Working alliance patterns in a context of supported employment programmes for people with a severe mental illness: An employment specialist perspective

Abstract

Background:

Developing a good working alliance with clients with a severe mental illness (SMI) is a core competency of the employment specialist (ES). The ES's assessment of the working alliance was found to be related to the client's acquisition of a job in the regular market but we have little information on the processes and factors involved.

Objective:

To understand the development of the work alliance as assessed by the ES and its relationship to the client's acquisition of employment. Factors that may facilitate or hinder the development and evolution of the alliance were also explored.

Methods:

Cluster analysis was used to define alliance development patterns, while frequency analyses were used to identify differences between the patterns in terms of whether the clients with SMI obtained (or not) employment. Interviews with ESs explored factors that may have explained the different patterns.

Results:

Three patterns of working alliance were found and the one most often linked to client employment was the very high and stable pattern. The factors that might explain the different patterns are complex and interrelated.

Conclusion:

The results can be considered in the ES's initial and ongoing training on the working alliance and the implementation of quality supported employment programmes.

Plain language summary title

Working alliance patterns in supported employment programmes.

Keywords

mental illness working alliance employment specialists supported employment programmes vocational rehabilitation

Introduction

Work is an important determinant of recovery for individuals with severe mental illness (e.g., psychotic and mood disorders) by providing structure, socialization, economic capital, validation of skills, and fostering positive self-esteem and self-image (Winsper et al., 2020). Although a large proportion of these individuals report wanting to work, only 10–25% are employed in the competitive labour market (Drake & Whitley, 2014; Mueser & McGurk, 2014). Supported employment (SE) programmes are recognized as evidence-based practices facilitating the work integration – job acquisition and job tenure – of individuals with SMI (de Winter et al., 2022; Frederick & VanderWeele, 2019; Suijkerbuijk et al., 2017). SE programmes focus on finding competitive employment as quickly as possible with individualized support for integration of the individuals with severe mental illness (SMI) into the regular labour market (Drake & Whitley, 2014). Research over the past 20 years shows that about 50% of people in these programmes obtain competitive employment which is a significant result considering that a small proportion of people with SMI are employed (de Winter et al., 2022; Frederick & VanderWeele, 2019; Suijkerbuijk et al., 2017).

Although most programmes have roughly the same guiding principles or intervention philosophies, significant variability ranging from 20% to 80% is observed across organizations’ employment integration percentages (Drake et al., 2006; Drake & Bond, 2014). These differences in performance may be explained in part by their fidelity to the models considered most successful or best suited to their sociopolitical context (Bond et al., 2008; Corbière et al., 2014b). Furthermore, within the same SE agency or programme, some employment specialist (ES) may be much more successful than others in helping their clients integrate and maintain employment (Drake et al., 2006). The primary objective of the ES is to facilitate the rapid integration of clients into the regular labour market and ensure job tenure (Drake et al., 2012) by assisting clients in selecting suitable jobs, supporting them in their job search, collaborating with community stakeholders (e.g., employers, mental health professionals), and advising them on adaptations that can help them maintain their job (Rinaldi et al., 2008). In 2017, Corbière et al. focused on the skills of ESs to predict the work integration of clients with SMI. Their results suggested that counselors’ interpersonal skills are particularly important. Indeed, developing quality relationships with employers and managers was one of the skills most predictive of getting a job (Corbière et al., 2017). Another important predictor was the quality of the working alliance that developed between the client and their ES (Catty et al., 2008; Corbière et al., 2017). The development of a solid working alliance between the ES and the client with a SMI is of paramount importance as it allows these stakeholders to work together to overcome barriers to employment (Charette-Dussault & Corbière, 2019; Corbière et al., 2020).

The working alliance is composed of three components. The first component is more affective in nature and corresponds to the positive bond created between client and therapist (or other professional), characterized by respect, mutual trust, and caring. The second two components, which are more cognitive in nature, are a shared agreement on the goals to be pursued and a shared agreement on the tasks to be performed to achieve those goals (Bordin, 1979). Working alliance has been consistently shown to contribute to clinical improvement in psychotherapy and counseling (Flückiger et al., 2018) and is considered an important and ubiquitous variable in all helping relationships (Bordin, 1983; Luborsky, 1976). Research has emphasized the critical role of a strong working alliance in promoting positive outcomes for clients with SMI, particularly in alleviating symptoms, mitigating the negative effects of self-stigma, and improving overall well-being (Kondrat & Early, 2010). A strong working alliance also fosters increased motivation, compliance, and treatment adherence, leading to improved treatment outcomes for people with SMI (Barrowclough et al., 2010; Tremain et al., 2020). Although there are far fewer studies on the contribution of the working alliance in the context of work rehabilitation, the scientific knowledge accumulated to date confirms that it is just as important as in the context of psychotherapy or counseling (Hasson-Ohayon et al., 2021; Lloyd, 2010).

Unlike studies in the field of psychotherapy and counseling where it is the client's perception of the working alliance that is most related to therapeutic outcomes (Flückiger et al., 2018), in SE programmes, the ES's assessment of the quality of the working alliance is as predictive, if not more, of the client obtaining a job (Catty et al., 2008; Corbière et al., 2017) than the client's assessment of the alliance. Since the working alliance is considered a process, its level does not necessarily remain the same throughout the counseling process (Safran et al., 2009). Most researchers who have examined the relationship between the working alliance and various therapeutic outcomes have nonetheless used a single measurement time for working alliance, despite the recognition of its dynamic and processual nature (Ardito & Rabellino, 2011).

Theoretically, according to Horvath et al. (Horvath et al., 2011), effective therapy consists of an initial phase where the alliance is high, followed by a second phase characterized by a decrease in the alliance caused by therapeutic work that proves to be confrontational for the client, and ends with a final phase where the alliance increases again as the therapist works with the client to repair these breakdowns.

Kivlighan and Shaughnessy (2000) tested this hypothesis in research on patterns of working alliance development in the first four encounters between therapists-in-training and their clients. Using cluster analysis, these authors identified three patterns of alliance development: a stable alliance, a linear growth alliance, and a U-shaped or quadratic growth alliance. This last pattern was associated with better therapeutic results in clients. Other authors have also been interested in working alliance patterns in the context of psychotherapy and the context of career counseling since then. In these studies, the most common patterns are: 1) a linearly increasing pattern (Covali et al., 2011; de Roten et al., 2004; Elad-Strenger & Littman-Ovadia, 2012; Loos et al., 2015; Stiles et al., 2004); 2) a stable, elevated pattern (Covali et al., 2011; de Roten et al., 2004; Loos et al., 2015; Stiles et al., 2004), and 3) a decreasing pattern (Loos et al., 2015; Stiles et al., 2004). The pattern most often associated with clinical improvement is the one representing linear growth (Covali et al., 2011; de Roten et al., 2004; Elad-Strenger & Littman-Ovadia, 2012). Even psychotherapy and career counseling processes that are considered to be short-term can be longer than what is found in SE programmes, where interventions are goal-oriented and can be as short as 3 meetings.

In 2008, Ross et al. (2008) examined the strengths and limitations of Bordin's conceptualization and improved it (explanatory depth) to better represent the challenges of creating and maintaining a working alliance. Their representation of the working alliance includes the characteristics of the therapist, the characteristics of the client, the cognitive and emotional processes that influence the interactions between the two actors, and the therapeutic and social context in which this interaction takes place. Although there are many factors to consider, factors related to the therapist, and more specifically his or her ability to be aware of the factors that may interfere with the working alliance and his or her ability to intervene, are of paramount importance (Ruiz-Aranda et al., 2021). It is known from other studies that it is the therapist's contribution to the alliance that most accounts for therapeutic change (Wampold & Owen, 2021). In other words, it is the therapist who is responsible for creating and maintaining this working alliance despite the symptoms, difficulties, and characteristics of the client who needs help to achieve their goals.

Although the working alliance is considered essential to the work integration process, very few studies have specifically attempted to better understand the mechanisms involved. Moreover, research addressing the working alliance in vocational rehabilitation has mainly focused on the client's point of view since the literature on psychotherapy and guidance counseling considered this to be more predictive of therapeutic effects (Donnell et al., 2004; Lecomte & Savard, 2006). Considering that the ES's perspective is also, if not more, predictive of obtaining employment in the competitive labour market (Catty et al., 2008; Corbière et al., 2017), particularly with evidence from large samples (>90 specialized counselors who followed over 600 clients), it is important to address the ES's perspective.

