HUMN 4920 CapstoneIntroductionAssessment, planning, and imp.docx

HUMN 4920 Capstone
Introduction
Assessment,
planning, and implementation of various services for clients
are fundamental
skills of the human services practitioner. Therefore, solid case
management skills are crucial to the functioning of effective
human
services delivery. You will be presented with
three clients and their current cases. Read through each case
and then decide
with whom you would like to work. As you reread the case
management notes of the client whom you have selected, think
about which resources
and services might be beneficial. How might you collaborate
with those
resources to provide services for your client, and how
might those resources work together to do the same?
Sean Brody
Eight-year-old
Sean Brody is a third grader with many challenges. Due to his
parents’ impending divorce, for the past 6 months, he has had
to split his time between their separate householdsas they
negotiate a custody agreement.
Before the separation, Sean’s biggest obstacle was his hearing
impairment. He is
currently enrolled in a self-contained classroom for the
hearing impaired where
the teacher and students arefluent in American Sign Language
(ASL). Another risk factor has been
the presence of consistently elevated lead
levels.
He has

increasingly shown aggression with his peers in situations
where he is both provokedand unprovoked. Minor teasing by his
classmates ends in physical fights. Being paired with others
to work on projects results in Sean acting irritably and giving
up. Lack
of participation in the classroom has resulted in lack of
nthusiasm for his homework. Thus, he is failing most of his
classes.
Last week, Sean
threw a chair at his tablemate, and he is now
facing expulsionas he has already been suspended
twice.Realizing
that Sean’s problems are much larger than he can handle, the
school guidance
counselor has referred Sean and his parents to you for further
assessment and
treatment.
Lanie Rosado
Lanie is a 22-year-old
“Operation Enduring Freedom” veteran who was born in the
United Statesbut raised in San Juan, Puerto Rico. After serving
in the military for 4 years,
she has returned from deployment with an honorable discharge
due to an injury.
While Lanie was on patrol, her Humvee hit a
roadside bomb and her dominant
right hand was severely injured.She
now has limited mobility in that hand.
Six months
removed from Afghanistan, she is enrolled full-time in her
local community
college, pursuing a bachelor’s degree
inbusiness administration while going through weekly physical
therapy sessions for her injured hand.
Lanie, who was

once very close to her family in Puerto Rico, has become
withdrawn and rarely
calls to update them on her well-being.
Her relationship with her boyfriend also isstrained.She has
been having
erratic mood swings, and they are causing instability in her
other personal relationships with friends and classmates.
Although she is only in her first semester of college, Lanie is
already failing.She has missed many classes. Her mood
swings have not endeared her to her classmates, so teamingwith
them to catch up on notes and group assignments has been
difficult.
With encouragement from her boyfriend,
Lanie has contacted military personnel for a psychologist
referral.The psychologist, after
reviewing Lanie’s case, has referred her to you for additional
testing.
Emma Kinch
Emma Kinch is a 78-year-old native of Barbados who has
spent the last 68 years living in the United States. Her
husband of 60 years died 3 months ago.Emma has been blind
since she developed severe cataracts at age 60, and her
relationship with her husband was the main way in which she
connected with the world beyond her immediate family.
More recently, she has been exhibiting signs of deep sadness
and irritability.She has become very withdrawn and no longer
takes part in social circles such as church and the gardening
club, both of which she and her husband were active
members.Also, her children have noticed that she is having
difficulty remembering and seems confused when faced with
daily routines.
Emma also has begun to have aggressive outbursts.Last month,
her doctor diagnosed her as having hypothyroidism, and this
condition combined with the mood changes and mental
confusion has resulted in her children bringing her to you for

additional assessment and treatment. Presenting Problems
Sean Brody
Age – 8
Race –
White
Gender –
Male
Ethnicity
– Jewish
Veteran Status – None
Immigrant
Status – American citizen
Language
– English, American Sign Language
Sensory
Impairment – Hearing impaired
Motor
Impairment – None
Medical
Conditions – High lead levels
Presenting
Problem – Behavioral and academic problems in school
Poor peer relationships
Aggression
Affective
Symptoms – Irritability
Behavioral
Symptoms – School failure
Suspensions and expulsions due to aggression
Isolation from peers
Cognitive

Symptoms – Poor concentration and attention in school
Family and
Support Systems – Only child
Split custody
Lanie
Rosado
Age – 22
Race –
Hispanic
Gender –
Female
Ethnicity
– Puerto Rican
Veteran Status – Operation Enduring Freedom veteran
Immigrant
Status – American citizen
Language
– English, Spanish
Sensory
Impairment – None
Motor
Impairment – Fine and gross
Medical
Conditions – Severely injured dominant hand
Presenting
Problem – Failing in college
Affective
Symptoms – Mood swings
Behavioral
Symptoms – Impulsivity
Unstable
relationships
Cognitive

Symptoms – Failing first semester of school
Family and
Support Systems – Conflict with family and partner
Emma Kinch
Age – 78
Race –
Black
Gender –
Female
Ethnicity
– Bajan
Veteran Status – None
Immigrant
Status – Bajan citizen
Language
– English
Sensory Impairment
– Blind
Motor
Impairment – None
MedicalConditions
– Hypothyroidism
Presenting
Problem – Sad
Withdrawn
Irritable
Affective
Symptoms – Depressed
Low
energy
Behavioral

Symptoms – Aggression
Cognitive
Symptoms – Memory impairment
Family and
Support Systems – Isolated
Recent death of husband
COMMENTARY
The Strengths Perspective: Proving
"My Strengths" and "It Works"
Richard C. Rapp
I
was in Tampa, Florida, recently conducting a
day-long follow-up training session for care
coordinators who a year prior had undergone
basic training in strengths-based case management
(SBCM). Since the initial training, they had been
using a brief model of SBCM to assist newly diag-
nosed people who were HIV-positive obtain initial
medical care. When I asked the group members
about their experiences using the strengths-based
approach over the past year, one woman spoke up
sofdy, but pointedly saying, "It works!" The com-
ment prompted widespread agreement and a discus-
sion of how using the strengths perspective assisted
people with HIV, and not trivially by any means,
helped the care coordinators as well.
The Tampa discussion about the strengths

perspective mirrored MacFarlane's description of
personal and professional experiences with the
perspective in "My Strength: A Look Outside the
Box at the Strengths Perspective" (MacFarlane,
2006). She offered a powerful firsthand view of how
her clients responded to the emphasis she placed
on helping them identify their strengths and take
charge of their own plans—both core principles of
strengths-based practice. Experiences like those of
MacFarlane and the care coordinators I trained in
Florida are typical of social workers who practice
from the strengths perspective.
Although practitioners and the clients they serve
may believe it is effective, strengths-based case
management will remain only a "feel good" state of
mind without empirical support for its effectiveness.
That lack of legitimacy would be most unfortunate
because strengths-based practice reflects several of
social work's core values. Some work toward evaluat-
ing the effectiveness of the approach has been taking
place in several locations and demonstrating that we
do have some empirical basis for several elements
of the strengths perspective.
Dr. Charles Rapp (no relation),Dr. Dennis Salee-
bey (emeritus), and others at the University of Kansas
School of Social Welfare provided early fmdings
about the value of strengths-based case management.
With a people-first orientation, they reported that
patients leaving state psychiatric hospitals were able
to accomplish many of the goals they had identified
in treatment (Rapp & Chamberlain, 1985). Since
that time they have contributed to our understand-
ing of the conceptual basis for strengths-based work

(Saleebey, 2006) and provided a tool for assessing the
key elements of strengths-based case management
(Marty, Rapp, & Carlson, 2001) .This work serves as
the touchstone for anyone interested in delivering
strengths-based services.
Empirical research, both quantitative and quali-
tative, has taken place elsewhere. For the past 15
years the Center for Interventions, Treatment, and
Addictions Research (CITAR) at Wright State
University's Boonshoft School of Medicine, Dayton,
Ohio, has focused on the process and outcomes as-
sociated with strengths-based case management with
people who have substance abuse issues. CITAR
has tested SBCM in controlled clinical trials funded
by the National Institute on Drug Abuse. Results
have shown that long-term SBCM, up to nine
months, provided during aftercare treatment, led
to improved retention in aftercare services and
reduced drug use and criminal justice involve-
ment (Rapp, Siegal, Li, & Saha, 1998; Siegal et al.,
1996; Siegal, Li, & Rapp, 2002) .The relationship
between SBCM and improved outcomes was not
direct. Rather it was mediated by the apparent
ability of strengths-based case managers to en-
courage retention in aftercare. SBCM was also
associated with improved employment function-
ing, although the effects were mediated by time
(Siegal et al., 1996).This is not surprising given
case management's focus on assisting clients with
employment. One study suggests that SBCM may
operate as a stand-alone treatment intervention,
rather than just as an adjunct to treatment (Siegal,
Rapp, Li, Saha, & Kirk, 1997).
CCC Code: 0037-8046/07 $3.00 O2007 National Association of

