Therapeutic alliance in vocational rehabilitation counseling: Assessing client factors and functioning

1.1 Client functioning and therapeutic alliance

One means of promoting a productive and growth oriented therapeutic alliance is through the use of client feedback on therapeutic process (Brattland et al., 2019). Significant research has been produced which supports the use of client feedback in promoting positive therapeutic outcomes (Miller et al., 2015). Feedback in therapy primarily serves to maintain the integrity of the therapeutic alliance; it encourages clients to take shared ownership of the therapy and facilitates an egalitarian engagement from the clinician. It also serves a secondary purpose of providing insight into the client’s experiences outside of therapy, thus providing a window into those client factors which may be influencing treatment.

Miller and Duncan (2000) created a self-report tool, The Outcome Rating Scale (ORS) to collect information about client functioning and feedback that are useful for the therapeutic process. Three areas of client functioning included in the ORS: 1) individual functioning, 2) interpersonal relationships, and 3) social role performance. These three areas of client functioning were adapted from the widely accepted Outcome Questionnaire 45 (OQ-45; Lambert et al. 1996). Individual functioning refers to individual’s degree of subjective comfort/discomfort; interpersonal functioning refers to functioning in intimate relationships, loneliness, conflict with others; and the social functioning refers to functioning at workplace, school and in other social roles (Lambert & Shimokawa, 2011).

1.2 Vocational rehabilitation counseling and therapeutic alliance

Vocational rehabilitation (VR) counseling is comprised of a comprehensive sequence of services, mutually planned by the client and rehabilitation counselor, to maximize employability, independence, integration, and participation of people with disabilities in the workplace and the community (Strauser, 2013). Rehabilitation counselors who work in VR settings play a critical role in helping clients assess and identify their strengths and limitations, explore, and develop work interests, assess aptitudes to develop realistic goals for obtaining and maintaining work, and aid future career development (Ballou et al., 2015). The state-federal VR program is the oldest and most successful public program supporting the employment and independence of individuals with disabilities (Chan et al., 2018). Nationwide, the United States’ state-federal VR agency serves more than 1 million individuals with disabilities who have significant physical or mental disabilities that seriously limit one or more functional capacities in mobility, communication, self-care, self-direction, interpersonal skills, work tolerance, and work skill (Rehabilitation Services Administration [RSA], 2016).

The construct of therapeutic alliance is particularly important to facilitate client’s shared ownership of the therapeutic work in VR counseling (Chan et al., 1997). Previous researchers have found that the working alliance predicts likelihood of positive employment outcomes in VR counseling services (Schelat, 2000). Specifically, the working alliance impacts VR outcomes for clients with traumatic brain injury (Lustig et al., 2003) and for those living with other mental impairment (Donnell et al., 2004). It has also been supported as an important variable in the vocational outcomes for cancer survivors (Strauser et al., 2010). The evidence shows that VR counselors can improve counseling and psychotherapy outcomes for individuals with intellectual disabilities or other disabilities by facilitating a strong working alliance (Strauser et al., 2004). Research findings also indicate that increases in therapeutic alliance between client and counselor, positively impacts clients’ compliance in rehabilitation programs (Schonberger et al., 2006).

A strong therapeutic alliance is established mutually between the client and the counselor. It is assumed that the characteristics each participant brings into the relationship will affect the quality of the therapeutic alliance (Kokotovic & Tracey, 1990). The VR literature can greatly benefit from research to provide a better understanding of the influence of client factors (such as age, gender, employment status) on therapeutic alliance. To date, no research has investigated the impact of clients’ perceived functionality (individually, interpersonally, socially, and overall) at the time they enter counseling, on the therapeutic alliance with their counselors in a VR setting. The findings of this research can be used to equip counselors with interventions for specific clients groups (e.g., transition students) and clients with different functioning levels (e.g., low social functioning).

The present study explored the relationship between client functioning as reported by the Outcome Rating Scale (ORS; Miller & Duncan, 2000) and the Working Alliance Inventory (Tracey & Kokotovic, 1989). More specifically, the researchers assessed how VR clients’ ratings on the global and subscale measure ratings of the ORS trend with ratings on the WAI and its subscales. Researchers asked the following questions of the data:

What client factors (age, gender, ethnicity, type of disability, education level, employment status) influence the quality of therapeutic alliance?

2.1 Participants

The participants in this study were Florida Division of Vocational Rehabilitation clients. To receive public VR services, individuals must (a) have a physical and/or mental impairment (documented by appropriate medical, psychological, or psychiatric reports) that substantially impedes his or her ability to secure employment and (b) be able to benefit from the VR services to obtain or maintain employment in an integrated work setting. For this study 280 clients were identified as meeting the inclusion criteria. To be eligible for inclusion in this study, clients were required to meet the following criteria: (1) be a current client of VR (2) be in the early stage of therapeutic alliance (for fair comparison for all participants), (3) have the ability to read and understand the English language at a fourth-grade level, and (4) have the ability to self-report and to make an independent decision (to be his or her own guardian).