Consequently, this research targets the working alliance as perceived by the ESs from SE programmes dedicated to people with SMI. The first objective is to better understand the development of the working alliance as assessed by the ES and its relationship with job acquisition in the regular labour market. Based on the literature, we expect to find 3 working alliance patterns: a linearly increasing pattern, a stable elevated pattern, and a decreasing pattern (hypothesis A). The first pattern is expected to be most strongly associated with job acquisition (hypothesis B) compared to other patterns. The second objective is to better understand, qualitatively, the factors that explain the working alliance pattern found in the first phase. More specifically, the following question is to be answered: What factors influence the different working alliance patterns from the ES's perspective? (question C). The goal is to describe and understand, from the ES's perspective, which factors related to the ES's characteristics, those of the client, and the context, may influence a particular working alliance pattern.

Methods

A two-phase sequential explanatory mixed-method design (Briand & Larivière, 2020) was used to address the research objectives. The first phase, which was correlational, longitudinal, and quantitative in nature aimed to answer the first objective, particularly hypotheses A and B; while the second phase, qualitative in nature, aimed to answer the last objective, particularly question C.

First phase

Procedure and participants

To achieve the first objective, ESs from SE programmes in the province of Quebec (Canada) were recruited. These SE programmes participated previously in a Pan-Canadian study in which only SE programmes that adhered to a recognized SE programme definition were retained (Corbière et al., 2017). To participate in the study, the ES had to meet two criteria: they had to have been employed by the organization for at least one year and they had to serve a clientele with an SMI. Selected ESs were familiar with the theoretical concept of the working alliance and demonstrated an interest in the concept in their clinical work. However, not all of them had benefited from supervision designed to help them develop and maintain a good working alliance in practice. ES were recruited to target five new clients from individuals seeking services from their organization, each with an SMI, based on the following inclusion criteria: 1) currently unemployed upon entry to the programme, 2) aspiring for competitive employment. Individuals diagnosed with neurodevelopmental disorder, neurological disorder, or dementia were excluded from the study. For each client, the ES was invited to measure the working alliance, according to their own perception, during the first 3 or 4 meetings with the client, with a follow-up on the results of the process, i.e., job acquisition or not within 6 months after the first meeting.

During the recruitment period, from September 2020 to April 2022 (19 months), the research project was presented to the team of ESs. The ESs met individually with the researchers using a videoconference platform to ensure their understanding of the research project and to allow the ESs to ask questions about the study. The first questionnaire, on the ES’ socio-demographic and professional characteristics, was conducted by telephone to obtain clear and complete answers. A tracking document of the different questionnaires to be filled in during the research project was also given to them at this time (Figure 1). This document contained all the links to the online questionnaires (LimeSurvey) as well as the timeline for their completion. As soon as a questionnaire was completed, the researcher received a notification. Monthly phone and email follow-ups were conducted by the first author (E.C-D.) to maintain contact with all ESs, assess problems encountered, and respond to their questions and concerns. When ESs recruited clients, a reminder was sent weekly to ensure that they completed the working alliance questionnaire quickly after each meeting with their clients. Six ESs recruited clients and completed questionnaires.

Figure 1.

Example of the tracking document provided to the employment specialist.

Instruments

ES's sociodemographic questionnaire

The first questionnaire was designed to obtain information about the ESs while ensuring that they meet the inclusion criteria. Socio-demographic questions covered gender, age, education, and years of experience as an ES (overall and for the current SE programme). This information was collected by phone to obtain clear and complete responses.

Clients’ sociodemographic questionnaire

The second questionnaire was designed to obtain information on the ESs’ clients. The sociodemographic questions included age, diagnosis, length of absence from the competitive labour market, and information on disability benefits received by the client.

Working alliance inventory

The short version of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) is validated in French (Corbière et al., 2006) and has the advantage of having been validated with rehabilitation workers and their clients with a SMI (Corbière et al., 2006). This self-reported tool, based on Bordin's design, includes 12 items with response choices corresponding to a Likert scale ranging from 1 (never) to 7 (always) points. The tool consists of two versions, a client version, and an ES version. Only the ES version was used in this study. Although the tool is built on three subscales corresponding to the three working alliance components, goals (4 items; e.g., We are working towards mutually agreed upon goals), tasks (4 items; e.g., The client and I agree on the steps to be taken to improve his/her situation), and bond (4 items, e.g., The client and I have built a mutual trust), a global score, which was used in this study, can also be calculated by averaging the scores of the 12 items.

Measure of job acquisition

The client was considered to have obtained employment when he or she had worked at least one day in a competitive job, i.e., a part-time or full-time job that was not restricted to persons with work disability and that provided a salary of at least the current minimum wage or higher.

Analysis

To verify hypothesis A, a hierarchical clustering analysis based on Ward's (1963) minimum variance method was used. Clustering analysis is a type of technique for grouping similar cases into distinct groups (Byrne & Uprichard, 2012). Ward's minimum variance method is a hierarchical case clustering method for creating clusters with minimal within-group variance and maximum between-group variance (Rokach & Maimon, 2005). Therefore, it ensures that clusters contain cases that are as similar as possible while ensuring that the cases contained in one cluster are different from those in other clusters. The number of clusters was determined based on an iterative reduction procedure to select the most optimal solution while considering the reduction of the agglomeration coefficient and ensuring that all clusters comprised at least 10% of the participants (Hair & Black, 2000). Unlike Kivlighan and Shaughnessy (2000), who used a deviation working alliance score obtained by subtracting the average alliance score (the level) from each of the ratings to isolate the shape from the level of the alliance pattern, we used direct WAI scores to obtain patterns influenced by both level and shapes as proposed by de Roten et al. (2004).

To address hypothesis B, frequency analyses were performed between the different clusters obtained and job acquisition.

Second phase

To address the second objective – a better understanding of the factors influencing the different patterns of the working alliance according to the perspective of the ES – a qualitative descriptive interpretative design was used. This design was particularly suited to the research aim since it involved understanding and describing a complex phenomenon from the perspective of the ES (Gallagher & Marceau, 2020). Therefore, the aim was to explore in more detail the results obtained in the first phase of the study to evaluate them from the perspective of the ES.

Procedure and participants

To do this, ESs recruited in the first phase were met individually for semi-structured interviews. Only five of the six ESs were interviewed because one of them left the organization and was no longer available. 17 interviews were conducted with the 5 ES's - ranging from one to five interviews, depending on the number of working alliance patterns collected by each ES. Each tape-recorded interview lasted between 40 and 75 min and focused on a single working alliance pattern to understand the factors that contributed to its development. The verbatims from these initial interviews were analyzed to extract meaning and ultimately construct a summary representing the experience as reported by the ES for each working alliance pattern. These individual summaries were sent to each ES before a second interview. The purpose of this second interview was to ensure that the summary reflected the consultant's perspective and to ask clarifying questions.

Instruments

Interview guide

A semi-structured interview guide was created for this project based on Ross et al.'s (2008) model and includes several questions from the Therapist Relationship Interview (Tri; Safran & Muran, 2007). The questions focused on the factors that may have, according to the perception of the ES, influenced the development of a specific working alliance pattern, as well as the potential impact on employment (obtaining a standard job or not). Specifically, the questions were designed to document the following factors based on Ross et al.'s model (2008), p. 1. Client factors (e.g., diagnosis, personal traits, and attitudes), 2. ES factors (e.g., personal traits and attitudes, level of burnout), 3. Factors related to the context (e.g., perceived workload, SE programmes). The interview outline included 5 main questions as well as follow-up questions and requests for clarification.

Analysis

To explore the ES’ perceptions of the factors that influenced the working alliance patterns and employment outcomes of their clients, the data obtained during the interviews was subjected to a thematic analysis following the approach of Paillé and Mucchielli (2021). This type of analysis is particularly appropriate when describing a complex, under-explored phenomenon while providing a rich and detailed understanding of that phenomenon (Paillé & Mucchielli, 2021). A descriptive interpretative level of analysis was chosen to capture the lived experience and its meaning to move toward an understanding of the phenomenon (Gallagher & Marceau, 2020). To do so, the content of the interviews was transcribed in full and imported into NVivo version 12 software (QSR International). Although general categories derived from Rokach and Maimon's (2008) conceptualization were used as a general framework for the interview, the thematization process in each of these broad categories was carried out inductively so that the themes represented, as much as possible, the words of the subjects participating in the study (Paillé & Mucchielli, 2021).

Results

Descriptive statistics

Statistical analyses were performed using SPSS 26.0 and R 4.2.0. The descriptive analysis provided information on the level of working alliance over time as perceived by the ES vis-à-vis their clients, and the rate of job acquisition.

