The working alliance and employment outcomes for people with severe mental illness enrolled in vocational programs

Authors: Lacaille, D., Sheps, S., Spinelli, J. J., Chalmers, A., & Esdaile, J. M.
Year Published 2009
Publication Rehabilitation Psychology
Volume 54
Number 2
Pages 175-163
Publisher American Psychological Association

Individuals with severe mental illness have a desire to work. however, they often face many barriers. The Working Alliance which is a collaborative working relationship within a counseling relationship has been a key element in therapeutic outcomes and has become linked to positive outcomes in psychiatric rehabilitation programs. Research has shown that a good working relationship between a person with mental illness and his service provider can improve symptoms, enhance medication compliance, improve quality of life and global functioning. More research on the working alliance in vocational rehabilitation services is needed. This study is a secondary analysis of data that was collected in a randomized control trial comparing to vocational models the Individual Placement and Support (IPS) model and the Diversified Placement Approach (DPA).


This study had two purposes. These included to examine the relationship between the working alliance and the employment outcomes of individuals with severe mental illness who were receiving vocational services. The study also looked at whether working alliance differences existed between client receiving evidenced based supported employment service and those receiving traditional vocational rehabilitation services (DPA). This is a highly regarded team model organized within a day program where individuals get ready to work, then work with a group and overtime progress through a series of placements and eventually move into competitive work. The hypotheses was individuals receiving supported employment services would have a stronger working alliance with their IPS vocational provider than those receiving traditional vocational services (DPA).


The setting was two vocational programs that provided employment services to individuals with severe mental illness.


Two hundred individuals were randomly assigned to the IPS or DPA model of supported employment in the parent study. The sample in this study included 91 (45 in the DPA and 46 in IPS). Most were men (61). The mean age was 38.9 years. About half (49.4%) had a schizophrenia-spectrum disorder. The majority or (63.7%) had more than a 12 year education. Most (81.3%) had prior work histories.

Data Collection

Individuals were randomly assigned to DPA or IPS. Afterwards they were followed for two years. Objective data related to paid employment outcomes was collected through quarterly participant interviews. Data pertaining to the predictor variable, working alliance were collected by participant interviews every 6 months for individuals who were working at the time.
Demographic variables were measured by the Uniform Client Data Inventory and work history by the Employment and Income Review at baseline. Psychiatric symptoms were assessed at baseline and semiannual periods using the Positive and Negative Symptom Scale. Employment outcomes included total duration of paid work and mean paid job tenure. A scale was developed to measure working alliance. It included items related to emotional support, instrumental/informational support, frequency of performance feedback, stressfulness of the relationship, how critical the vocational worker was to the client and the person's overall satisfaction with the relationship.
Fidelity to the IPS or DPA model tenants were assessed every 6 months for both sites where individuals received services.
Stepwise hierarchical multiple regression analysis were run to determine relationships between the working alliance and employment outcomes. Baseline variables were controlled for and were entered into the regression model. Related to the number of days of paid work and job tenure applicable covariates were entered.
The working alliance variable was added in the second step of the regression analysis. Zero order correlates were also run. Independent t test was used to determine differences between IPS and DPA on working alliance.


The comparison condition was low or no working alliance.


The first hypothesis stating that the working alliance would be positively associated with employment was not confirmed. The second hypothesis that individuals would have a stronger working alliance with their vocational workers in IPS was confirmed.


The finding that there is a lack of associations between working alliance and employment outcomes is not in alignment with previous literature. Evidenced based supported employment appears to lead to better relationships than the DPS approach. Additional research is needed.

Disabilities Emotional disturbance
Populations Hispanic or Latino | Black / African American | White / Caucasian | Male & Female
Outcomes Other
Research Design Randomized Controlled Trials (RCTs)
Peer Reviewed Yes