Social Workers 185
Recently, CITAR has begun to examine
the possible benefits of SBCM delivered at the
beginning of the treatment continuum. A brief
model of SBCM, up to five sessions delivered in
two months, was found to improve linkage with
medical care among people who were recently
diagnosed as HIV-positive (Gardner et al.,2005).
As yet unpublished results demonstrated that
among people with substance abuse problems
there was a significant improvement in linkage
rate for the group that received brief SBCM
compared with the standard care group.
Qualitative studies are particularly suited to help-
ing identify the elements of strengths-based case
management that are associated with the outcomes
mentioned earlier. In one ethnographic study,
clients identified the focus on strengths and the
relationship with their case managers as central to
their continued participation in treatment (Brun &
Rapp, 2001). Elsewhere, clients noted that learning
how to identify and set goals was one of the most
beneficial activities they had with strengths-based
case managers (Rapp, 2006) and that the work-
ing alliance between client and case manager was
critical to their success (Redko, Rapp, & Carlson,
in press).
The work we and others have conducted still rep-
resents SBCM research in its infancy. What is really
needed is a comprehensive research agenda that sys-
tematically examines the outcomes and mechanisms

of action associated with strengths-based approaches.
Both the National Association of Social Workers
and the Institute for the Advancement of Social
Work Research are important in promoting such
an agenda.These organizations, and social work
researchers in general, should come together to
propose a plan to evaluate the role of SBCM in
diverse groups of people who have various life
challenges. A possible mechanism for beginning
such a plan is the recently released National
Institutes of Health program announcement.
Research on SocialWork Practice and Concepts
in Health (PA 06-234).
Finding out whether strengths-based case man-
agement is effective in helping individuals with
life challenges gives the social w ôrk profession an
opportunity to support an evidence-based prac-
tice activity that is based on our core values. An
organized research effort will serve to determine
whether there is indeed support for the anecdotal
observation that "It works!"
REFERENCES
Brun, C , & Rapp, R . C. (2001). Strengths-based case
management: Individuals' perspectives on strengths
and the case manager relationship. Social Work, 46,
278-288.
Gardner, L. I., Metsch, L. R., Anderson-Mahoney, P.,
Loughlin,A. M., del Rio, C , Strathdee, S., Sansom,
S. L., Siegal, H. A., Greenberg,A. E., Holmberg, S.D.,
& the Antiretroviral Treatment and Access (ARTAS)
Study Group. (2005). EfFicacy of a briefcase manage-
ment intervention to link recently diagnosed HIV-

infected persons to care. AIDS, i9,423-431.
MacFarlane, C. D. (2006). My strength: A look outside
the box at the strengths perspective. Social Work, 51,
175-176.
Marty, D., Rapp, C. A., & Carlson, L. (2001).The experts
speak: The critical ingredients of strengths model
case management. Psychiatric Rehabilitation Journal, 24,
214-221.
Rapp, C. A., & Chamberlain, R. (1985). Case management
services for the chronically mentally ill. Social Work,
30,417-422.
Rapp, R. C. (2006).The strengths perspective and persons
with substance abuse problems. In D. Saleebey (Ed.),
The strengths perspective in social work practice (4th ed.,
pp. 77-96). NewYork:Allyn & Bacon.
Rapp, R. C , Siegal, H. A., Li, L., & Saha, P. (1998). Predict-
ing postprimary treatment services and drug use
outcome: A multivariate analysis. American Journal of
Drug and Alcohol Abuse, 24, 603-615.
Redko, C , Rapp, R. C , & Carlson, R. G. (in press).
Understanding the working alliance between persons
with substance abuse problems and strengths-based
case management. JoKma/ of Psychoactive Drugs.
Saleebey, D. (2006). The strengths perspective in social work
practice (4th ed.). NewYork:Allyn & Bacon.
Siegal, H. A., Fisher,}. H., Rapp, R . C , Kelliher, C.W.,
Wagner,J. H., O'Brien,W. F, & Cole, P A. (1996).
Enhancing substance abuse treatment with case

management: Its impact on employment.Jowraa/ of
Substance Abuse Treatment, 13,93-98.
Siegal, H. A., Li, L., & Rapp, R . C. (2002). Case manage-
ment as a therapeutic enhancement: Impact on
post-treatment criminality. JoMraa/ of Addictive Diseases,
21,37-46.
Siegal, H. A., Rapp, R. C , Li, L., Saha, P, & Kirk, K.
(1997). The role of case management in retaining
clients in substance abuse treatment: An exploratory
analysis. JoMrna/ of Drug Issues, 21, 821—831.
Richard C. Rapp, MSVf{ACSl1{ is assistant professor and
principal investigator, Center for Interventions, Treatment and
Addictions Research, Wright State University, Boonshoft
School
of Medicine, 3640 Colonel Glenn Highway, Dayton, OH, USA
45435; e-mail: [email protected]
Original manuscript received July 7, 2006
Accepted August 8, 2006
186 SocialWork VOLUME 52, NUMBER i APRIL 2007
Understanding the Working Alliance
Between Persons with Substance
Abuse Problems and Strengths-Based
Case Managers^

Cristina Redko, Ph.D.*; Richard C. Rapp, M.S.W.**; Cindy
Elms, M.S.W.***;
Mindy Snyder, M.A.*** & Robert G. Carlson, Ph.D.****
Abstract—A substantial body of literature has examined the
importance of the working alliance in
psychotherapy; few works have examined it in the context of
case management. Qualitative methods
were used to examine how 26 persons with substance abuse
problems perceived the working alliance
with case managers who practice from the strengths perspective.
Clients' narratives emphasized the
personal qualities of the case manager and the nature of the
client-case manager relationship. Their
narratives also reflected two guiding principles of strengths-
based case management: personal control
over goal-setting, and an emphasis on strengths. Most clients
concluded that a positive working alliance
helped them to build trust, self-worth, and self-esteem.
Keywords—case management, qualitative research, strengths
perspective, substance abuse treatment,
working alliance
A therapeutic or working alliance is defined broadly in
psychotherapy research as the collaborative and affective
bond between therapist and client, a condition considered
essential for the therapeutic process (Bachelor & Horvath
1999). The quality of the therapeutic alliance has been found
to predict the success of counseling and psychotherapy.
regardless of theoretical underpinning, and across clients
with a variety of disorders (Hubble, Duncan & Miller 1999).
For persons with substance abuse problems, the development
of a working alliance early in treatment has been a consistent
predictor of successful engagement and retention in treat-

ment (Meier, Barrowclough & Donmall 2005; Barberet al.
tThis research was supported by National Institute on Drug
Abuse
(NIDA) grant #DA 15690 for a study entitled "Reducing
Barriers to Drug
Abuse Treatment Services"; Richard C. Rapp, Principal
Investigator, Robert
G. Carlson, Co-Principal Investigator. Special gratitude to the
late Harvey A.
Siegal, founder of the Center for Interventions, Treatment, and
Addictions
Research. The authors thank Tracy D. Daus for qualitative
interview
transcription. The views expressed in this article do not
necessarily reflect
those of NIDA or any government agency.
•Research Assistant Professor, Center for Interventions,
Treatment, and Addictions Research (CITAR), Wright State
University,
Dayton, OH.
Journal of Psychoactive Drugs 241
»•Assistant Professor, Center for Interventions, Treatment, and
Addictions Research (CITAR), Wright State University, Dayton,
OH.
• • • C a s e Manager, Center for Interventions, Treatment, and
OH
••••Professor and Director, Center for Interventions, Treatment,
and

OH
Please address correspondence and reprint requests to Cristina
Redko,
Ph.D., Centerfor Interventions, Treatment and Addictions
Research, Wright
State University Boonshoft School of Medicine, 3640 Colonel
Glenn
Highway, Dayton, OH, USA 45435. Telephone: 937-775-3856,
Fax: 937-
775-3395; email: [email protected]
Volume 39 (3), September 2007
Redko et al. Understanding the Working Alliance
1999; Petry & Bickel 1999), but an inconsistent predictor
of post-treatment outcomes (Meier et al. 2005).
Most studies that describe the therapeutic or working
alliance and its effects come from psychotherapy research
(Martin, Garske & Davis 2000; Horvath & Symonds 1991).
Conversely, little work has been undertaken to examine the
nature of the relationship between client and case manager
(Brun & Rapp 2001). This is surprising, since case man-
agement is a ubiquitous social service intervention used by
health professionals in their work with geriatric populations,
adolescents, and persons with substance abuse and/or mental
health concems, developmental disabilities, and HIV/AIDS
(Austin & McClelland 1996; Siegal et al. 1995; Reishman,
Mor&Piette 1991).
The current study employs qualitative methods to pro-
vide a rich description of the working alliance that develops
between individuals with substance abuse problems and

case managers who practice from a strengths perspective.
Understanding the working alliance can help substance
abuse professionals identify how the interaction between
client and case manager encourages treatment linkage and
engagement and leads to improved outcomes. This article
will address two research questions: How do persons with
substance abuse problems perceive the working alliance with
strengths-based case managers? and How does the working
alliance produce change, according to these clients' percep-
tions? Qualitative methods are best suited to focusing on a
description of clients' perceptions because they provide an
inductive approach that offers a richer understanding of the
working alliance phenomenon and greater clinical relevance
than interpretations imposed on the clinical situation from
outside (Bachelor 1995). Also, clients' perceptions of the
alliance have been more consistent predictors of improve-
ment, when compared to perceptions of health professionals
(Horvath & Symonds 1991).
WORKING ALLIANCE: AN OVERVIEW
Terms that have been used to describe the relationship
between therapist and client include: therapeutic alliance
(Zetzel 1956), helping alliance (Luborsky 1976) and work-
ing alliance (Greenson 1965). Although there are some
differences among these terms, most definitions have three
themes in common: the collaborative nature of the relation-
ship, the affective bond between client and therapist, and the
client's and therapist's ability to agree on treatment goals
and tasks (Martin, Garske & Davis 2000; Gaston 1990;
Bordin 1979). Contemporary approaches for viewing the
working alliance represent a spectrum that ranges from a
classic psychoanalytic framework based on the model of
positive transference to more reality-based perspectives of
the therapeutic relationship (Crits-Christoph & Gibbons
2003; Horvath 2000). Greenson (1965) introduced the term

working alliance to emphasize the reality-based attachment
in addition to the positive transference component of the
relationship. He stressed the collaboration between patient
and psychoanalyst working purposefully together in the
therapy situation.
Psychotherapy research of the past three decades has
suggested that the working alliance is a common factor re-
sponsible for clients' change in all forms of psychotherapy
(Bachelor & Horvath 1999; Luborsky 1976). Apantheoreti-
cal formulation emphasizes collaboration and is applicable
to other helping processes besides psychotherapy in that
". . . the working alliance between the person who seeks
change and the one who offers to be a change agent is one
of the keys, if not the key, to the change process" (italics
in original) (Bordin 1979: 252). From this perspective the
working alliance is not, in and of itself, considered curative
or an intervention, but it is the vehicle through which thera-
peutic gain may be facilitated (Horvath & Luborsky 1993).
While not an intervention, the working alliance has
both technical and relational aspects (Bordin 1994; Gelso &
Carter 1994). The technical aspects of the working alliance
include goals (general objectives towards which therapy is
directed) and tasks (the specific activities the client must
engage in to attain goals and benefit from therapy). The
bond consists of the affective quality of the relationship
between client and therapist. The strength of the working
alliance is both affected by and affects the extent to which
therapist and client agree on the goals of their work, agree
on the tasks that are useful to attain the goals, and experience
an emotional bond with each other. The interdependence
between relational and technical factors in therapy and
positive developments in each facilitate the growth of the
other. Furthermore, the interactive nature of the relationship