Demographic characteristics of participants are presented in Table 1. Fifty eight percent of the respondents (n = 163) were men. Participants ranged in age from 16 to 69 (M = 32.3, SD = 13.7). Most participants reported that they have multiple disabilities (71.4%; n = 200). Forty six percent (n = 129) of the respondents identified themselves as individuals of White/Caucasian origin, 26%(n = 73) Black/African American, and 23%(n = 64) Hispanic/Latino. Twenty five percent of the respondents had less than a high school degree (i.e., no formal schooling, special education, elementary education, secondary education) whereas 43%(n = 119) had high school diploma or GED. Most of the respondents were unemployed (n = 193).

2.3 Procedure

Upon the approval of the Florida Atlantic University Institutional Review Board (Approval number 995899-1), permission was obtained from VR headquarters to recruit clients. All clients invited to participate in the study were at their first or second meeting with their counselors. The unit supervisors were provided the purpose of the study, time requirements, and measures to protect confidentiality. Counselors identified potential clients in their caseload that match the inclusion criteria and inform support staff before their scheduled session. Initial contact with these clients was made by the support staff, one-on-one, when the clients arrive at the VR office. Consent information was provided verbally. Clients were informed that participation would not impact their current VR services. Clients who accepted to participate the study were given a) the ORS instrument before their meeting, b) the WAI-S instrument after the meeting. There was no risk for loss of confidentiality as all data were collected anonymously. To identify the two forms of instruments from the same participant, a coding system was utilized. In each unit, support staff helped providing consent information and collecting instruments.

4.1 Client age and therapeutic alliance

In this study, younger clients reported better therapeutic alliance. The results revealed a small effect size for age, but it is important to further investigate this client factor because the transition-age youth with disabilities (ages between 16–21) has become the priority of state-federal VR agencies. Currently, limited research exists addressing the relationship between the client age and therapeutic alliance in the VR counseling. Past studies in mental health settings demonstrated mix results. For example, clients with severe mental illness showed that age has no significant association with therapeutic alliance (Robiner & Storandt, 1983) or, in contrast to our findings, being older was significantly correlated with a higher positive alliance (Draine & Solomon, 1996; Cichocki, 2015). This could be related to the differences between the therapeutic alliance in a VR counseling and other counseling and psychotherapy fields. In VR counseling, the alliance is related to the client’s perception of future employment prospect and satisfaction (Lustig, 2002). It is possible younger adults, being in an earlier stage of career development, perceive higher potential for future employment opportunities, positively influencing their therapeutic alliance with their counselors.

The deviation of this result from previous studies could also be related to generational differences which impact perceptions of the therapeutic alliance. Previous research has shown that older adults disproportionately underutilize professional mental health services relative to younger adults (Bogner et al., 2009; Crabb & Hunsley, 2006; Wang et al., 2005). In addition, some evidence exists that older individuals are less open to acknowledging psychological problems (James & Buttle, 2008), which may provide some context for the inverse relationship between older age and a stronger therapeutic alliance that was found in this study. In addition, for the past couple of decades, the access to mental health and rehabilitation services for youth with physical and mental disabilities has been improved. Particularly, the Workforce Innovation and Opportunity Act (WIOA) signed in 2014 allocated large funds to attract youth, of ages 16–21 and with physical and mental disabilities, to start receiving VR counseling while still in high school. This early exposure may help youth perceive counselors as a part of the team of professionals helping them explore, determine, and achieve future vocational goals, leading to better alliances. This novel finding, whether related to differences in the field-specific nature of the alliance or generational differences, provides counselors with insights into age as a factor that can impact their therapeutic alliances with their clients.

4.2 Employment status and therapeutic alliance

In this study, people who were already employed or became employed during the first few sessions reported stronger therapeutic alliance. This result supports the previous evidence that indicates that employed clients have a stronger therapeutic alliance with their counselors than unemployed clients (Lustig et al., 2003). Unemployment status impacts the therapeutic alliance by creating diminishing expectations in vocational outcomes (i.e. outcome expectancy; Iwanaga et al., 2019). It seems that there is a symbiotic relationship between the alliance and employment status. Not only does employment status contribute to a stronger alliance, but a positive therapeutic alliance also correlates with attainment of employment (Catty et al., 2011; Lustig et al., 2002; Schelat, 2000; Schönberger et al., 2006a). This evidence provides further insight into the utility of VR counseling.

