contribute to how important the patient believes the provider is to their recovery. However, those that have seen their provider for longer (e.g., more chronically ill) may be less active in managing their own mental health care. Limitations and possible future directions are discussed.