and the integration of the technical and relational aspects
distinguish the working alliance from other relationship
constructs (Bordin 1994).
Persons with substance abuse problems are often
considered one of the more difficult groups to engage in a
helping relationship or effective working alliance. Correct
or not, this perception may be due to substance abusers
frequently being referred to treatment by the criminal justice
system and the effects of drug-using environments that can
be characterized by mistrust and dysfunctional relation-
ships. Whether or not a working alliance is more difficult
to establish with substance abusers, it has been shown to be
a predictor of retention in substance abuse treatment (Meier
et al. 2005; Barber et al. 1999; Petry & Bickel 1999). The
relationships between clients and substance abuse treatment
staff have been found to be related to client motivation and
readiness for treatment, and these two factors in turn can
be predictive of substance abuse treatment retention and
outcomes (De Leon 2001; De Weert-Van Oene et al. 2001;
Simpson, Joe & Rowan-Szal 1997; Simpson et al. 1997).
Other studies provide mixed results on whether the work-
ing alliance can predict post-treatment outcomes (Tetzlaff
etal. 2005; Barber et al. 2001; Beldingetal. 1997; Carroll,
Nich & Rounsaville 1997). A common feature of all of these
Journal of Psychoactive Drugs 242 Volume 39 (3). September
2007
Studies is that working alliance is usually measured early in
treatment and at only one or two time-points, which may not
reflect the changing nature of the relationship and its final

influence on engagement, retention and outcome (Meier et
al. 2005).
Case Management and Working Alliance
While much has been written about the working alliance
in the context of psychotherapy, few studies have addressed
the working alliance between case managers and their
clients (Brun & Rapp 2001). This is surprising, since case
management is a major source of supportive care for many
disadvantaged populations (Ballew & Mink 19%). Unlike
in many models of psychotherapy, the working alliance is
seldom addressed directly in case management. An excep-
tion is the strengths-based approach to case management
(SBCM). in which one of the fundamental principles, and
all practice activities, stress successful development of an
effective working relationship (Rapp 2006; Brun & Rapp
2001). The goal of therapy involves finding solutions to
treatment of interpersonal and intrapersonal problems, while
case management assists individuals in identifying and ac-
cessing needed resources and developing a plan to acquire
those resources (Ballew & Mink 1996). Additionally, the
status and importance attributed to "doing therapy" is gener-
ally much higher than that of "doing case management." As
a result, the nature of the working alliance may be different
as well. Bordin's model has been used to examine the case
management working alliance because of its potential to re-
flect the significance of the relationship from the standpoint
of problem-solving. The conceptualization of goals, tasks,
and bonds closely mirrors the steps involved in case manage-
ment planning (Howgego et al. 2003). The strengths-based
model of case management assists marginalized individuals
in accessing needed resources and improves treatment link-
age, engagement, and subsequent outcomes (Rapp 2006).
Five principles guide SBCM: (a) client strengths,

abilities and assets are emphasized during assessment and
planning; (b) clients retain control over goal-setting and the
search for needed resources; (c) the relationship between
client and case manager is important; (d) the community
(especially informal sources) is viewed as a resource and not
a barrier; and (e) case management is conducted as an active,
community-based process. The principles form the basis for
all practice activities. A strengths assessment encourages
clients to Identify skills, interests, and evidence of past suc-
cesses and positive traits. The focus on positive attributes
is based on the theory of self-efficacy—the hypothesis that
people will be more likely to begin and maintain positive
behaviors if they recognize that they have engaged in those
behaviors in the past (Bandura 1977). Case managers help
clients weigh alternatives and consider the short- and long-
term implications of their goals, objectives, and strategies,
but will not attempt to steer clients in a certain direction or
otherwise manipulate the plan (Rapp 2006).
Studies that have examined the working alliance in case
management have assessed the relationship in the context of
community mental health. Some of these studies have used
a retrospective approach to document a strong association
between client-rated alliance and positive clinical outcomes,
such as reduced symptom severity, improved global func-
tioning and satisfaction with mental health treatment (Neale
& Rosenheck 1995; Solomon, Draine & Delaney 1995).
Chinman, Rosenheck, and Lam (2000) conducted one of the
few prospective studies that has shown a positive association
between the client-rated alliance with the case manager and
general life satisfaction.
METHODS
This article is based on qualitative interviews and
focus group discussions conducted as part of the Reducing

Barriers to Drug Abuse Treatment Services Project (RBP),
a five-year study funded by the National Institute on Drug
Abuse. The RBP is a three arm clinical trial designed to as-
sess the effectiveness of strengths-based case management
and motivational interviewing, relative to a standard refer-
ral process, in linking clients with treatment services and
subsequently engaging them in services. This article focuses
on the strengths-based case management arm of the larger
trial.
Eligible subjects were: (a) over 18 years of age; (b)
diagnosed as having a substance abuse and/or dependence
disorder using criteria from the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR; APA 2000);
(c) not suffering from schizophrenia or any other psychotic
disorder; and (d) referred to either residential or outpatient
substance abuse services. Alcohol abusing or dependent
individuals without other substance disorders were not
eligible.
The RBPsite is located in a centralized intake unit (CIU)
in a midwestern region with a county population of 552,000
according to the 2000 census. The CIU is the county's only
point of entry for uninsured individuals seeking treatment
for substance abuse and mental health problems. Assessment
therapists conduct psychosocial, mental health, and sub-
stance abuse assessments to determine the nature and extent
of clients' problems. Clients are referred to an appropriate
level of care within the community treatment system based
on American Society for Addiction Medicine (ASAM 2001)
criteria and situational factors such as treatment availability
and client preference. Referrals are made to eight state-certi-
fied, specialty substance abuse treatment programs. Clients
generally do not contact the treatment program immediately
after the assessment, but must wait to get a specific date from
the CIU, which may take from several days to over a week

after the assessment. Clients who are admitted to the trial
are randomized into the standard services provided by the
CIU while awaiting substance abuse treatment, or into one
of the clinical trial's two experimental arms. During the next
Journal of Psychoaclive Drugs 243 Volume 39 (3), September
2007
Redko et al. ,. Understanding the Working Alliance
60 days clients receive up to five sessions of strengths-based
case management (Rapp 2006), one session of motivational
interviewing (Miller, Rollnick & Conforti 2002), or they
receive standard services.
The project ethnographer (first author) invited a conve-
nience sample of clients who had been randomly assigned
to the strengths-based case management intervention to
participate in the present study before entering substance
abuse treatment. However, clients who were assigned to
the case management group but did not attend any of the
sessions were not included in this sample. Only one client
refused to participate. Two focus groups were conducted to
explore the range of views and opinions clients expressed
regarding strengths-based case management. Qualitative
interviews were also conducted with the clients individually,
A semi structured protocol was used to elicit their perceptions
of substance' abuse problems and treatment history, including
their perceptions of the strengths-based case management
services they received. For each qualitative interview or
focus group, lasting approximately 90 minutes, clients
were compensated $20 for their time. Clients completed an
informed consent form approved by Wright State University
Institutional Review Board. Throughout this article case

examples of drug users are provided under fictitious names
to protect the anonymity of research participants.
We used an inductive approach for qualitative data
analysis (Patton 2002; Erlandson et al, 1993). According to
Lincoln and Guba (1985) inductive data analysis involves
taking constructions that have emerged from the context
(e.g, interactions between interviewer and interviewee) and
reconstructing them in meaningful wholes. Data analysis
is developed by unitizing the data (identifying themes),
emergent category designation, and negative case analysis.
A coding system was created by the ethnographer while
examining the correspondence among various themes, by
investigating relationships between themes, and by discover-
ing unanticipated relationships. The next step in this kind of
analysis was to look for significant recurrences, repetitions,
and contradictions between and within themes. This step
often contributed to the emergence of other subthemes that
opened ground to exploring the data in new and unexpected
ways.
The coding system included themes such as "working
alliance" which identified all the sections of text in which
clients discussed their relationship with the strengths-based
case manager. The working alliance theme was subdivided
into other codes such as "client reactions towards the case
manager" and "case manager reactions towards the client."
For instance, "persistence," "support," and "personalization"
(treating the client as a person) are examples of emergent cat-
egories identified by clients as meaningful for the client/case
manager relationship. Afterwards, alternative interpretations
for the data were also considered (negative case analysis);
particularly data that would tend to refute the ethnographer's
reconstructions of reality. For example, the ethnographer
checked for occurrences of negative reactions of clients

towards the case managers, and how this influenced the
working alliance. Audiotapes of focus groups and qualita-
tive interviews were transcribed verbatim and then coded
by using NVivo®, a program designed for qualitative data
analysis (Richards 1999; Fielding & Lee 1998),
RESULTS
Characteristics of Study Participants
Sixteen men (61,5%) and ten women (38,5%) who
received strengths-based case management services agreed
to participate in either a focus group (14) or a qualitative
interview (17), while five of these participants participated
in both. Average age of participants was 39.0 (SD = 10,55),
The study sample was. equally divided between African
Americans and White participants. Seventeen participants
(65,4%) had completed high-school or more. Regarding
marital status, 53.8% (14) were single, 38.5% (10) were
separated, divorced or widowed, and 7.7% (two) were mar-
ried or living as married. While receiving the strengths-based
case-management services, almost half of the participants,
42.3% (11), were homeless and very few (four, or 15,3%)
were employed.
Considering drug of choice, 69.2% ( 18) of participants
preferred to use crack or powdered cocaine, while the
remaining 30.8% (eight) preferred heroin and/or nonpre-
scribed opioids. At the time of the CIU assessment, three
participants received the additional diagnosis of depressive
disorder, two had bipolar disorder, and one participant had
obsessive compulsive disorder. The majority of the par-
ticipants, 84.6% (22), had previously been in some form of
substance abuse treatment. Of those, 31.8% (seven) had been
to treatment once, and 68.2% (15) had multiple treatment
episodes. Fourteen participants (53.8%) had been in treat-