The 6 ES, all women ranging from 27 to 50 years old (M = 40), had 1 to 14 years of experience (M = 6.5) as an ES and worked in 5 different SE programmes in the province of Quebec (Canada). All ES had at least a bachelor's degree, while one also had a master's degree. They were trained in secondary school teaching (1), social work (1), career development (2) and psychoeducation (2).

All ESs recruited 30 clients whom they met between 1 and 4 times. In this cohort, 18 clients met with their ES at least 3 times. Clients who agreed to have their information used were between 21 and 57 years old (M = 38). Information about their diagnoses, length of time out of the labour market, and the benefits they received at the time of the study are presented in Table 1.

Table 1.

Client's sociodemographic information.

Baseline characteristics	N = 18 (%)[SD]	Job acquisition
Baseline characteristics	N = 18 (%)[SD]	Yes (N = 12)	No (N = 6)
Age	37.94 [9.96]	37.83	38.17
Diagnosis
Anxiety disorder	6 (33.3)	83.3% (5)	16.7% (1)
Mood disorder	5 (27.8)	60% (3)	40% (2)
Psychotic disorder	6 (33.3)	50% (3)	50% (3)
Borderline Personality Disorder	1 (5.6)	100% (1)	0% (0)
Absence from the labour market
Less than a year	9 (50)	66.7 (6)	33.3% (3)
1 to 2 years	2 (11.1)	50% (1)	50% (1)
2 to 5 years	5 (27.8)	60% (3)	40% (2)
More than 5 years	5 (11.1)	100% (2)	0% (0)
Benefits
No benefits	4 (22.2)	100% (4)	0% (0)
Benefits (social assistance, social solidary, long-term insurance)	9 (50)	44.4% (4)	55.6% (5)
Short term benefits (Benefits for participating in the SEP, Canada Emergency Response Benefit)	5 (27.8)	80% (4)	20% (1)

A high proportion of clients diagnosed with an anxiety disorder obtained a job (83.3%), whereas 60% of the clients with a mood disorder and 50% with a psychotic disorder obtained a job at the 6-month follow-up. Other than one client who had been out of the labour market for more than 5 years and who had obtained a job as part of the study, a slightly higher proportion of the clients who had been out of the labour market for less than a year obtained a job (66.75%), compared to those who had been out of the labour market for 1 to 2 years (50%) and 2 to 5 years (60%). Clients with no social benefits and clients with very short-term social benefits (benefits for participating in the SE programme or Canada Recovery Benefit (CRB) obtained employment at higher rates (100% and 80% respectively) than those receiving social benefits (44.4%; e.g., social assistance). Of the 18 clients, 12 (67%) obtained a job at the 6-month follow-up. The average time to obtain a job was 59.25 days (SD = 21.01), about 2 months (Table 1).

Working alliance patterns

Cluster analysis of the three WAI scores revealed, as expected, three different patterns (see Figure 2) but one of the patterns differed from the anticipated result (see Figure 2 and Table 2). Instead of a linearly increasing pattern, we found a stable low pattern. The clients characteristics associated with these 3 alliance patterns are presented in Table 3.

Stable high alliance pattern (SHA). This cluster included 5 cases (27.78%), with a mean alliance of 6.64 (SD = 0.15).

Stable low alliance pattern (SLA). This cluster included 10 cases (55.56%), with a mean alliance of 5.09 (SD = 0.34).¹

Linear decrease alliance pattern (LDA). This cluster included 3 cases (16.67%), with a mean alliance of 6.07 (SD = 0.29).

Figure 2.

Evolution of WAI scores across times 1–3 for the three patterns (shape and level) detected by cluster analysis. LDA = Linear decrease alliance pattern, SLA = Stable low alliance pattern, SHA = Stable high alliance pattern.

Table 2.

Means and standard deviations of working alliance ratings across three meetings.

			1^st meeting		2^nd meeting		3^rd meeting		Mean of the 3 meetings
Cluster	n	%	M	SD	M	SD	M	SD	M	SD
Stable high alliance (cluster 1)	5	27.78	6.55	0.16	6.67	0.14	6.72	0.21	6.64	0.15
Stable low alliance (cluster 2)	10	55.56	5.11	0.11	5.05	0.10	5.10	0.15	5.09	0.34
Linear decrease alliance (cluster 3)	3	16.67	6.50	0.21	6.17	0.18	5.56	0.27	6.07	0.29

Table 3.

Description of clients by cluster.

Cluster	Clients (ES#_Client#)	Age	Diagnosis	Absence	Benefits	Job
SHA	ES#11_C1	33	Anxiety disorder	Less than a year	No benefits	Yes
	ES#11_C2	31	Anxiety disorder	Less than a year	No benefits	Yes
	ES#11_C4	21	Anxiety disorder	Less than a year	Short term benefits	Yes
	ES#16_C4	48	Psychotic disorder	Less than a year	No benefits	Yes
	ES#22_C1	57	Mood disorder	Less than a year	Benefits	No
SLA	ES#5_C2	31	BPD	2 to 5 years	Short term benefits	Yes
	ES#5_C3	29	Psychotic disorder	2 to 5 years	Benefits	Yes
	ES#5_C.4	48	Mood disorder	Less than a year	Short term benefits	Yes
	ES#5_C5	51	Mood disorder	2 to 5 years	No benefits	Yes
	ES#6_C1	48	Psychotic disorder	More than5 years	Benefits	Yes
	ES#6_C2	28	Anxiety disorder	1 to 2 years	Benefits	Yes
	ES#6_C4	34	Psychotic disorder	2 to 5 years	Benefits	No
	ES#6_C5	49	Mood disorder	More than5 years	Benefits	Yes
	ES#6_C7	28	Psychotic disorder	1 to 2 years	Benefits	No
	ES#6_C9	33	Psychotic disorder	Less than a year	Benefits	No
LDA	ES#5_C1	37	Anxiety disorder	Less than a year	Short term benefits	Yes
	ES#16_C2	38	Anxiety disorder	Less than a year	Short term benefits	No
	ES#18_C1	39	Mood disorder	2 to 5 years	Benefits	No

SHA = Stable high alliance pattern, SLA = Stable low alliance pattern, LDA = Linear decrease alliance pattern, ES = Employment specialist, BPD = borderline personality disorder.

Working alliance patterns and job acquisition

Frequency analyses revealed that clients in clusters SHA and SLA were more likely to be employed at 6-month follow-up than clients in cluster LDA (Cluster SHA = 80%, Cluster SLA = 70%, Cluster LDA = 33%).

Factors affecting the working alliance profiles

The results of the qualitative analyses are presented in 2 categories: 1) the factors that may have positively or negatively affected the development of the alliance between the ESs and their clients and 2) the relative importance of the 3 components of the working alliance in achieving the objectives of the SE programme.

Factors affecting the working alliance

In the interviews, ESs raised many factors that may have affected the development of the working alliance with their clients. Some factors were related to the client's characteristics, such as their diagnosis and their attitudes, others were related to the ES's characteristics such as their work experience or personality, and some were related to the context (e.g., workload). However, it seems clear that the personal characteristics of clients and ESs alone did not increase or decrease the working alliance; it was the complex interrelationship between the characteristics of both stakeholders that affected the level of working alliance perceived by the ES.

In fact, despite certain client characteristics, such as a tendency to be defensive or to mistrust, that made creating and maintaining a good working alliance more difficult for many ESs, most client characteristics were experienced differently by different ESs. For example, one ES could react positively to a client who showed a certain passivity in the work integration process because they are comfortable with taking a more active role in the meetings, while another ES could react negatively, perceiving this passivity as a major obstacle to the relationship and the work integration.

The similarity in characteristics between the client and ES often positively affected the working alliance but a positive and solid alliance can also be developed despite significant personal differences.

The alliance was there from the start, even though we were completely different people. We both agree that we were different, he is a very colorful artist, and I'm conventional, but it doesn't matter that we're different, we can establish a common goal and we move forward. ES#11_C4 (Cluster SHA, obtained a job)

The client's diagnosis, or more specifically, the symptoms associated with it, may influence the perceived working alliance for some ESs, but it appears to be linked to their personal strengths, challenges and competencies:

It's harder for me to create a good alliance with people who have a depressive pattern. It seems to feel a bit helpless because it affects their sleep, it affects their attendance, it affects their ability to function daily, so sometimes I don't really know what to do to help them. ES#5_4 (Cluster LDA, obtained a job).

