Leslie B. Alexander

Two helping alliance methods for predicting outcomes of psychotherapy: a counting signs Vs. a global rating method

This paper reports on the development of measures of helping alliances in psychotherapy, i.e., the patients experience of the treatment or relationship with the therapist as helpful, or potentially helpful. The helping alliance counting signs measure, which is the special focus of this paper, entails the counting of certain types of patient statements (signs) which are identified in a manual. The main findings were: a) these types of statements were found to be “scorable” with moderate interjudge agreement; b) scores based on the manual showed moderate agreement with a similar helping alliance manual based upon global ratings; c) scores were fairly to moderately consistent from early to late in treatment; d) scores predicted outcome significantly, e.g., early positive signs of helping alliance correlated .57 (p < .01) with rated benefits, and .59 (p < .01) with change in the first target complaint (Battle, C., Imber, S., Hoehn-Saric, R., et al. Target complaints as criteria of improvement. Am. J. Psychother., 20:184–192, 1966); and e) basic background similarities between patient and therapist, such as in age and religious activity, attained highest correlations with the helping alliance measure, e.g., the sum of 10 similarities correlated .60 (p < .01) with early positive helping alliance counting signs.

Client Participation: Central and Underinvestigated Elements of Intervention

Although client participation is central to psychosocial interventions, most investigations conceptualize and measure participation in rather crude ways. This review suggests that essential elements of treatment participation are largely unknown, links between participation and outcomes are not clear, and most investigations of influences on within-treatment variations in participation are based on outdated causal models. Drawing on literature on health and mental health care, this article develops a comprehensive conceptual model of treatment participation. It proposes an agenda for future research aimed at understanding participation phenomena in various contexts.

Preserving families at risk of child abuse and neglect: The role of the helping alliance

Family preservation services are increasingly employed to decrease the use of foster care and preserve maltreating families at high risk of child placement. First studies of family preservation services appeared to support their effectiveness in achieving these goals. However, questions are raised increasingly about their effectiveness, particularly with those families whose functioning is impaired by psychopathology and substance abuse. The time has come to seek fuller understanding of family preservation services and their differential successes. In this paper, we draw on current research in the field of psychotherapy--specifically on studies of the helping alliance and its relationship to treatment outcome--to purpose a new look at family preservation services and to inform of treatment of high-risk families.

Neglected voices: consumers with serious mental illness speak about intensive case management.

ABSTRACTThis study explores early alliance formation between adult consumers with schizophrenic-spectrum disorders and their case managers from the consumers’ perspectives using a prospective, cohort design. While quantitative studies have demonstrated positive links between the alliance and some client outcomes, such methods cannot reveal in concrete and authentic ways what consumers want in the case management relationship. This study finds that consumers can provide tangible and insightful information about the specifics of their case management relationships, confirming previous findings about the desire for connection with others, while extending it to include the desire for connection to the social world through the case manager relationship.

Misbehaviors of Front-Line Research Personnel and the Integrity of Community-Based Research

There has been little empirical research into misconduct and misbehavior among community research workers who recruit and collect data in vulnerable and marginalized health populations and are also members of those same communities. We conducted qualitative interviews with community research workers and traditional research assistants to understand the context and consequences of misbehaviors that pose a threat to research ethics and data integrity. In our sample, more community research workers acknowledged engaging in research wrongdoing than did traditional research assistants. These behaviors were most prevalent among community research workers who were not well-integrated into the research team. We suggest best practices for investigators to promote an environment that supports research integrity in research projects that employ community research workers.

Ethical Dilemmas in Evaluations Using Indigenous Research Workers

This article addresses ethical dilemmas experienced by street-level research and evaluation workers recruiting and gathering data in community-based research projects. The authors focus on a subgroup of street-level research workers, whom they call research extenders (REs), employed because they share important characteristics with the target population. Like other street-level research workers, some REs are single role (only do research work) and others are dual role (do research work and provide services). They discuss relevant literature and findings from pilot focus groups exploring how REs understand responsible ethical conduct in their research work in the community. REs face ethical issues somewhat different from those of more traditional, non-indigenous street-level research workers. These issues increase social risk for study participants and could compromise the validity of data. Researchers need to be aware of and address the distinctive set of ethical issues raised by research and evaluation projects employing indigenous, street-level research workers.