ment within the past two years. Four participants (15.4%)
had no previous treatment experience. Participants received
an average of 3.5 case management sessions offered by one
of the two female strengths-based case managers. Each
case manager had a small caseload of about 12 clients per
week. One case manager was White with a background
in chemical dependency and dual diagnosis while the other
was African-American with a background in social work.
The case management intervention was guided by a manual
created for this study. Case managers received weekly su-
pervision from the Reducing Barriers clinical director.
Personal Qualities of the Strengths-Based Case Manager
Clients frequently started talking about strengths-based
case management by identifying the case manager's personal
qualities that they valued the most. Harry, an African-American
who abused crack, said, "She is a good listener; she listens,
she also has some good responses to the things that I say."
Aline, a 36-year-old White woman who abused both crack
and heroin, mentioned: "She didn't put me down for what I
Journal of Psychoactive Drugs 244 Volume 39 (3), September
2007
did in my life... she listened, listened very well." Similarly,
Diana, a 33-year-old African-American who used crack,
emphasized, "She listened to me, because I was hurting,
and I was going through a whole lot."
Clients reported that much of their past experience with
other counselors and case managers was not about listening

or being listened to—they were just being told what they
had to do. Likewise, clients often claimed that other people
did not pay any attention to them anymore. By listening
carefully to what clients had to say, the strengths-based case
manager introduced the possibility of clients developing
trust in relationships again. Besides being a good listener,
clients perceived the strengths-based case manager as being
understanding and nonjudgmental. Harry added, "She took it
in, she understood, she wasn't judging me, OK, she wasn't
saying 'you was right you was wrong' she wasn't judging
me; she was understanding, I think that's a key to a lot of
recovery right there."
Several clients appreciated this understanding and
nonjudgmental attitude because they did not feel stigma-
tized by the strengths-based case managers, which is how
they often felt they were treated by other people. Dwayne,
an African-American who used crack cocaine, explained:
"She was very understanding, when you come into a place
like this, everybody has this criteria of a crack head." The
listening, understanding, and nonjudgmental attitudes can be
key ingredients that promote recovery, as Harry suggested
above.
Relationship with the Case Manager
Clients understood the working alliance in terms of the
good relationship they were building with the strengths-
based case manager. They valued the fact that the case
manager was trying to build a good relationship with them,
and that the case manager related well with people: Shandi,
an African-American female who used crack, said, "Yeah we
talked, we got a good relationship." Jack, a White male who
used crack, claimed that "She was a godsend, she related to
me well. I am sure that she would relate well with whoever
the situation was." In many cases, just being present with the

client was sufficient to create a good helping relationship.
Martin, a 47-year-old White male who used crack, com-
mented on "Just her demeanor, her actions, her questions,
the way she went about things." Diana said, "She helped me
out a great deal. She was there for me, and I didn't know
where I was going."
Clients felt the relationship with the case manager
lightened the burden of the addict life-style. Alex, an Af-
rican-American who used heroin, said, "When I was left
talking to her, I felt like I was on a cloud, I was floating, she
was very—left a very great impression on me." Experiencing
a feeling of lightness, or increased optimism, made clients
feel more confident about themselves and about the possi-
bility of making changes in their lives. Harry described this
with enthusiasm: "But after I get through talking to her, I'm
feeling like I'm on the cloud, you know I feel like there's
nothing I can't do." Since clients were so immersed in the
confusion of the drug-using life style, they believed they
had nobody they could trust. For many, the strengths-based
case manager soon became the "friend" they could talk to,
the friend they needed, a person they could trust or feel
comfortable with. As Harry stated, "Talking with her lease
manager] was like talking to a friend, I felt relaxed. I felt
comfortable; I feel like I can come from the heart." Rowan,
an African-American who used crack, said: "She is the only
friend I have; she encourages me. She is my angel."
Clients felt at ease talking with the strengths-based case
manager because they could talk at their own pace and time
without feeling pressured, so they were able to express their
emotions and feelings. By "bringing it out" or by "opening
up," clients were also able to build trust in the relationship.
For example. Jamar, an African-American who used crack,
commented:

I can be mad and talk to her 'cause she knows how to "bring it
out of you" easy. She knows how to bring o u t . . . you talking
to her without pushing you to talk. I found I'm real comfort-
able with her, and I'm not comfortable with everybody. Yeah
I'm very comfortable 'cause I can just like open up with
h e r . . . I just feel like I can trust her, I'm like that, if I feel
like I
can trust you I'll open up, but I got to have that feeling that I
can
trust you, and I felt like that, I could trust her from day one.
Feeling comfortable implies the absence of sources of
pain or distress, freedom from stress or anxiety, peace of
mind. When clients start to feel comfortable talking about
their problems with the case manager, it can encourage them
to start talking to other people as well. John, a young White
male who smoked marijuana, said, "She helped me bring
a side out of me that I try to hide from people, she made
me feel comfortable with talking about my problems," In
some ways the case manager was modeling the possibility
of the client having more positive relationships with other
persons again. Greg, a 40-year-old African-American who
used crack, commented:
She's making the transition a lot easier, she made it easier for
me to want to talk to somebody else, 'cause that was my prob-
lem, that would be where I would relapse. She made it easier
for me to bring out the stuff that I am . . . not to be scared to
talk about how I feel to somebody else, without the fear of
them trying to judge me, since I'm in the program [SBCM], I
got to talk to them [his family], so it's making it little easier of
me not wanting to hold it in, just talk to them too.
The opportunity to set personal goals was encouraged by
his strengths-based case manager.

A common development of the good relationship was
summarized by Alex. He reported that the case manager
maintained a persistent approach, like making phone calls
to check if he was following through with the plans that
they had developed. As Alex recalled, "She always gave me
t h a t . . . uplift, OK, do the right thing, keep on doing what
2007
you're doing." She invariably had enough time to help Alex
accomplish tasks related to his goals: "When she would
take me somewhere, and they might be closed, and I might
want to give up, 'well we'll come back tomorrow [the case
manager would sayl, we got enough time, we can stay and
do this' !" In short, having the time and being persistent were
additional components of the strong working alliance that
strengths-based case managers promoted. Arthur, an Afri-
can-American who smoked marijuana, said: "She was like
don't give up, we're gonna get it for you." Archie, a White
male who used crack, noted: "She gave me that boost to get
off of my butt, and do things that I did." Martin added, "It
is just the extra push that does it."
Clients reported that establishing goals and then ac-
complishing tasks builds the awareness that one can have
goals in life. Dwayne, an African-American who used crack,
explained: "We set goals that were achievable. It wasn't
nothing where I would set myself up for failure, so that
really helped out, she was there for me, t'o help me achieve
them." Setting goals frees the person to have more trust in

oneself, as explained by Carla, a 30-year-old White female
who used heroin: "I'm following all my goals, it just help
me to see that I can do it, even though I'm addicted to drugs,
doesn't mean that I still can't have goals."
During the focus group discussions, clients were sur-
prised to discover that each case manager had a full case
load of clients. Beforehand, they were feeling special and
unique, since they had the impression the strengths-based
case manager was completely focused on them individually,
Harry explained, "It's just like I was her world, whenever,
she just completely focused on what I needed, and what was
going on in my life, and what needs to be done." Helen, a
42-year-old African-American who used crack, said "Yeah,
I'm trying to think how did she have time for you all [other
focus group participants] because I thought she was just
mine, I mean my case manager."
Feeling special and unique can also be related to the
client-driven nature of the relationship. Clients recognized
this by observing that case managers usually respected their
opinions, feelings, and desires while trying to follow what
they, the clients, wanted. Harry said, "I always got positive
feedback from her, 'well what do you want to do, and how
do you want to do it,' she wanted my input always." Jamar
declared, "As we talked she didn't just force the issue of
what was wrong with me, and I just felt kind of openly
enough to tell her, I told her she uplifted my spirit, which
she did, and from there we just had a pleasant thing going."
Alex claimed, "All the goals that I've I set forth, she just
encouraged me to do them, and she stood by, she was there
for me." Alex also had the opportunity of attending sessions
with both case managers, because on a particular day his
case manager was off sick. He was surprised to observe that
although both case managers were different persons with
different personalities, they provided him the same quality

of service.
Focusing on Strengths, Seeing the Positives
The working alliance was impacted by the strengths
assessment, an activity where case managers help clients
identify personal strengths and skills. Clients commented
that in some circumstances they were able to recognize some
of their personal strengths, while in others, the case manag-
ers pointed out some of the strengths that emerged during
the working alliance relationship. For instance, if a client
showed up on time to appointments with the case manager,
or if the client called when an appointment needed to be
cancelled and rescheduled, the case manager would suggest
that the client was being responsible and that responsibility
is a strength. Many of the strengths that clients identified
were related to behaviors they demonstrated while interact-
ing with the case manager, like responsibility, determination,
and the desire to help oneself.
When clients interacted with the case managers they
often expressed negative and overwhelming experiences
regarding themselves or their drug-using lifestyles. One of
the major roles of the case manager was to show that there
were more positive ways to perceive one's life situation,
leading clients to slowly change their perceptions to a more
positive view. According to Thom, a White male who used
heroin, "Letting me take that negative attitude, they always
use positive reinforcement to find a way around the road
blocks that get thrown up in your way. I think that's the
biggest thing I got from them as far as positive influence."
In other words, instead of focusing on the negatives, which
clients seemed to be constantly doing, strengths-based case
managers guided clients to bring out some of the positives;
they guided clients to start making some changes. Greg
pointed out:

She wouldn't let me stay focused on the negatives, I know my
biggest barrier is always me, when I'm trying to do something
positive, a lot of times I Just have that fear of success, like I
was really scared to win, that was one thing she helped me
knock down. She helped me knock it down, she gave me some
just positive things to do . . . she just kind of led the way will-
ing to help.
Focusing on strengths or stimulating positive thinking
increases a client's sense of self-worth. This is significant
because clients often perceived their own selves as their
biggest barrier to following through with treatment. Karen,
a 55-year-old White female who used crack and alcohol,
mentioned:
She made me feel worthy enough to go and get help, I was
down, low enough, so she really helped me a lot. Worthy, she
was always giving me a positive attitude, she said good things
about me, and how the things that I was doing . . . like making
a schedule, and getting things done.
Building Self-Esteem, Allowing Change
Having the opportunity to talk about oneself and one's
drug problems helped clients gradually change views about
2007
themselves and improve their self-esteem. Thom observed,
"If a person gets to tell other things about themselves, then

they start looking at themselves too." Arthur noted, "She
basically opened my eyes that there's a lot more potential in
me, if I get the awareness that I need about drugs." Yasmin,
an African-American female who used crack, said, "That's
why I'm doing this—because the more that I can talk about
my problems and the drugs, the stronger it makes me in-
side."
Besides rebuilding self-esteem, clients like Alex (below)
commented how the working alliance with the strengths-
based case manager helped them build self-confidence:
When I sit and talk to her, things that she didn't know about,
she would listen, she would ask questions, and she would like
learning, and I would feel at ease. I gave it the truth and kept it
real and she gave me support. I don't have that self confidence
in me, she tried to tell me, she gave me self confidence.
Strengths-based case managers also helped some clients
overcome the stigma of being labeled a drug addict. For
instance, Diana described substance abuse treatment as an
environment where "everybody gets the same diagnosis and
they treat you the same" and her reaction would be "that's not
me." In contrast, the strengths-based case manager behaved
differently with her because "She actually cared, she's talk-
ing to you, trying to see where you're a t . . . giving some
feedback and input." In this context, several clients started
to perceive themselves as persons again—not stigmatized
addicts, but persons with feelings. Aline mentioned, "It's
helped me tremendously, it gives me feelings about myself
again."
Relating with the strengths-based case manager gradu-
ally stimulated changes. During this process, some clients
were able to recover their own identity and a sense of self-
worth, as described by Harry:

You have an identity, and she's helping you releam your iden-
tity, 'cause you lose it out there in the street, you don't have
that same identity anymore, now the identity is within the
drugs. She actually took the time to show you that it is not
about the drugs, it's about you, and the things that you want
to accomplish in life; I feel that that is the biggest difference
right there.
In short, the working alliance evolved in ways that allowed
many clients to build self-esteem, self-confidence, regain a
sense of identity different from their previous drug-using
life style, and consequently, seek substance abuse treatment.
Aline exclaimed, "I have grown so much I mean and I'm
still growing, she's made a big difference in my life, because
I didn't think there was any hope. Thom said, "Just take a
little bit of interest in me, help me get through this, I'll do it.
She helped me a great deal, I wouldn't have done it without
her. Martin affirmed, "A little bit of help went a long way,
a little bit of help went a long way."
DISCUSSION
This article describes how persons with substance abuse
problems understood their relationship, or working alliance,
with case managers who practice from a strengths perspec-
tive. Contacts between client and case manager took place
immediately following assessment at a centralized intake
facility but before entry into treatment. The analysis of cli-
ents' narratives revealed three major themes as they relate
to the working alliance: the personal qualities of the case
manager, client control over goal-setting, and the focus on
client strengths and abilities. Taken together, these aspects
of the working alliance assisted some clients in building
self-esteem and improving self-efficacy, leading to positive
change.

Being a good listener, demonstrating understanding,
and maintaining a nonjudgmental attitude were the personal
qualities that clients valued most in the case manager. Clients
felt free from stigma; they were being treated like persons
again. Clients described the relationship as one where they
progressively felt more confident and comfortable, and able
to talk to their case manager like a friend. The nature of
the relationship was also defined in relation to the attitudes
demonstrated by case managers: taking time, showing per-
sistence, and maintaining a client-driven approach. Clients
valued the fact that case managers took the time necessary so
they could express themselves at their own pace. They also
remarked on the persistence demonstrated by case manag-
ers towards helping them in every possible way: constant
phone calls, finding alternative ways to solve a problem or
to reach a goal, and "walking that extra mile." Mostly, they
appreciated the client-driven attitude of the case managers
because they carefully listened to what clients had to say
and supported what clients wanted to do.
Clients disclosed spontaneously how the relationship
with the case manager stimulated them to start a move
towards personal change, at least during the period immedi-
ately following assessment. These changes were generated
by building trust, bringing out positives, and by increasing
clients' sense of self-worth and self-esteem. Clients believed
that building trust strengthened the alliance. This trust
building process also helped clients to set up some tasks
and goals; accomplishing some of the goals helped clients
have more confidence in themselves, teaming that one
can trust people helped many clients open up to talk about
themselves, first with the case manager, and then with other
key persons. Consistent with the literature, a positive work-
ing alliance may lead to improved relationships with other
persons besides the case manager (Greenson 1965; Henry

& Strupp 1994).
From the perspective of clients, the working alliance
affected change by generating gradual transformations in
their sense of self. Clients commented on how acquiring
more positive views about themselves increased their levels
2007
of confidence, self-worth, and ultimately, of self-esteem. In
a similar vein, the change process evoked by the alliance
was also related to recovering a sense of worth and of self-
esteem. During the process of enhancing clients' self-esteem,
interpersonal relationships were also improved, according
to participants' perceptions. Clients also indicated that the
working alliance triggered some of the changes they were
starting to make. In particular, several clients acknowledged
that interacting with the case manager reassured them that
seeking substance abuse treatment was "the right thing to do."
Clients' narratives about the working alliance also
have implications for the strengths-based model that guided
implementation of case management. Three of the guiding
principles of strengths-based case management are reflected
in the themes describing the importance of relationship, per-
sonal control over goal-setting, and emphasis on strengths.
The client's control over goal-setting integrated the process
of building trust, self-worth, and self-esteem. Clients also
reiterated that assessing one's strengths, often understood
as bringing out the positives, slowly induced change and
increased self-esteem. Study participants pointed out how

bringing out the positives is more than just positive think-
ing; it is a collaborative interaction with the case manager
that reminds them that they already have the ability to make
changes. These findings provide support for case managers'
adherence to the strengths-based model.
Study Limitations
Some persons with substance abuse problems (about
20%) did not participate in any meetings with case managers
after being assigned to that arm of the trial. These individu-
als were not part of the sample, as the intent of this study
was to examine the working alliance. This may have been
due to their unwillingness to link with treatment. Had these
individuals participated with a case manager they may have
recounted a distinctly different experience with the working
alliance, one that would not have been so positive.
Further, it is possible that clients may have felt an
obligation to present their case manager and their interac-
tions in the most favorable light possible, perhaps out of
loyalty to their case manager. Clients may have expected that
positive comments about the alliance were what researchers
really wanted. This possibility may have been minimized
somewhat since these results were extracted from broader
interviews that did not focus on the working alliance alone.
Interviews also contained discussions about subjects' treat-
ment history, including expectations regarding treatment and
their perceptions about their own substance use.
The view that clients have of the working alliance
is likely influenced by a number of personal factors and
environmental considerations such as homelessness, be-
ing court referred, and previous experience with treatment
professionals. Although these factors were present among
people in the current study, there were an inadequate number

of participants to draw conclusions about the effect of these
on working alliance. Future studies with more homogeneous
groups (e.g., all persons who are homeless) .will help to de-
termine the influence of those characteristics on the type of
working alliance that develops. Many of the clients involved
in the study were also involved with other professionals at
the same time they were meeting with strengths-based case
managers. These relationships may also have influenced the
view that clients had about their work with case managers.
Another limitation is related to the experimental nature
of this study. Most experimental studies employ carefully
selected and highly trained therapists who may be more
prone to develop uniformly positive alliances with their
clients. For instance, studies of manual-based psychothera-
pies usually show very positive client-rated alliance scores,
near the top of the scale. For this reason, a greater range
of poor/positive alliances may be expected in naturalistic
studies (Crits-Cristoph & Gibbons 2003; Crits-Cristoph &
Connolly 1999).
Implications For IVeatment Professionals
The observations of these persons about their case
managers have implications for other treatment professionals
as well. Although persons with substance abuse problems
are seen as difficult to engage, our findings suggest that
this is not necessarily the case. The persons in this sample
responded positively to the same characteristics that psy-
chotherapy clients value: being heard and being respected.
Treatment professionals who provide services to persons
who have alcohol or other drug problems will be challenged
to establish a productive working alliance with them. While
treatment professionals' theoretical orientation and training
in specific treatment approaches or therapeutic techniques

are valuable in some clinical situations, the persons in this
study didn't directly identify them as important to the work-
ing alliance. Although certain skills may enhance the ability
to assist clients, these may only be useful in the context
of a trusting and respectful relationship where clients are
shown respect and given help in identifying their personal
strengths.
Initial contacts between substance abuse clients and
treatment professionals are all too frequently driven by rote
and repetitive completion of admission paperwork, rather
than an opportunity to listen to goals or promote strengths.
Practice settings that are driven by emphasizing and diag-
nosing pathology do not offer clients or professionals an
opportunity to show respect for the efforts that individuals
have made to improve their lives. This is in direct opposi-
tion to what the individuals in this study described as being
important.
The challenge for treatment professionals in all of
these settings is to engage clients in a working alliance
as described by the individuals in this study. When focus
group participants were asked what one recommendation
they would give to treatment professionals to improve their
early relationship with client,s one participant responded
2007
deliberately and emphatically, "Tell them |the worker] to
just put their pen and their forms down and listen to what I
have to say!" This most basic of human needs, to be heard.