For some clients, it is the ES's conscious effort to actively adapt to the client's personality, needs, and goals that foster the working alliance. “With him, I had to analyze what I was doing more. You know, I had to be more careful, not rush him, and respect his limits. It was more mentally demanding with him than with the first client.” ES#11_C2 (Cluster SHA, obtained a job).

ESs do not always perceive, in action, the complex interrelationships that affect their perceived level of the working alliance. Some ESs are aware of their challenges and the emotions that may emerge when they encounter certain characteristics of their clients. Whether it is a difficulty in tolerating the possible anger of a client who reacts strongly to criticism, the feeling of not being competent enough to deal with a much older person, or the tendency to take responsibility for the success of the job acquisition process, altogether, these reactions can make the working alliance more fragile if the ES does not consider them.

Some ESs were able to address their perceptions of the working alliance with some of their clients:

There was transparency in our relationship. At one point I said to him: “I realize that you and I are not going at the same pace as if I wanted more than you. Could it be that I'm in more of a hurry than you? ES#11_C1 (Cluster SHA, obtained a job).

However, directly addressing working alliance perceptions is not easy and ESs were not able to do so with every client:

You know, there are some clients where it's easier to do that, to address things, but with her, I couldn’t do so. I didn't want her to be angry, I didn't want her to be upset, I didn't want to break the fragile bond! ES#16_C2 (Cluster SLA, did not obtain a job).

This leads to an important factor that appears to differentiate SHA cluster cases from the other two clusters. In the SLA and LDA clusters, the ESs may be confronted with emotions they don't fully understand when in contact with their clients, or they become aware of these emotions, manage to link them to the attitudes, symptoms, or characteristics of the clients, but fail to use them to serve the client and the process. The clients associated with these patterns had disparate characteristics that were difficult to link to the pattern in question. However, ESs belonging to these patterns were more likely to avoid raising perceived challenges in the relationship or disagreements about tasks and goals, or they preferred to focus primarily on the technical aspect of the process (e.g., resume writing) rather than the more emotional aspect of the relationship. These patterns may have stagnated due to a lack of interventions focused on the relationship itself.

In the SHA Cluster, the 4 cases analyzed in more depth showed that the 2 ESs to whom these cases belonged, reacted to certain client characteristics or attitudes, but they were able to address their perceptions to help clients progress and develop better skills. In these patterns, according to the interviews, ESs report feeling trusted quickly by the clients and if the challenges in terms of mutual agreement on goals and tasks are addressed quickly, a stable good working alliance across time is formed. Clients associated with these patterns usually have favourable interpersonal qualities or demonstrate good motivation in the process. ESs who belonged to this pattern usually had several years of experience and were able to perceive their reactions to the client's characteristics and attitudes to adjust their interventions and work on both the working alliance and the achievement of the objectives during the process.

The context in which ESs and clients are embedded also affects the development of the working alliance. The factors raised by the ESs were workload and meeting methods (phone, video conference, or face-to-face). Most ESs felt overwhelmed by their workload, and they did not always have time to adequately care for the working alliances they were developing with their clients, especially with clients where the work was most challenging. “You know I wish I had more time to take care of the alliance I am developing with him. Sometimes I feel more in survival mode, so I try to save my energy”. ES#5_C2 (Cluster LDA, obtained a job). The ESs agreed that it was possible to intervene via technology, but that it was more appropriate for clients who had good technical and relational skills and where the focus of the intervention was more technical. Even in these situations, ESs pointed out that information was still missing (e.g., physical appearance, style), especially if the telephone was used. Even in face-to-face situations, the use of a medical mask could make it more difficult to perceive the clients’ reactions, which could sometimes lead to misunderstandings and rupture the working alliance.

The relative importance of the three working alliance components

ESs readily discussed the 3 components of the working alliance, the bond, the mutual agreement about the task and objective to pursue, as well as their perception of their relative contribution as ES to achieving the goals of the SE programme with their clients.

One of the central criteria for assessing the level of the working alliance as perceived by the ES is the level of trust that the client seems to have in the ES. For some clients, this trust is established quickly, while for others, the ES must make additional effort to gain the client's trust. Trust seems to be closely related to a common understanding of the targets to be reached (the objectives) and the means to achieve them (the tasks).

He trusted me enough. I felt quickly that what I was saying made sense to him. My proposals also made sense to him, which means that I understood his situation, that I had understood what his difficulties were, and his expectations. ES#16_C4 (Cluster SHA, obtained a job).

Sometimes mistrust seems so ingrained in the client that counselors feel unable to make an emotional connection. This weak emotional bond leads the ES to focus their efforts on concrete tasks and mainly technical support.

I think it was his distrust that scared me. I felt like I didn't have access to him, but I wasn't pushing it either. I was always afraid that it would reinforce his distrust, that he would become even more withdrawn, even more secretive. So, I was more focused on the task with him. ES#5_C2 (Cluster SLA, obtained a job)

In some cases, despite a good relationship and mutual respect, it was difficult to reach a clear agreement on the objectives, affecting the working alliance as a whole, and the SE process and work outcomes. “I had a vision of a helping approach for this client. But she was reluctant. So, she pulls on one side, and I pull on the other, so we don't go to the same place, and it doesn't work.” ES#16_C2 (Cluster LDA, did not obtain a job)

Conversely, in some cases, the affective bond may be neutral, yet still respectful, fostering a collaborative effort to help the client achieve their goal of obtaining employment. If there was agreement on the tasks, the objectives could be reached.

In our meetings, it was “OK straight to the point”, it was clear in terms of the task, she knew where she was going, and it was consistent with her pattern. That reassured me and favored my alliance with this person.” ES#5_C4, (Cluster SLA, obtained a job)

Finally, in some cases, like one client (Cluster LDA, did not obtain a job), the 3 components of the working alliance were sufficient and the person did not get a job because both the ES and the client agreed that it may not be the right time for them to integrate the competitive labour market, even though that was the original objective.

In 3 of the 5 patterns qualitatively analyzed from the ES’ point of view, where the client did not obtain employment, the ES reported significant difficulties in agreeing on the objectives to be pursued and the tasks to be performed in order to achieve them. In the other two patterns where there was no job acquisition, there was either agreement that competitive employment was perhaps not the right objective to pursue at the moment or the presence of a significant obstacle to employment unrelated to the person's mental illness (criminal record limiting employment opportunities).

Discussion

Main results and comparison with existing literature

A first surprising result was the ease with which study participants were able to find employment. Two-thirds of the clients who were recruited by ESs obtained employment at 6-month follow-up, which is higher than the 50% employment acquisition found in studies on the effectiveness of SE programmes (Frederick & VanderWeele, 2019; Kern et al., 2018; Modini et al., 2016; Suijkerbuijk et al., 2017). Also, the time required for obtaining competitive employment in our study, approximately 2 months, was significantly shorter than in previous studies, with means ranging from 4 to 9 months (Bond et al., 2007; Drake et al., 1999; Hoffmann et al., 2012; Latimer et al., 2006; Michon et al., 2014; Mueser et al., 2004). One of the possible reasons for these differences, as suggested by ESs in the interviews, is the staff shortage in Canada, and more specifically in Quebec, since the COVID-19 pandemic. Indeed, although there was a large increase in the unemployment rate in the first months of the pandemic (going up to 18.3% in April 2020), the rate then decreased to around 4% (Belzile et al., 2022). This context is a major difficulty for employers who are struggling to recruit employees, especially for jobs with little or no specialization (Institut de la statistique du Québec, 2022).

In this study, the first objective was to better understand the development of the working alliance as assessed by the ES vis-à-vis their client. To do this, we investigated the process of working alliance development over the first three employment support encounters using a methodology previously used in the context of psychotherapy and counseling. Three different working alliance patterns from the perspective of the ESs were revealed using cluster analysis: SHA (28%), SLA (56%), and LDA (17%).

The SHA cluster, representing just under one third of the working alliance patterns, corresponds to one of the two patterns most often found in studies that have examined the longitudinal development of the working alliance as perceived by the client in the context of psychotherapy (de Roten et al., 2004; Loos et al., 2015; Stiles et al., 2004) or career counseling (Covali et al., 2011). This pattern corresponds to a very strong working alliance (average working alliance = 6.6/7) from the outset with very little variability throughout the process. In the study by Loos et al. (2015) high and stable patterns and high and linearly increasing patterns were grouped and constituted 82% of their patterns. In the present study, the patterns in the SHA cluster have a very high average working alliance score (6.64/7 or 79.68/82) and it is possible that the scores were limited by a ceiling effect, preventing a perceived increase in scores over time since the first measure was very high (6.55/7 or 78.6/82). This ceiling effect is frequently observed in longitudinal studies using the WAI or other working alliance measures (Meier, 2022; Meier & Feeley, 2022).