4.3 Client perceived functioning and components of therapeutic alliance

The therapeutic alliance has three components: bond, task, and goal. The results of this study showed that clients’ perceived individual, interpersonal and overall functioning have a significant positive relationship with the task and bond components of therapeutic alliance. Based on this, if individuals believe that they are doing well individually, interpersonally, and overall, in their lives, they would be more likely to connect well with someone (bond) and align with their counselors on the tasks to be accomplished. However, the goal component of a therapeutic alliance only correlated with the clients’ perceived social functioning, not with individual, interpersonal, and overall functioning. It is necessary to look at this result closer, considering the fact that the VR is a goal-oriented counseling approach. First, if someone perceives their work-life to be going poorly (which is part of social functioning), it could logically deflate the perception of the relationship with the person who is helping with their employment goals (i.e. VR counselor). Second, it is possible that clients perceive their work-life (not personal, interpersonal, and overall functioning) to be aligned with the goal portion of the VR counseling relationship. This fits well with the ultimate goal of VR counseling.

4.4 Clients’ perceived functioning and therapeutic alliance

The results of this study indicated that clients’ perception of their social functioning is a significant predictor of the quality of the therapeutic alliance. People who reported higher social functioning also reported higher therapeutic alliances with their counselors. This result is consistent with the current literature. For example, patients with a high level of psychosocial functioning establish better therapeutic alliance while patients with personality disorders tended to report a weaker alliance (Johansson & Eklund, 2004). Likewise, client interpersonal factors were found to be significant predictors of the therapist-rated alliance in the treatment of clients with schizophrenia (Couture et al., 2006).

This result also appears theoretically consistent with Self Efficacy Theory (Bandura, 1997) which postulates that people who have high levels of confidence in their ability to perform well in a domain are more likely to persist in their efforts to increase skills in that particular area. The perceived self-efficacy also determines how people think and motivate themselves, thus impacting the way individuals feel and behave (Bandura, 1994). Individuals with a strong sense of efficacy are more likely to feel confident in their abilities to accomplish a difficult task and see this as a challenge to be conquered, rather than a task that should be avoided (Bandura, 1994). On the other hand, individuals with a low sense of efficacy tend to focus on their personal deficits and view difficult tasks as threats; they are more likely to avoid these tasks because of their fear of failure (Bandura, 1994). Based on the results of this study, a higher sense of self-efficacy in social functioning leads to a more impactful therapeutic alliance.

4.5 Implications into practice

The results of the current study lend support to much of the existing literature on the therapeutic alliance in counseling. A stronger alliance leads to better outcomes in many types of counseling and case management-oriented endeavors (De Leeuw et al. 2012; Johnson et al., 2005; Norcross, 2010). This conclusion is supported by the findings of this study. Being employed and age have an impact on the therapeutic alliance. When providing therapy to older clients, replacing the “top-down” or “expert” approach with a more relational approach between perceived equals may lead to the establishment of better alliances. It is possible that a more collaborative relational stance may help older clients to openly acknowledge their limitations, and eliminate the obstacles related to viewing a (potentially younger) VR counselors as “experts.”

In this study, those who had a job and those who were younger tended to rate their therapeutic alliance as stronger. Counselors would be wise to attend more closely to the relationship with those who are unemployed. The findings of this study suggested that VR counselors should be more attentive to the task and bond components of the therapeutic relationship with the age group forty and older, those who are unemployed, and those who perceive their social functioning as lower or have lower self-efficacy.

4.6 Limitations and future research

While the design of the present study had many strengths (such as a large sample size, diverse populations reflecting ethnicity, age, education level, sex, and disability type), some limitations emerged. A primary limitation of the present study was the use of a convenience sample of participants whose treatment goal was focused primarily on employment. While employment-focused goals are very common in VR settings, employment is not always a focus of the client. For example, Koch (2001) used open-ended qualitative surveys completed by 65 adults referred to state VR services and found that only 56.9%of 65 participants stated that employment was one of their goals. Others identified goals such as vocational training (46.2%), increasing independence (9.2%), enhancing personal growth (7.7%). As a result of restricting the sample to clients whose focus is employment, it may not be possible to generalize the current result to all VR clients. For this reason, it is recommended that future research on the relationship between the alliance and functional outcomes include measures of disability severity or include goals unrelated to obtaining employment.

Furthermore, the sample included only clients who were able to speak English, indicating higher levels of acculturation in this sample than may be typical in VR settings. The present sample may be more homogenous in cultural attitudes towards work which pertain to wellbeing and self-efficacy, than is typical in VR settings. These results may not be reflected in less acculturated populations. Finally, the majority of the clients that participated in this study were in the age group of thirty nine and younger. In order to address this limitation, it is recommended that this research be replicated in broader samples in terms of age groups and multilingual samples with varying degrees of acculturation to the mainstream Western culture.