can facilitate development of a working alliance that leads
to positive change.
REFERENCES
American Psychiatric Association (APA) 2000, Diagnostic and
Statistical
Manual of Mental Disorders (DSM-IV-TR). Fourth Edition,
Text
Revision. Washington D.C: American Psychiatric Association.
American Society of Addiction Medicine (ASAM), 200. Patient
Placement
Criteria for the Treatment of Substance-Related Disorders.
Second
Ed. Chevy Chase. MD: American Society of Addiction
Medicine.
Austin, C D . & McClelland, R,W. (Eds.) 1996, Perspectives on
Case
Management Practice. Milwaukee, Wl: Family Intemational Inc.
Bachelor, A. 1995. Clients' perception of the therapeutic
alliance: A
qualitative analysis. Journal of Counseling 42 (3): 323-37.
Bachelor. A. & Horvath, A, 1999, The therapeutic relationship.
In: M.
Hubble; B.L. Duncan & S.D. Miller (Eds.) The Heart and Soul
of Change: What Works in Therapy. Washington D.C: American
Psychological Association.
Ballew, J,R. & Mink. G. 1996. Case Management in Social
Work:
Developing the Profe.ssional Skills Needed for Work with

Multiprohlem
Clients. Springfield, IL: Charles C Thomas.
Bandura, A. 1977. Self-efficacy: Toward a unifying theory of
behavioral
change. Psychological Review S4 (2): 191-215.
Barber, J.P; Luborsky, L,; Gallop, R.; Crits-Christoph, P ;
Frank, A.;
Weiss, R.D,; Thase, M.E; Connolly, M.B.; Gladis, M.; Foltz, C.
&
Siqueland, L. 2001, Therapeutic alliance as a predictor of
outcome
and retention in the National Institute on Drug Abuse
collaborative
cocaine.treatment study. Journal of Consulting and Clinical
P.sychology 69 (I): 119-24,
Barber, J.P,; Luborsky, L ; Crits-Christoph, P;Thase, M.E.;
Weiss, R. Frank,
A. ; Onken, L. & Gallop, R. 1999. Therapeutic alliance as a
predictor
of outcome in treatment of cocaine dependence, P.sychotherapy
Research9{): 54-13.
Belding, M.A.; Iguchi, M,Y.; Morral,A.R. & McLellan,T.
1997,Assessing
the helping alliance and its impact in the treatment of opiate
dependence. Drug and Alcohol Dependence 48 ( 1 ): 51 -59,
Bordin, E S I 994. Theory and research on the therapeutic
working alliance:
New directions. In: A.O. Horvath & L, S. Greenberg (Eds,) The
Working Alliance: Theory, Research, and Practice. New York:
John
Wiley & Sons, Inc.

Bordin, E S . 1979. The generalizability of the psychoanalytic
concept of
the working alliance, P.sychotherapy: Theory, Research and
Practice
16 (3): 252-59.
Brun, C & Rapp, R.C. 2001. Strengths-based case management:
Individuals'
perspectives on strengths and the case manager relationship.
Social
Wort 46 (3): 278-88.
Carroll, K.M.; Nich, C & Rounsaville, B.J, 1997. Contribution
of
the therapeutic alliance to outcome in active versus control
psychotherapies. Journal of Consulting and Clinical Psychology
65 (3): 510-14.
Chinman, M.J.; Rosenheck, R. & Lam, J.A. 2000, The case
management
relationship and outcomes of homeless persons with serious
mental
illness./'í^c/iía/rícServí'ce.s 51 (9): 1142-47.
Crits-Christoph, P & Connolly, M.B, 1999. Alliance and
technique in
short term dynamic therapy. Clinical Psychology Review 19 (6):
687-704.
Crits-Christoph, P & Gibbons, M.B.C 2003. Research
developments on the
therapeutic alliance in psychodynamic psychotherapy.
Psychoanalytic
Inquiry li (2): 332-49,

De Leon, G. 2001. A commentary on "Retention in substance
dependence
treatment: The relevance of in-treatment factors," Journal of
Substance Abuse Treatment 20 (4): 263-64.
De Weert-Van Oene, G.H.; Schippers, G.M,; De Jong, C A , &
Schrijvers,
G.J. 2001. Retention in substance dependence treatment: The
relevance of in-treatment factors. Journal of Substance Abuse
Treatment 20 (4): 253-64.
Erlandson, D,A.; Harris, E L ; Skipper, B.L. & Allen, S.D.
1993. Doing
Naturalistic Inquiry: A Guide to Methods. Newbury Park,
California:
SAGE
Fielding, N.G, & Lee, R.M, 1998, Computer Analysis and
Qualitative
Research. Thousand Oaks, CA: SAGE.
Fleishman, J.A,; Mor, V, & Piette, J. 1991, AIDS case
management: The
client's perspective. Health Services Research 26 (4): 447-48,
Gaston, L. 1990. The concept of the alliance and its role in
psychotherapy:
Theoretical and empirical considerations. Psychotherapy:
Theory,
Research, Practice, Training 27 (2): 143-53.
Gelso, C.J. & Carter, J,A. 1994. Components of the
psychotherapy
relationship: Their interaction and unfolding during treatment,
Journalof Counseling Psychology A (3): 296-306,

Greenson, R,R, 1965, The working alliance and the transference
neurosis.
Psychoanalytic Quarterly 34: 155-81,
Henry, W.P & Strupp, H.H. 1994. The therapeutic alliance as
interpersonal
process. In: A O , Horvath & L,S, Greenberg (Eds,) The
Working
Alliance: Theory, Research and Practice. New York: John Wiley
& Sons,
Horvath, A,0. 2000. The therapeutic relationship: from
transference to
alliance. In Session: Psychotherapy in Practice 56 (2): 163-73
Horvath, A.O. & Luborsky, L. 1993, The role of the therapeutic
alliance
in psychotherapy. Journal of Consulting and Clinical
Psychology
61 (4): 561-73,
Horvath, A , 0 . & Symonds, B,D. 1991, Relation between
working
alliance and outcome in psychotherapy: A meta-analysis.
Journal of
Counseling Psychology Zi (2): 139-49.
Howgego, I.M,; Yellowlees, P ; Owen, C ; Meldrun, L. & Dark,
F 2003,
The therapeutic alliance: The key to effective patient outcome?
A
descriptive review of the evidence in community mental health
case
management, Australian and New Zealand Journal of Psychiatry
37 (2): 169-83.

Hubble, M,A.; Duncan, B,L, & Miller, S.D. (Eds.). 1999. The
Heart and
Soulof Change— What Works in Therapy. Washington DC:
American
Psychological Association,
Lincoln, Y.S. & Guba. E G , 1985. Naturalistic Inquiry. Beverly
Hills,.
CA: SAGE.
Lubbrsky, L. 1976, Helping alliance in psychotherapy. In: J,
Claghom (Ed,)
Successful Psychotherapy. New York: Brunner-Mazel
Martin, D,J.; Garske, J.P, & Davis, M.K. 2000, Relation of the
therapeutic
alliance with outcome and other variables: A nieta-analytic
review.
Journal of Consulting and Clinical Psychology 68 (3): 438-50,
Meier, P,S.; Barrowdough, C & Donmall, M,C 2005, The role of
the
therapeutic alliance in the treatment of substance misuse: A
critical
review of the literature. Addiction 100 (3): 304-16,
Meier, PS,; Donmall, M.C; Barrowdough, C ; McElduff, P &
Heller, R,F
2005, Predicting the early therapeutic alliance in treatment of
drug
misuse. Addiction 100 (4): 500-11,
Miller, W,R,; Rollnick, S, & Conforti, K, 2002, Motivational
Interviewing:
Preparing People for Change. Second Ed, New York: Guilford
Press,

Neale, M,S, & Rosenheck, R,A. 1995. Therapeutic alliance and
outcome
in a VA intensive case management program. Psychiatric
Services
46 (7): 719-21,
Patton, M.Q. 2002, Qualitative Research and Evaluation
Methods. Third
Edition. Thousand Oaks, CA: SAGE
Petry, N,M. & Bickei, W,K, 1999, Therapeutic alliance and
psychiatric
severity as predictors of completion of treatment for opioid
dependence. Psychiatric Services 50 (2): 219-27,
Rapp, R.C 2006. Strengths-based case management: Enhancing
treatment
for persons with substance abuse problems. In: D. Saleebey
(Ed,) The
2007
Strengths Perspective in Social Work Practice, Fourth Ed.
Boston:
Pearson.
Richards, L. 1999. Using NVivo in Qualitative Research.
Thousand Oaks,
CA: SAGE.

Siegal, H.A.; Rapp, R.C; Kelliher, C.W.; Fisher, J.H.; Wagner,
J.H. &
Cole, P.A. 1995. The strengths perspective of case management:
A
promising inpatient substance abuse treatment enhancement.
Journal
of Psychoactive Drugs 27 (1): 67-72.
Simpson, D.D.; Joe.G.W. & Rowan-Szal,G.A. 1997. Drug abuse
treatment
retention and process effects on follow-up outcomes. Drug and
Alcohol Dependence 47 (3): 227-35.
Simpson, D.D.; Joe.G.W.; Rowan-Szal, G.A. & Greener, J.M.
1997. Drug
abuse treatment process components that improve retention.
Journal
of Substance Abuse Treatment 14 (6): 565-72.
Solomon, P; Draine, J. & Delaney, MA. 1995. The working
alliance and
consumer case management. Journal of Mental Health
Administration
22(2): 126-34.
Tetzlaff, B.T.; Kahn, J.H.; Godley, S.H.; Godley, M.D.;
Diamond, G.S.
& Funk, R.R. 2005. Working alliance, treatment satisfaction,
and
patterns of post-treatment use among adolescent substance
users.
Psychology of Addictive Behaviors 19(2): 199-207.
Zetzel, E. 1956. Current concepts of transference. International
Journal
of Psychoanalysis 37: 369-75.