The SLA pattern corresponds to a little more than half of the cases. These cases show little variability throughout the process, like the previous cluster, but the level of the working alliance is lower (average working alliance = 5.1/7). This score, although described as low, is consistent with the average working alliance level found in other studies of therapist perception of working alliance with individuals having SMI, where only one measurement time was used (Evans-Jones et al., 2009; Hasson-Ohayon et al., 2021; Johansen et al., 2013).

The LDA pattern found in this study is scarce (16.7%) and represents a very strong initial working alliance that diminishes throughout the process. This type of pattern is also found in small numbers (12.7%, 11.3%) in two studies on the development of the working alliance as perceived by the clients (Loos et al., 2015; Stiles et al., 2004).

The second objective was to better understand the link between the working alliance as perceived by the ES and the client's job acquisition, an important link already reported in the literature (Catty et al., 2008; Corbière et al., 2017). The clients represented by the patterns in the SHA and SLA clusters integrated employment more often than those in the LDA cluster.

Although there appears to be a distinction between these clusters, the connection between the working alliance and job acquisition is tenuous in the first phase of the study. In some cases, despite a suboptimal working alliance, clients still secure employment by the end of the process. Furthermore, despite variations in job acquisition rates, based on cluster membership, neither working alliance scores at times 1, 2, or 3, nor the average working alliance score, were related to job acquisition six months after programme commencement. Some of these results might be explained by the previously discussed labour shortage, but other factors could also be at play, such as the technical aspect of the ES job (Corbière et al., 2014a), or simply an effect of the small sample size in the present study.

The third and final objective was to better understand which factors (related to the client, to the counsellor, to their relationship, and to the context) could explain the different patterns of working alliance development and their potential links with job acquisition. Interviews with the ESs shed light on some of the factors that, from their point of view, may have affected the working alliance pattern developed with their clients.

The working alliance is a process that involves two individuals, the professional (e.g., therapist, ES) and the client, and both actors contribute to the alliance. In this study, although certain client characteristics or attitudes may facilitate (e.g., commitment, motivation) or limit (e.g., distrust) the creation and maintenance of the alliance, it was primarily the counsellor's affective, cognitive, and especially behavioural response to these characteristics and attitudes that seem important. ESs with stable and high working alliance patterns consciously make efforts to adapt to the client's characteristics, needs, and objectives. They are aware of the emotions that arise when they come into contact with certain characteristics of their clients, and they address their perceptions and anticipate possible pitfalls or ruptures in the relationship (e.g., disagreement on objectives). On the other hand, ESs with stable and low or declining working alliance patterns encounter challenges in recognizing their responses to client characteristics. Even when such awareness arises, they struggle to effectively utilize these insights, often due to uncertainty about how to apply them or heightened anxiety inhibiting their utilization. These findings are consistent with previous research on therapist effect (Ruiz-Aranda et al., 2021; Wampold & Owen, 2021).

In the psychotherapy literature, the working alliance is seen as the process that explains the therapist's effect and would reflect essential characteristics and skills of a good therapist, intrapersonal and interpersonal skills (Wampold et al., 2017; Wampold & Owen, 2021). One of these essential skills is mentalization which refers to the capacity to understand and interpret one's own and others’ mental states, including thoughts, feelings, and intentions (Bateman & Fonagy, 2019; Reading et al., 2019). Creating and maintaining a good working alliance involves mentalization and being aware of one's countertransference, which is cognitive and emotional reactions to the client, moment-by-moment (Gelso & Perez-Rojas, 2017). A lack of awareness of self and how the client affects the therapist leads to less appropriate interventions and, thus less therapeutic effectiveness (Hayes & Vinca, 2017). These emotions are unavoidable and can be beneficial to the therapeutic work as long as the therapist is aware of them, questions where they are coming from, and makes a conscious decision to take appropriate actions with the client (Gelso & Perez-Rojas, 2017). The therapist must be able to recognize what they are experiencing, but also be able to tolerate these emotions (Wolf et al., 2013). Among these emotions is anxiety, which acts as an important indicator of the presence of countertransference and can lead to behaviours such as experiential avoidance (e.g., not addressing certain topics that arouse anxiety in the therapist), withdrawal, and a decrease or even increase in the therapist's involvement (Hayes et al., 2019). These affective skills, while perceived and acted upon by some ESs in their contact with clients in this study, seem to be missing in other interviews. The ability to mentalize, to be aware of emotions and to regulate them is linked, at least in part, to the therapist's attachment security (Cologon et al., 2017). The link between the therapist's attachment security and his or her ability to form and maintain a good working alliance has also been studied multiple times (Degnan et al., 2016; Steel et al., 2018). These studies have shown that therapists with a secure attachment style feel more confident and comfortable in the relationship, enabling them to use their skills to resolve conflicts or breakdowns in the therapeutic relationship and thus maintain a better relationship over time (Marmarosh et al., 2014). An insecure attachment style on the part of the therapist often resulted in an initial high working alliance that diminished over time. These therapists, more vulnerable to reactivation of their attachment anxieties, failed to regulate their anxiety and used defensive strategies that prevented them from remaining attentive to the client and to the relation (Ruiz-Aranda et al., 2021).

The ES also raised two contextual factors that may have influenced the alliance pattern they developed with their clients; workload and the modality used for meetings. According to best practices, a small caseload (maximum 25 cases) is crucial, allowing the counsellor to adequately do their job in a successful SE programme (Drake et al., 2012). In practice, however, many settings exceed these recommended targets, requiring ESs to choose with which customers to deploy their energies (McDowell et al., 2022). Regarding the modality of encounters, several studies have looked at the effectiveness of services delivered via technologies and the effects of the use of its technologies on working alliance since the onset of the pandemic (Simpson et al., 2020). However, very few studies have focused on SMI clienteles (Greenwood et al., 2022). The results of studies carried out to date show that these technologies can be used to develop as good working alliance as face-to-face encounters, especially if the participants (clients and professionals) are comfortable using them (Simpson et al., 2020). It should be noted that COVID-19, with its demands for adaptation, learning new practices, and contact with vulnerable individuals made even more fragile by the context, has impacted mental health professionals, leading to increased fatigue (Ricks & Brannon, 2023).

The ESs interviewed perceived the working alliance as an important factor in their work. However, among the three components of the working alliance, the ones that, from their point of view, seem to explain more the achievement of the client's goal (acquisition of a job) are agreement on the goal and on the tasks to achieve it. Although the importance of the affective relationship was raised by several counselors, many of the clients with whom they developed a more neutral or task-oriented relationship (e.g., writing resumes, calling employers) obtained jobs. In cases where there were unresolved disagreements about goals and tasks, the client's chances of getting a job decreased. In 1979, Bordin addressed not only the trans-theoretical aspect of the working alliance but also the differences in working alliances between different types of psychotherapy. Although his model proposed three main essential components (affective bonding, goal agreement and task agreement), different contexts could place greater emphasis on one or the other of these components. It is also possible that these two components are more easily linked to the goal being pursued, i.e., obtaining a job. However, other objectives may be pursued in the context of employment support: helping clients to make choices consistent with their characteristics, abilities, and needs, developing a greater sense of personal efficacy, reducing self-stigmatization (Corbière et al., 2014b, 2017), and it is possible that these objectives are more closely linked to the affective aspect of the working alliance.

Clinical implications

The ES is a relatively new role for which specific training is not usually provided; it is learned in action (Butenko et al., 2022; McDowell et al., 2022) and has been scarcely studied (Teixeira et al., 2020). However, we know that the performance of this role varies significantly across counselors (Drake et al., 2006) and this variability can be explained, at least in part, by the ES's skills (Corbière et al., 2014a; Glover & Frounfelker, 2011, 2013; Kinn et al., 2021; Teixeira et al., 2020; Whitley et al., 2010). The importance of the working alliance and relational skills of ESs have been raised both in studies focusing on the outcomes of the employment support process (Catty et al., 2008; Corbière et al., 2017) and the subjective experiences of clients participating in these same programmes (Kinn et al., 2021). This study has the advantage of going further in understanding the factors and processes involved in creating and maintaining the working alliance in the context of employment support and highlights intrapersonal and interpersonal skills to focus on in the development of ESs.

ESs in this study confirm that they see the working alliance as an important factor in achieving their goals with their clients. Some ESs are actively engaged in this area and are seeking to improve their ability to build strong working alliances, while others appear to have more difficulty doing so and may need support. Although the importance of supervision for employment counselors has been raised by research in the past (Rinaldi et al., 2010), the availability of quality supervision for these professionals is still reportedly lacking (Butenko et al., 2022).