Proximity, Ethical Dilemmas, and Community Research Workers

Background: In community-engaged research (CEnR), recruitment and data collection are often assigned to community research workers (CRWs). CRWs are hired because of close ties with target communities and presumed greater success recruiting and gathering data from marginalized populations. The value conflicts and personal stress facing CRWs have been described in the international context; however, less attention has been paid to these issues in U.S. settings. Methods: Qualitative interviews were held with CRWs about their experiences with CEnR. Interviews were transcribed and coded using Atlas.ti. Results: The data indicate that CRWs working in settings controlled by the participants, such as neighborhood streets and participant homes, are more likely to face conflicts between following the norms of research and meeting what they perceive to be their everyday obligations to help specific others (duties of relational ethics) and to keep themselves safe. This suggests that “physical proximity” (understood as degree of penetration into the physical domain of the target research community) is an important factor in the ethics of actual practice in CEnR. Conclusions: CRWs often experience ethical complexities that are simply not in the realm of experience of most higher level researchers. How CRWs navigate conflicting ethical obligations can affect the quality and usefulness of the data collected and thereby affect communities by influencing policies informed by these data. Soliciting the perspectives of CRWs early in the process of research design and development is recommended to maximize the benefits achievable through CEnR.

Social Work's Freudian Deluge: Myth or Reality?

One of the popular current explanations of social works gradual disengage-ment from the poor and social reform during the past fifty years has been its so-called deep immersion in psychoanalytic theory. This essay provides a comparison of primary and secondary literature sources on social work theory and practice in the 1920s, which challenges the psychoanalytic inundation thesis. Weaknesses of this thesis in addition to historical inaccuracy are indicated. The primary conclusion is that psychoanalytic theory influenced an elite minority fringe rather than the main body of theory and practice during the 1920s.

Case managers' perspectives on the therapeutic alliance: a qualitative study.

PurposeIn order to understand the nature of the therapeutic alliance in intensive case management, this study used qualitative methods to assess the dynamics of the case managers’ relationships with their consumers by examining their perspectives on their own and their consumers’ likeability, how helpful consumers perceive them to be, as well as their expectations for their relationships with their consumers.MethodsThe study employed content analysis of open-ended responses from 49 intensive case managers about their consumers.ResultsFrom case managers’ responses, four themes emerged describing the dynamics of the case manager/consumer relationship: motivation, monitoring, creating dependency, and being there.ConclusionsThe current qualitative findings suggest that current constructions and measures of the therapeutic alliance developed in psychotherapy research are not fully capturing the ways in which the unique structure and constraints of intensive case management influence relationships between workers and consumers.

Moral Stress, Moral Practice, and Ethical Climate in Community-Based Drug-Use Research: Views From the Front Line

Background: The role of front-line researchers, those whose responsibilities include face-to-face contact with participants, is critical to ensuring the responsible conduct of community-based drug use research. To date, there has been little empirical examination of how front-line researchers perceive the effectiveness of ethical procedures in their real-world application and the moral stress they may experience when adherence to scientific procedures appears to conflict with participant protections. Methods: This study represents a first step in applying psychological science to examine the work-related attitudes, ethics climate, and moral dilemmas experienced by a national sample of 275 front-line staff members whose responsibilities include face-to-face interaction with participants in community-based drug-use research. Using an anonymous Web-based survey we psychometrically evaluated and examined relationships among six new scales tapping moral stress (frustration in response to perceived barriers to conducting research in a morally appropriate manner); organizational ethics climate; staff support; moral practice dilemmas (perceived conflicts between scientific integrity and participant welfare); research commitment; and research mistrust. Results: As predicted, front-line researchers who evidence a strong commitment to their role in the research process and who perceive their organizations as committed to research ethics and staff support experienced lower levels of moral stress. Front-line researchers who were distrustful of the research enterprise and frequently grappled with moral practice dilemmas reported higher levels of moral stress. Conclusion: Applying psychometrically reliable scales to empirically examine research ethics challenges can illuminate specific threats to scientific integrity and human subjects protections encountered by front-line staff and suggest organizational strategies for reducing moral stress and enhancing the responsible conduct of research.