2007
Match or Mismatch: Use of the
Strengths Model with Chinese
Migrants Experiencing Mental
Illness: Service User and
Practitioner Perspectives
Samson Tse
Department of Social Work and Social Administration,
Faculty of Social Sciences, The University of Hong Kong,
Hong Kong
Monika Divis
Affinity Services, Auckland, New Zealand
Ying Bing Li
Centre for Asian Health Research and Evaluation,
School of Population Health, Faculty of Medical and
Health Sciences, University of Auckland, Auckland,
New Zealand
The strengths model assists service users and mental health
practitioners to
identify individual and environmental strengths and to secure
resources to

facilitate integration into the community and improve quality of
life. Interven-
tions are based on goals determined by the person with the
mental illness and
include support in accessing resources required to achieve
goals. Aim: The
study aimed to explore the use of the strengths model as a
recovery inter-
vention with Chinese people with mental illness in New
Zealand. Method:
This study was a qualitative study using individual interviews
and focus
Address correspondence to Samson Tse, Department of Social
Work and Social
Administration, Faculty of Social Sciences, The University of
Hong Kong, Hong Kong.
E-mail: [email protected]
American Journal of Psychiatric Rehabilitation, 13: 171–188,
2010
Copyright # Taylor & Francis Group, LLC
ISSN: 1548-7768 print=1548-7776 online
DOI: 10.1080/15487761003670145
171
groups to explore the views of Chinese service users, significant
others, and
health practitioners who have experience in using the strengths
model.
Analysis: Data were analyzed using a general inductive

approach to identify
key themes relevant to the research objectives. Results: The
focus on personal
and collective strengths and pragmatic approach adopted by the
strengths
model were regarded by participants as distinctive features of
the model.
On the whole, the service user participants regarded the
strengths model as
helpful in assisting their settlement and integration into the host
society.
Practitioners were confronted by the following three challenges
in applying
the model with Chinese migrants: passive role played by service
users, diffi-
culties in understanding the concept of strengths, and service
users with
complex needs. Conclusion: The Chinese migrant population is
a growing
community in most English-speaking countries. To provide
culturally respon-
sive strengths-based mental health services to Chinese migrants,
it is critical
for a number of factors to be taken into account, including
language barriers
and settlement issues, the Chinese cultural values of working
with the family,
and assessment and training tools that need to be translated
from English to
Chinese. It is important to measure the effectiveness of
applying strengths-
model interventions with Chinese users, particularly in
comparison with
conventional practice of case management.
Keywords: Cross-cultural approaches; Culturally responsive

services; Recovery
Since the 1950s, the major trend in health care for people with
persistent mental illness has moved away from long-term
institu-
tionalization toward community-based support. More recently,
the
focus has been on achieving wellness and recovery rather than
merely on rehabilitation and treatment of illness (Mental Health
Commission, 1998; Ministry of Health, 2005). The strengths
model
of case management is designed to enhance recovery outcomes
for
mental health service users (Chamberlain & Rapp, 1991; Rapp
&
Goscha, 2006; Rapp & Wintersteen, 1989). The strengths model
assists the mental health practitioner and service user (a) to
ident-
ify individual and environmental strengths, desires, and aspira-
tions and (b) to secure the resources needed by the service user
to facilitate integration into the community and improve quality
of life (Rapp & Chamberlain, 1985; Stanard, 1999).
Interventions
are based on goals determined by the service user and include
providing support in accessing the resources required to achieve
their goals. These goals may be in any one or more of six life
domains: (a) daily living, (b) financial situation, (c) vocational
and=or educational, (d) social support, (e) health, and (f) leisure
172 S. Tse et al.
and=or recreational, cultural, and spiritual. In practice, the
strengths model is guided by six principles:

1. People with mental illness can recover, reclaim, and
transform their
lives.
2. The focus is on individual strengths rather than deficits.
3. The community is viewed as an oasis of resources.
4. The service user is the director of the helping process.
5. The practitioner-service user relationship is primary and
essential.
6. The primary setting for our work is the community. (Rapp &
Goscha,
pp. 54–72)
It is predicted that approximately 47% of the total population in
New Zealand will experience a mental disorder at some time in
their lives and that almost 40% had already met criteria for a
disorder by 2006 (Oakley Browne, Wells, & Scott, 2006). New
Zealand’s ethnic distribution is rapidly changing, with Asian
being
the fastest growing population group (Statistics New Zealand,
2007). Consequently, it is imperative that the New Zealand
health
system is responsive to the growing language and cultural
differ-
ences amongst Asian peoples presenting to health services (Tse,
2004). Mental health services, in particular, need to modify
inter-
ventions to address the unique needs of identified population
groups.
For Chinese people, depression and psychosomatic illness are
frequently observed together with a complex interplay including
social isolation (from migration), language barriers,
underemploy-
ment, or unemployment (Ho, Au, Bedford, & Cooper, 2002).

The
stigma of psychiatric illness contributes to reluctance by Asian
people with mental illness and=or their family members seeking
early treatment, which further compounds problems. One of the
few studies on Chinese people’s mental health reported that up
to
26% of older Chinese migrants recruited through Chinese com-
munity organizations and general practitioners met the criteria
for depressive symptomatology (Abbott, Wong, Giles, Young, &
Au, 2003).
Rationale for Study
First, previous research studies show that the strengths model
intervention produces promising outcomes for people with
mental illness. These outcomes include reduction in psychiatric
Strengths Model with Chinese Migrants 173
hospitalization, significant improvement in overall physical and
mental health, increase in people’s rate of goal setting, positive
effects on social functioning and social supports, and improved
subjective measures of quality of life (Barry, Zeber, Blow, &
Valenstein, 2003; Bjorkman, Hansson, & Sandlund, 2002;
Macias,
Farley, Jackson, & Kinney, 1997; Stanard, 1999). However, to
date,
there has been no published study on the application of the
strengths model for service users from diverse cultural back-
grounds. Chinese traditions, in general, regard the family as the
fundamental unit of society and source of strengths in times of
adversity (e.g., experience of serious mental illness), whereas
Western strengths-based models tend to focus on the individual
(e.g., Lin & Cheung, 1999; Yip, 2003). Chinese concepts of

mental
health advocate a holistic and naturalistic approach. This
involves
the notion of harmony, an integration of individual and family
as
well as the wider social context such as villages in Chinese
rural
areas or political party of the country. These characteristics
suggest
that the strengths model may not be easily transferable from
European culture to another culture. It demands a careful
examin-
ation of the application of a strengths model in Chinese as
outlined
in the present study. Second, concern has been raised about the
mental health of Asian migrants in New Zealand (e.g., Abbott
et al., 2003; Ho et al., 2002). It is increasingly important to
identify
an intervention that could be used and=or adapted to contribute
to Chinese mental health care both in New Zealand and abroad.
Third, unlike other case management approaches in the mental
health field, the strengths model (Rapp, 1998; Rapp & Goscha,
2006) is relatively well-defined in terms of assessment and data
collection, therapeutic process, quality assurance, and
evaluation.
Aim and Objectives
The overall aim of this qualitative study is to investigate the use
of
the strengths model as a form of community mental health
service
for Chinese people in a New Zealand setting. The specific
objectives
of the study were the following:

1. To investigate how the strengths model is viewed from a
Chinese
cultural perspective.
2. To identify the challenges encountered by practitioners in the
appli-
cation of the strengths model.
174 S. Tse et al.
METHOD
Research Design
A partnership was established between university researchers
and
Affinity Services to enhance the feasibility and integrity of the
pro-
ject. Affinity Services is the longest operating nonprofit
community
mental health provider in Australasia and applies Charles
Rapp’s
Strengths Model and Mary Ellen Copeland’s Wellness Recovery
Action Plan (Copeland, 1997) in daily operational service
delivery.
We used qualitative methods to explore and critically evaluate
the
optimal use of the strengths model for Chinese populations.
Indivi-
duals were invited to participate in both individual and focus
group
interviews. Topics covered in the interviews included the
following:

. Participants’ experiences receiving or working with strengths
model
mental health support services.
. Individuals’ reflections about the association (or otherwise)
between the
strengths model and their cultural values and practices.
. Challenges in application of the strengths model with Chinese
people.
We obtained ethical approval from the Auckland Ethics
Commit-
tee of New Zealand on August 10, 2004 for a period of 16
months
(Reference AKX=04=07=203).
Sample
Three groups of people were involved in this study: (a) service
users who self-identify as Chinese, (b) service user’s family
mem-
bers interested in sharing their understanding of the strengths
model, and (c) practitioners of Charles Rapp’s strengths model
supporting people recovering from psychiatric illness.
Participants
were 16 years of age or older and resided in the Auckland
region of
New Zealand. Individuals who were unable to concentrate for a
45-min interview or focus group and those who posed danger
to self or others were not included in the present study. Tables 1
and 2 summarize the distribution and background of research
participants. Altogether, 35 individuals participated in this
study.

Data Collection Procedures
We conducted individual and focus group interviews with
service
users in Mandarin or Cantonese, and interviews with
practitioners
T
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176
T
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;
fo
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s
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b
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.
177
in English. Data were recorded in note form in the language
used in
the first instance; notes were translated to English by a
registered
translator, for subsequent analysis and reporting.
Data Analysis
Data collection and analysis took place concurrently. Analysis
commenced following the first interview and focus group
discus-
sions. Initial data and the research objectives were used to
create
a preliminary framework within which emerging topics were
identified and addressed in subsequent interviews and focus
groups. In other cases, as the findings emerged, we modified the
interview guidelines or searched for unique individuals such as
who reported experiencing particular difficulties with the use of
strengths model but still had positive recovery outcomes. Data
were analyzed using a general inductive approach to identify
key
themes relevant to the research objectives (Thomas, 2006). The
steps

included the following: (a) initially reading participants
responses
or the transcripts from individual interviews and focus groups,
(b) identifying text segments specifically related to the research
objectives, (c) labeling segments of text to create themes and
sub-
themes, (d) creating new themes and subthemes if findings
evident
in later interviews or focus group discussions did not readily
relate
to the existing framework, and (e) reducing overlap and
redundant
themes and subthemes. An important part of the rigor in the
present study was the confirmation of qualitative accounts with
participants. Consistent with the principles of members
checking,
we presented the data and interpretations to the research parti-
cipants in the present study to verify that their experiences were
adequately represented in the findings.
RESULTS
Theme 1: Perceived Features of the Strengths Model and
Its Alignment with Chinese Values and Beliefs from
Service User, Family, and Practitioner Perspectives
The subsequent sections summarize participants’ experiences
receiving or working with the strengths model and
understandings
about the association (or otherwise) between the strengths
model
and Chinese cultural values and practices.
178 S. Tse et al.