Limitations

Despite the strengths of this study and the innovative contribution to the literature on the working alliance in the context of employment support, there are important limitations to consider. First, the study sample is small, limiting the analyses performed and the generalization of results. This limitation can be explained in part by recruitment difficulties related to the COVID-19 context. The small sample size of ES and the over-representation of work alliance patterns associated with certain ESs in some clusters make respondent bias possible. Therefore, the results should therefore be treated with caution. Additional studies, incorporating a larger sample size that allows for the isolation of the contribution of Es's and enables the use of inferential analyses, are needed to ensure the validity and transferability of results. Another limitation of this study is that it only addresses job acquisition, but not job tenure. Job integration involves not only acquiring a job but also maintaining it over the long term. Altogether, this study remains an important cornerstone in the domain since the ES perspective in SE programmes is understudied.

Conclusion

In conclusion, this study suggests that alliance development patterns provide more nuanced and comprehensive information than a single alliance measure when evaluating the working alliance in the context of SE programmes and job acquisition. Although the most frequent pattern in this study is a rather low and stable pattern, it is the high and stable patterns that are more often linked to job acquisition among SMI clients. The in-depth interviews also explored and highlighted important factors related to the ES-client relationship (e.g., level of trust), ES competencies (e.g., awareness of one's countertransference), and context (e.g., workload) that ultimately affect the working alliance development patterns and job acquisition. This information can be considered in the initial and ongoing training of ESs and in the implementation of quality SE programmes.

Footnotes

Ethics statement

The study was approved by the Research Ethics Board of the Université du Québec à Montréal (CERPÉ UQAM; certificate number: 4189, date of approval: 15-06-2020) and all procedures followed were in accordance with the ethical standards of with the Declaration of Helsinki of 1975, as revised in 2000.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors would like to thank the Institut de recherche Robert-Sauvé en Santé et en Sécurité du Travail (IRSST) for the PhD scholarship (2020–2024) that made it possible to finance the work associated with this article.

Informed consent

Informed consent was obtained from all participants included in the study.

Acknowledgements

The authors would like to thank the SE programme administrators who agreed to participate in this study, all the ESs who agreed to share their vision of their work, as well as the statistician, Charles-Edouard Giguère of the Research Centre of Institut Universitaire en Santé Mentale à Montréal (CR-IUSMM) for his support.

Notes

References

Ardito

R. B.

Rabellino

(2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270. https://doi.org/10.3389/fpsyg.2011.00270

Barrowclough

Meier

Beardmore

Emsley

(2010). Predicting therapeutic alliance in clients with psychosis and substance misuse. The Journal of Nervous and Mental Disease, 198(5), 373–377. https://doi.org/10.1097/NMD.0b013e3181da4d4e

Bateman

A. W.

Fonagy

(Eds.) (2019). Handbook of mentalizing in mental health practice. American Psychiatric Publishing.

Belzile

Braham

Savard

Homsy

Diallo

(2022, febuary 17). Bilan 2021 de l’emploi au Québec. Institut du Québec. https://institutduquebec.ca/bilan-2021-de-lemploi-au-quebec/ .

Bond

G. R.

Drake

R. E.

Becker

D. R.

(2008). An update on randomized controlled trials of evidence-based supported employment. Psychiatric Rehabilitation Journal, 31(4), 280–290. https://doi.org/10.2975/31.4.2008.280.290

Bond

G. R.

Salyers

M. P.

Dincin

Drake

R. E.

Becker

D. R.

Fraser

V. V.

Haines

(2007). A randomized controlled trial comparing two vocational models for persons with severe mental illness. Journal of Consulting and Clinical Psychology, 75(6), 968–982. https://doi.org/10.1037/0022-006X.75.6.968

Bordin

E. S.

(1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885

Bordin

E. S.

(1983). A working alliance based model of supervision. The Counseling Psychologist, 11(1), 35–42. https://doi.org/10.1177/0011000083111007

Briand

Larivière

(2020). Les méthodes de recherche mixtes : Illustration d’une analyse des effets cliniques et fonctionnels d’un hôpital de jour psychiatrique. In M. Corbière & N. Larivière (Eds.), Méthodes qualitatives, quantitatives et mixtes : Dans la recherche en sciences humaines, sociales et de la santé (2nd ed., pp. 865–893). Presses de l’Université du Québec.

10.

Butenko

Rinaldi

Brinchmann

Killackey

Johnsen

Mykletun

(2022). Turnover of IPS employment specialists: Rates and predictors. Journal of Vocational Rehabilitation, 57(1), 23–32. https://doi.org/10.3233/JVR-221195

11.

Byrne

Uprichard

(2012). Useful complex causality. In Kincaid

(Ed.), The Oxford handbook of philosophy of social science (pp. 109–129). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780195392753.013.0006.

12.

Catty

Lissouba

White

Becker

Drake

R. E.

Fioritti

Knapp

Lauber

Rössler

Tomov

van Busschbach

Wiersma

Burns

(2008). Predictors of employment for people with severe mental illness: Results of an international six-centre randomised controlled trial. The British Journal of Psychiatry, 192(3), 224–231. https://doi.org/10.1192/bjp.bp.107.041475

13.

Charette-Dussault

Corbière

(2019). An integrative review of the barriers to job acquisition for people with severe mental illnesses. The Journal of Nervous and Mental Disease, 207(7), 523–537. https://doi.org/10.1097/NMD.0000000000001013

14.

Cologon

Schweitzer

R. D.

King

Nolte

(2017). Therapist reflective functioning, therapist attachment style and therapist effectiveness. Administration and Policy in Mental Health and Mental Health Services Research, 44(5), 614–625. https://doi.org/10.1007/s10488-017-0790-5. PMID: 28132188

15.

Corbière

Bisson

Lauzon

Ricard

(2006). Factorial validation of a French short-form of the Working Alliance Inventory. International Journal of Methods in Psychiatric Research, 15(1), 36–45. https://doi.org/10.1002/mpr.27

16.

Corbière

Brouwers

Lanctôt

van Weeghel

(2014a). Employment specialist competencies for supported employment programs. Journal of Occupational Rehabilitation, 24(3), 484–497. https://doi.org/10.1007/s10926-013-9482-5

17.

Corbière

Charette-Dussault

Villotti

(2020). Predictors of job acquisition and job tenure for people with severe mental disorders. In Bültmann

Siegrist

(Eds.), Handbook of disability, work and health (pp. 1–26). Springer International Publishing. https://doi.org/10.1007/978-3-319-75381-2_29-1.

18.

Corbière

Lecomte

Reinharz

Kirsh

Goering

Menear

Berbiche

Genest

Goldner

E. M.

(2017). Predictors of acquisition of competitive employment for people enrolled in supported employment programs. The Journal of Nervous and Mental Disease, 205(4), 275–282. https://doi.org/10.1097/NMD.0000000000000612

19.

Corbière

Villotti

Toth

Waghorn

(2014b). La divulgation du trouble mental et les mesures d’accommodements de travail: Deux facteurs du maintien en emploi des personnes aux prises avec un trouble mental grave [Disclosure of a mental disorder in the workplace and work accommodations: Two factors associated with job tenure of people with severe mental disorders]. L’Encéphale, 40(S2), 91–102. https://doi.org/https://doi-org/10.1016/j.encep.2014.04.006

20.

Covali

Bernaud

J.-L.

Di Fabio

(2011). Processus de changement et variabilité individuelle au cours des consultations d’orientation. Swiss Journal of Psychology, 70(3), 175–183. https://doi.org/10.1024/1421-0185/a000053

21.

Degnan

Seymour-Hyde

Harris

Berry

(2016). The role of therapist attachment in alliance and outcome: A systematic literature review. Clinical Psychology & Psychotherapy, 23(1), 47–65. https://doi.org/10.1002/cpp.1937

22.

de Roten

Fischer

Drapeau

Beretta

Kramer

Favre

Despland

J.-N.

(2004). Is one assessment enough? Patterns of helping alliance development and outcome. Clinical Psychology & Psychotherapy, 11(5), 324–331. https://doi.org/10.1002/cpp.420

23.

de Winter

Couwenbergh

van Weeghel

Sanches

Michon

Bond

G. R.

(2022). Who benefits from individual placement and support? A meta-analysis. Epidemiology and Psychiatric Sciences, 31, e50. https://doi.org/10.1017/S2045796022000300

24.

