Abstract
The recent article by Howgego et al. [1] provides a timely synopsis of the key issues in contemporary mental health care. Specifically, the work of Howgego and her colleagues reminds us of the need to demonstrate the effectiveness of case management as a routine part of clinical practice and of current strategies being developed to enhance such effectiveness. Currently as part of the National Outcomes and Casemix Collection [2], a range of measures are being introduced into routine clinical practice that can be used to demonstrate the effectiveness of mental health services. Among others, these measures include the Health of the Nation Outcome Scales (HoNOS) and the Life Skills Profile (LSP). Mental health services across Australia have agreed to collect these measures as part of routine clinical practice and this data will provide a rich ‘real world’ longitudinal data set that can be used to demonstrate changes in symptoms and disability in people receiving case management services. Future research on case management should be mindful of the collection of this information. However, to demonstrate the effectiveness of a particular type of service delivery, change must be attributable to that service. Howgego et al. [1] are right to remind us of the importance of the therapeutic alliance. Although there is evidence that alliance is associated with increased medication adherence, our work has shown that mental health workers view patient factors such as insight as primarily associated with adherence and alliance as the least important [3]. Medication Alliance [4] is a program that uses aspects of the therapeutic alliance to facilitate medication adherence and in doing so, generally improve the patient–case manager relationship. Although Bordins’ model is obviously attractive, we would add that ‘tasks’ should not be limited to intratherapy activities but include extra-therapy homework activities, with the model of case management a significant moderator of the importance of extra-therapy activities to skills development and recovery. Indeed, we have demonstrated that training focusing on the development of a therapeutic alliance does have an effect on staff attitudes toward medication adherence (‘Medication Alliance – a skills based program for mental health workers to facilitate neuroleptic medication adherence: Preliminary research outcomes.’ Unpublished Manuscript: University of Wollongong, 2003). The next phase for the Medication Alliance project is to empirically demonstrate that improvements in the therapeutic alliance CORRESPONDENCE 629 between patient and case manager produce enduring enhancements in mental health service outcomes, much in the same way as proposed by Howgego and her colleagues.