Focus on Strengths. Most participants identified a positive
focus on personal and collective strengths as the predominant
feature of the strengths model. Participants reported that this
focus
replaces the shame and blame often associated with mental
illness
among Chinese people.
‘‘Think of good things, more positive things, so I am able to
talk with
people. Telling me positive things are important . . . compared
with
traditional treatment received in hospital, SM is dealing with
the nice
and ‘healthy’ part of me.’’ (Service User 11)
‘‘She (the practitioner) asks me to recall previous successful
experiences to
be strong and provides very helpful life support.’’ (Service User
4)
‘‘Service users can get help to see their strengths during times
when they
usually feel bad or ashamed about themselves and see things in
a negative
light.’’ (Practitioner 2)
‘‘In China, if someone has a mental illness, it means he or she
is being
punished for what they did in their former life. The person has
to be locked
in a hospital and lose their freedom . . . whereas the Model
advocates
identifying and using patients’ strengths during their recovery.
There is

no blame, no judgement . . . ’’ (Service user focus group)
‘‘Chinese (recovering from mental illness) can see themselves
very negati-
vely . . . SM helps them see their own strengths. Mental illness
is just part of
the person.’’ (Practitioner 1)
The Practitioner–Service User Relationship. A perceived
feature of the strengths model for many service users was the
respectful and supportive relationship they had with their
strengths
model practitioner.
‘‘In Chinese culture, people with mental illness suffer
prejudices and
discrimination. SM services workers’ attitudes and personalities
are good.
The services are continuous, not one-off.’’ (Service User 13)
‘‘The community practitioner listens and talks to me, he treats
me like a
friend and shows his understanding . . . has a very kind attitude
and nice
personality.’’ (Service User 2)
‘‘He has never used any negative words or made judgement on
the things
I have done, he is a good listener . . . has a variety of
knowledge and
experiences in many fields so he can approach his service users
easily
and establish rapport with them.’’ (Service User 14)

Furthermore, the relationship was not considered prescriptive or
instructive. Rather, service users and family members were
offered
suggestions and opportunities to evaluate their options and
choose
a course of action.
‘‘Community practitioners help patients find direction, meaning
in their
life and options, then patients can build up their self-esteem to
recover.’’
(Service User 12)
‘‘The worker shows her respect to us . . . she is straight to the
point, she does
not tell us what to do. She provides us with analysis of the
situation and
suggestions.’’ (Family member focus group)
‘‘The SM helps patients learn self-help. It helps patients
recognise their
power, their rights.’’ (Service user focus group)
It is not entirely evident how much of the client-centeredness
was attributed to the strengths model per se or the general
recovery
approach used by mental health professionals practicing in New
Zealand.
Practical Service Delivery Method. The strengths model
was described as a very practical model by service users and
practi-
tioners. Its focus on setting goals toward recovery outcomes
coupled with regular reviews provided service users with

practical
assistance with addressing everyday needs and generating
motiv-
ation and achievement.
‘‘Chinese and other Asian service users like the SM because it
is a prag-
matic approach. Asian service users want results. They set goals
and
achieve them bit by bit.’’ (Practitioner 2)
‘‘The worker goes to court with me . . . she helps me read
English letters and
explains my situation to relevant organisations or services.’’
(Service User 3)
Connection to Chinese Values and Beliefs. Some parti-
cipants considered the strengths model a good fit with Chinese
values and beliefs as Chinese place a strong emphasis on being
achievement focused. This is best captured by the following
comment:
‘‘The SM fits well with Chinese culture. Chinese people are
good at setting
up goals in their life for example, strict educational
achievements,
hard-working attitude.’’
180 S. Tse et al.
Others considered some aspects of the strengths model to be not
compatible with Chinese traditional values and practices. Com-
pared with Europeans, Chinese people tend to be reserved and
less

inclined to talk about their successes and strengths. However,
dur-
ing further discussions, participants reframed this
incompatibility
as an opportunity to learn from Western culture and adopt a
differ-
ent worldview toward mental illness.
‘‘There are potential conflicts between Chinese tradition and
the SM.
Chinese tradition tends to be critical about oneself and
emphasises
modesty and being humble. The SM talks about strengths and
what one
is good at. But that’s why we go overseas. We have to accept
the emphasis
on strengths, giving people praise and encouragement.’’
(Service user focus
group)
Some participants reported that the strengths model practitioner
helped to improve family relationships. Among Chinese people,
mental illness may be considered a threat to the balance or har-
mony of family relationships because of the shame associated
with
mental illness. Practitioners worked alongside family to restore
the
family as the source of support and unity in times of adversity.
‘‘Mental illness is seen as a shame in Chinese families. The
family try to
protect the patient at home and do not allow them to go out . . .
it is impor-
tant to work with their family effectively.’’ (Practitioner 2)
‘‘The worker also deals with my family problems, he organised

counselling
services to help improve my family relationships.’’ (Service
User 15)
‘‘My community practitioner is very kind and helpful. I never
received this
kind of support services before in my home country. She also
works with
my husband and my daughter to support me.’’ (Service User 16)
Benefits for Migrants. Service users and practitioners ident-
ified that the strengths model is a useful tool for Chinese
migrants
who experience mental illness. As a mainstream model, it was
per-
ceived to support integration into the host community. It was
also
considered beneficial because it encouraged reconnection to the
capacity and resourcefulness Chinese migrants had shown in
their
country of origin, thus rebuilding self-confidence and self-
esteem.
‘‘Migrants easily feel negative and think they failed. The SM
shifts their
mindset from negative to positive.’’ (Practitioner 5)
‘‘Most Chinese migrants have excellent talents that are not
known by
people in New Zealand. The SM is a useful tool to find out their
strengths
that are normally ignored.’’ (Practitioner 4)

‘‘Chinese people are a minority group in New Zealand. The SM
is a mainstream
model that helps us integrate with the society.’’ (Service user
focus group)
‘‘The SM is flexible so it can accommodate Chinese service
users’ needs at
different stages of their recovery from mental illness and
settlement in the
country.’’ (Practitioner focus group)
Theme 2: Challenges in Applying the Strengths Model
with Chinese People with Mental Illness (Practitioner
Perspectives)
Service User Expectations. Practitioners reported the fore-
most challenge in applying the strengths model is balancing
their
role with service user expectations. In the view of practitioners,
Chinese service users often perceive practitioners as
professionals,
and their perception of a professional is one who will dictate a
required plan of action to get results on behalf of the service
user.
‘‘Demanding Chinese service users, service users who have a
lot of practi-
cal needs are difficult to deal with . . . community practitioners
need to
work for service users as ‘maid.’ Some service users treat
workers as their
drivers and use them.’’ (Practitioner 6)
‘‘Community practitioners are not there to provide solutions to
their pro-

blems—immediate needs, obtaining social welfare benefits,
settling their
immigration issues.’’ (Practitioner 7)
Service user expectations of practitioners are further
complicated
for those service users who have been in the mental health
system
for an extensive period of time. They had greater difficulty
accept-
ing the concept of making shared decisions about their own
lives.
Practitioner 8 stated, ‘‘Long-term institutionalised service users
want people to tell them what to do . . . there is some resistance
in
talking about strengths . . . You’re the professional. You should
do
it for me.’’
Difficulty Understanding Concept of Strengths. Practi-
tioners explained that Chinese service users’ expectations of the
practitioner possibly stems from their lack of understanding
about
182 S. Tse et al.
emerging concepts in Western mental health care. Notions of
service user-centeredness, self-determination, self-efficacy, and
autonomy are foreign concepts for Chinese people, particularly
among Chinese service users who come from less-developed
regions of their country of origin and=or have limited
education.
Independent of their ability to speak the language, practitioners
found it difficult to explain these concepts in terms that were

true
to their meaning as well as understood by the service user in the
context of their culture. Some of these concepts are core compo-
nents of the strengths model, which further hinders Chinese
service
users’ opportunity to take full advantage of the model.
‘‘Language barrier! Even I can speak Chinese and come from
the same
country of origin. It is very hard to explain certain concepts to
Chinese ser-
vice users, for example, ‘autonomy, and independency.’ Those
are abstract
words and lead to different interpretations. I have to convey the
meaning
by using simple, plain, everyday words.’’ (Practitioner 6)
Practitioners identified that an unfortunate effect of service
users differing expectations of practitioners coupled with a
limited
understanding of Western mental health care concepts somehow
facilitates development of service users’ dependency on practi-
tioners.
‘‘It is easy to develop dependency on workers . . . some service
users tend to
direct workers to do things for them.’’ (Practitioner focus
group)
The Challenge of Working with Chinese People with
Complex or Multiple Needs. Practitioners expressed that it
was challenging applying the strengths model with Chinese
service
users whom had complex or multiple needs. These included the
needs of service users associated with their mental illness as
well

as their migrant settlement needs and language barriers.
‘‘Chinese people would tend to focus on the language and forget
their
strengths. Language barrier is the biggest difficulty in their
everyday life.
They do not consider themselves having any strength.’’
(Practitioner 5)
‘‘Some Chinese users who are struggling with both mental
illness
and post-immigration adjustments find it hard to talk about
‘strengths’.’’
(Practitioner focus group)
Practitioners acknowledged that it is often exhausting to work
with migrants with these complex needs and suggested they
need
support to remain inspired and enthusiastic about their own
practice.
‘‘It is easy to get into a negative mindset . . . it is important to
be persistent
. . . and read the book at least once a year to refresh the mind.’’
(Practitioner 1)
DISCUSSION
On the whole, the service user participants identified the
respectful
and nonprescriptive relationship with the strengths model prac-
titioner as a predominant feature of the strengths model. Rapp

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