Donnell

C. M.

Lustig

D. C.

Strauser

D. R.

(2004). The working alliance: Rehabilitation outcomes for persons with severe mental illness. The Journal of Rehabilitation, 70(2), 12–18. https://doi.org/10.3233/JVR-211165

25.

Drake

R. E.

Bond

G. R.

(2014). Introduction to the special issue on individual placement and support. Psychiatric Rehabilitation Journal, 37(2), 76–78. https://doi.org/10.1037/prj0000083

26.

Drake

R. E.

Bond

G. R.

Becker

D. R.

(2012). Individual Placement and Support: An evidence-based approach to supported employment. Oxford University Press.

27.

Drake

R. E.

Bond

G. R.

Rapp

(2006). Explaining the variance within supported employment programs: Comment on “ What predicts supported employment outcomes?”. Community Mental Health Journal, 42(3), 315–318. https://doi.org/10.1007/s10597-006-9038-7

28.

Drake

R. E.

McHugo

G. J.

Bebout

R. R.

Becker

D. R.

Harris

Bond

G. R.

Quimby

(1999). A randomized clinical trial of supported employment for inner-city patients with severe mental disorders. Archives of General Psychiatry, 56(7), 627–633. https://doi.org/10.1001/archpsyc.56.7.627

29.

Drake

R. E.

Whitley

(2014). Recovery and severe mental illness: Description and analysis. The Canadian Journal of Psychiatry, 59(5), 236–242. https://doi.org/10.1177/070674371405900502

30.

Elad-Strenger

Littman-Ovadia

(2012). The contribution of the counselor–client working alliance to career exploration. Journal of Career Assessment, 20(2), 140–153. https://doi.org/10.1177/1069072711420850

31.

Evans-Jones

Peters

Barker

(2009). The therapeutic relationship in CBT for psychosis: Client, therapist and therapy factors. Behavioural and Cognitive Psychotherapy, 37(5), 527–540. https://doi.org/10.1017/S1352465809990269

32.

Flückiger

Del Re

A. C.

Wampold

B. E.

Horvath

A. O.

(2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172

33.

Frederick

D. E.

VanderWeele

T. J.

(2019). Supported employment: Meta-analysis and review of randomized controlled trials of individual placement and support. PloS One, 14(2), e0212208. https://doi.org/10.1371/journal.pone.0212208

34.

Gallagher

Marceau

(2020). La recherche descriptive interprétative: Exploration de concept de la validité en tant qu’impératif social dans le contexte de l’évaluation des apprentissages en pédagogie des sciences de la santé. In Corbière

Larivière

(Eds.), Méthodes qualitatives, quantitatives et mixtes: Dans la recherche en sciences humaines, sociales et de la santé (2^nd ed, pp. 5–32). Presses de l’Université du Québec. https://doi.org/10.2307/j.ctv1c29qz7.6.

35.

Gelso

C. J.

Perez-Rojas

A. E.

(2017). Inner experience and the good therapist. In Castonguay

L. G.

Hill

C. E.

(Eds.), How and why are some therapists better than others?: Understanding therapist effects (pp. 101–115). American Psychological Association. https://doi.org/10.1037/0000034-007.

36.

Glover

C. M.

Frounfelker

R. L.

(2011). Competencies of employment specialists for effective job development. American Journal of Psychiatric Rehabilitation, 14(3), 198–211. https://doi.org/10.1080/15487768.2011.598093

37.

Glover

C. M.

Frounfelker

R. L.

(2013). Competencies of more and less successful employment specialists. Community Mental Health Journal, 49(3), 311–316. https://doi.org/10.1007/s10597-011-9471-0

38.

Greenwood

Krzyzaniak

Peiris

Clark

Scott

A. M.

Cardona

Griffith

Glasziou

(2022). Telehealth versus face-to-face psychotherapy for less common mental health conditions: Systematic review and meta-analysis of randomized controlled trials. JMIR Mental Health, 9(3), e31780. https://doi.org/10.2196/31780

39.

Hair

J. F.

Black

W. C.

(2000). Cluster analysis. In Grimm

L. G.

Yarnold

P. R.

(Eds.), Reading and understanding MORE multivariate statistics (pp. 147–205). American Psychological Association.

40.

Hasson-Ohayon

de Jong

Igra

Carter

S. A.

Faith

L. A.

Lysaker

(2021). Longitudinal changes in therapeutic alliance with people with psychosis: Relationship between client and therapist assessments. Clinical Psychology & Psychotherapy, 28(5), 1243–1253. https://doi.org/10/gmprng

41.

Hayes

J. A.

Gelso

C. J.

Kivlighan

D. M.

Goldberg

(2019). Managing countertransference. In Norcross

J. C.

Lambert

M. J.

(Eds.), Psychotherapy relationships that work: Evidence-based therapist contribution (3^rd ed, pp. 522–548). Oxford University Press. https://doi.org/10.1093/med-psych/9780190843953.003.0015.

42.

Hayes

J. A.

Vinca

(2017). Therapist presence, absence, and extraordinary presence. In Castonguay

L. G.

Hill

C. E.

(Eds.), How and why are some therapists better than others?: Understanding therapist effects (pp. 85–99). American Psychological Association. https://doi.org/10.1037/0000034-006.

43.

Hoffmann

Jäckel

Glauser

Kupper

(2012). A randomised controlled trial of the efficacy of supported employment. Acta Psychiatrica Scandinavica, 125(2), 157–167. https://doi.org/10.1111/j.1600-0447.2011.01780.x

44.

Horvath

A. O.

Del Re

A. C.

Flückiger

Symonds

(2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. https://doi.org/10.1037/a0022186

45.

Horvath

A. O.

Greenberg

L. S.

(1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223–233. https://doi.org/10.1037/0022-0167.36.2.223

46.

Institut de la statistique du Québec (2022). Comment évolue la participation au marché du travail en temps de pandémie au Québec et ailleurs au CanadaQuatrième trimestre de 2021. https://statistique.quebec.ca/fr/document/participation-marche-travail-pandemie-quebec-et-canada-quatrieme-trimestre-2021.

47.

Johansen

Iversen

V. C.

Melle

Hestad

K. A.

(2013). Therapeutic alliance in early schizophrenia spectrum disorders: A cross-sectional study. Annals of General Psychiatry, 12(1), 1–10. https://doi.org/10.1186/1744-859X-12-14

48.

Kern

R. S.

Zarate

Glynn

S. M.

Turner

L. R.

Smith

K. M.

Mitchell

S. S.

Sugar

C. A.

Bell

M. D.

Liberman

R. P.

Kopelowicz

Green

M. F.

(2018). Improving work outcome in supported employment for serious mental illness: Results from 2 independent studies of errorless learning. Schizophrenia Bulletin, 44(1), 38–45. https://doi.org/10/gcwk5h

49.

Kinn

L. G.

Costa

Voll

Austrheim

Aas

R. W.

Davidson

(2021). Navigating between unpredictable icebergs”: A meta-ethnographic study of employment specialists’ contributions in providing job support for people with mental illness. Journal of Occupational Rehabilitation, 31(3), 512–531. https://doi.org/10.1007/s10926-020-09943-6

50.

Kivlighan

D. M.

Shaughnessy

(2000). Patterns of working alliance development: A typology of client’s working alliance ratings. Journal of Counseling Psychology, 47(3), 362–371. https://doi.org/10.1037/0022-0167.47.3.362

51.

Kondrat

D. C.

Early

T. J.

(2010). An exploration of the working alliance in mental health case management. Social Work Research, 34(4), 201–211. https://doi.org/10.1093/swr/34.4.201

52.

Latimer

E. A.

Lecomte

Becker

D. R.

Drake

R. E.

Duclos

Piat

Lahaie

St-Pierre

M.-S.

Therrien

Xie

(2006). Generalisability of the individual placement and support model of supported employment: Results of a Canadian randomised controlled trial. The British Journal of Psychiatry, 189(1), 65–73. https://doi.org/10.1192/bjp.bp.105.012641

53.

Lecomte

Savard

(2006). Les effets d’une intervention de counseling sur la réadaptation de travailleurs accidentés à risque de chronicité (R-448). Institut de Recherche Robert-Sauvé en Santé et Sécurité au Travail. https://www.irsst.qc.ca/media/documents/pubirsst/r-448.pdf.

54.

Lloyd

(2010). Vocational rehabilitation and mental health. Blackwell Publishing. https://doi.org/10.1002/9781444319736.

55.

Loos

Arnold

Slade

Jordan

Del Vecchio

Sampogna

Süveges

Nagy

Krogsgaard Bording

Østermark Sørensen

Rössler

Kawohl

Puschner

, & The CEDAR study group. (2015). Courses of helping alliance in the treatment of people with severe mental illness in Europe: A latent class analytic approach. Social Psychiatry and Psychiatric Epidemiology, 50(3), 363–370. https://doi.org/10.1007/s00127-014-0963-4

56.

Luborsky

L. L.

(1976). Helping alliances in psychotherapy. In Claghorn

J. L.

(Ed.), Successful psychotherapy (pp. 92–116). New York Brunner/Mazel.

57.

Marmarosh

Kivlighan

Bieri

Schutt

Barone

Choi

(2014). The insecure psychotherapy base: Using client and therapist attachment styles to understand the early alliance. Psychotherapy, 51(3), 404–412. https://doi.org/10.1037/a0031989

58.

McDowell

Fossey

Harvey

(2022). Moving clients forward: A grounded theory of disability employment specialists’ views and practices. Disability and Rehabilitation, 44(19), 5504–5512. https://doi.org/10.1080/09638288.2021.1937341

59.

Meier

S. T.

(2022). Investigation of causes of ceiling effects on working alliance measures. Frontiers in Psychology, 13, 1–8. https://doi.org/10.3389/fpsyg.2022.949326

60.

Meier

S. T.

Feeley

T. H.

(2022). Ceiling effects indicate a possible threshold structure for working alliance. Journal of Counseling Psychology, 69(2), 235–245. https://doi.org/10.1037/cou0000564

61.

Michon

van Busschbach

J. T.

Stant

A. D.

van Vugt

M. D.

van Weeghel

Kroon

(2014). Effectiveness of individual placement and support for people with severe mental illness in The Netherlands: A 30-month randomized controlled trial. Psychiatric Rehabilitation Journal, 37(2), 129–136. https://doi.org/10.1037/prj0000061

62.

Modini

Tan

Brinchmann

Wang

M.-J.

Killackey

Glozier

Mykletun

Harvey

S. B.

(2016). Supported employment for people with severe mental illness: Systematic review and meta-analysis of the international evidence. The British Journal of Psychiatry, 209(1), 14–22. https://doi.org/10.1192/bjp.bp.115.165092

63.

Mueser

K. T.

Clark

R. E.

Haines

Drake

R. E.

McHugo

G. J.

Bond

G. R.

Essock

S. M.

Becker

D. R.

Wolfe

Swain

(2004). The hartford study of supported employment for persons with severe mental illness. Journal of Consulting and Clinical Psychology, 72(3), 479–490. https://doi.org/10.1037/0022-006X.72.3.479

64.

Mueser

K. T.

McGurk

S. R.

(2014). Supported employment for persons with serious mental illness: Current status and future directions. L’Encéphale, 40(2), S45–S56. https://doi.org/10.1016/j.encep.2014.04.008

65.

Paillé

Mucchielli

(2021). L’analyse qualitative en sciences humaines et sociales—5e éd. Armand Colin.

66.

Reading

Safran

Origlieri

Muran

(2019). Investigating therapist reflective functioning, therapeutic process, and outcome. Psychoanalytic Psychology, 36(2), 115–121. https://doi.org/10.1037/pap0000213

67.

Ricks

Brannon

G. E.

(2023). It’s real. It’s a thing:” Mental health counselors’ listening exhaustion during COVID-19. Qualitative Research in Medicine & Healthcare, 7(2), 11261. https://doi.org/10.4081/qrmh.2023.11261

68.

Rinaldi

Miller

Perkins

(2010). Implementing the Individual Placement and Support (IPS) approach for people with mental health conditions in England. International Review of Psychiatry, 22(2), 163–172. https://doi.org/10.3109/09540261003720456

69.

Rinaldi

Perkins

Glynn

Montibeller

Clenaghan

Rutherford

(2008). Individual placement and support: From research to practice. Advances in Psychiatric Treatment, 14(1), 50–60. https://doi.org/10.1192/apt.bp.107.003509

70.

Rokach

Maimon

(2005). Clustering methods. In Maimon

Rokach

(Eds.), Data mining and knowledge discovery handbook (pp. 321–352). Springer Science & Business Media. https://doi.org/10.1007/0-387-25465-X_15.

71.

Ross

E. C.

Polaschek

D. L. L.

Ward

(2008). The therapeutic alliance: A theoretical revision for offender rehabilitation. Aggression and Violent Behavior, 13(6), 462–480. https://doi.org/10.1016/j.avb.2008.07.003

72.

Ruiz-Aranda

Cardoso-Álvarez

Fenollar-Cortés

(2021). Therapist attachment and the working alliance: the moderating effect of emotional regulation. Frontiers in Psychology, 12, 784010. https://doi.org/10.3389/fpsyg.2021.784010

73.

Safran

J. D.

Muran

J. C.

(2007). Therapist relationship interview [Unpublished manuscript].

74.

Safran

J. D.

Muran

J. C.

Proskurov

(2009). Alliance, negotiation, and rupture resolution. In Levy

R. A.

Ablon

J. S.

(Eds.), Handbook of evidence-based psychodynamic psychotherapy: Bridging the gap between science and practice (pp. 201–225). Humana Press. https://doi.org/10.1007/978-1-59745-444-5_9.

75.

Simpson

A. I.

Chatterjee

Darby

Jones

R. M.

Maheandiran

Penney

S. R.

Saccoccio

Stergiopoulos

Wilkie

(2020). Management of COVID-19 response in a secure forensic mental health setting: Réponse à la gestion de la COVID-19 dans un établissement sécurisé de santé mentale et de psychiatrie légale. The Canadian Journal of Psychiatry, 65(10), 695–700. https://doi.org/10.1177/0706743720935

76.

Steel

Macdonald

Schroder

(2018). A systematic review of the effect of therapists’ internalized models of relationships on the quality of the therapeutic relationship. Journal of Clinical Psychology, 74(1), 5–42. https://doi.org/10.1002/jclp.22484

77.

Stiles

W. B.

Glick

M. J.

Osatuke

Hardy

G. E.

Shapiro

D. A.

Agnew-Davies

Rees

Barkham

(2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51(1), 81–92. https://doi.org/10.1037/0022-0167.51.1.81

78.

Suijkerbuijk

Y. B.

Schaafsma

F. G.

van Mechelen

J. C.

Ojajärvi

Corbière

Anema

J. R.

(2017). Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. The Cochrane Database of Systematic Reviews, 2017(9), CD011867. https://doi.org/10.1002/14651858.CD011867.pub2

79.

Teixeira

Rogers

E. S.

Russinova

Lord

E. M.

(2020). Defining employment specialist competencies: Results of a participatory research study. Community Mental Health Journal, 56(3), 440–447. https://doi.org/10.1007/s10597-019-00497-3

80.

Tremain

McEnery

Fletcher

Murray

(2020). The therapeutic alliance in digital mental health interventions for serious mental illnesses: Narrative review. JMIR mental Health, 7(8), e17204. https://doi.org/10.2196/17204

81.

Wampold

B. E.

Baldwin

S. A.

Holtforth

M. g.

Imel

Z. E.

(2017). What characterizes effective therapists? In Castonguay

L. G.

Hill

C. E.

(Eds.), How and why are some therapists better than others?: Understanding therapist effects (pp. 37–53). American Psychological Association. https://doi.org/10.1037/0000034-003.

82.

Wampold

B. E.

Owen

(2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham

Lutz

Castonguay

L. G.

(Eds.), Bergin and garfield’s handbook of psychotherapy and behavior change: 50th anniversary edition (pp. 297–326). John Wiley & Sons, Inc.

83.

Ward

J. H.

(1963). Hierarchical grouping to optimize an objective function. Journal of the American Statistical Association, 58(301), 236–244. https://doi.org/10.1080/01621459.1963.10500845

84.

Whitley

Kostick

K. M.

Bush

P. W.

(2010). Desirable characteristics and competencies of supported employment specialists: An empirically-grounded framework. Administration and Policy in Mental Health, 37(6), 509–519. https://doi.org/10.1007/s10488-010-0297-9

85.

Winsper

Crawford-Docherty

Weich

Fenton

S. J.

Singh

S. P.

(2020). How do recovery-oriented interventions contribute to personal mental health recovery? A systematic review and logic model. Clinical Psychology Review, 76, 101815. https://doi.org/10.1016/j.cpr.2020.101815

86.

Wolf

A. W.

Goldfried

M. R.

Muran

J. C.

(2013). Transforming negative reactions to clients: From frustration to compassion. American Psychological Association. https://www.jstor.org/stable/j.ctv1chrt4g .