The relation between the working alliance and therapeutic outcome was examined in 21 therapist-client dyads. This relation was analyzed in terms of the level of alliance at the third counseling session, midpoint of treatment, and last session with linear and curvilinear models of the temporal development of the working alliance. Analyses were conducted with hierarchical linear modeling. Results revealed a significant association between the linear growth function of therapist ratings of the working alliance and therapeutic outcome. The use of hierarchical linear modeling in counseling psychology research and the need for conceptualizing the working alliance as a temporally variant, as opposed to a static, process are discussed. Studies of the working alliance represent an important recent focus as well as a growing edge for research in counseling psychology (Hill & Corbett, 1993). Developed from psychoanalytic principles governing the conduct of therapy (e.g,. Freud, 1913/1958), the working alliance has come to be seen as a necessary component of counseling of all types, regardless of theoretical frame (Gelso & Fretz, 1992; Hartley & Strupp, 1983; Robbins, 1992). Although several definitions of the working alliance have been offered, Bordin's (1979) definition has been the most heuristic, spawning a number of theoretical and empirical works. Bordin defined the working alliance as the collaboration between the client and the therapist based on their agreement on the goals and tasks of counseling and on the development of an attachment bond. Gelso and Carter (1985) provided a catalyst for recent research on the counseling relationship in general and the working alliance in particular (Gelso & Fretz, 1992; Hill & Corbett, 1993; Sexton & Whiston, 1994). In Gelso and Carter's (1994) recent refinement of the propositions set forth in their 1985 article, they emphasized the temporal unfolding of the relationship components. Specifically, their 12th proposition regarding the dimensions of the counseling relationship was stated as follows: "Especially in treatments that abbreviate duration, an initially sound working alliance will subsequently decline, but in successful therapy this decline will be followed by an increase to earlier, high levels" (Carter & Gelso, 1994; pp. 301-302). This specific proposition, which the present study was designed to examine, is an example of a recent trend in theorizing about the

Patterns of working alliance development were detected by clustering working alliance ratings across 4 sessions of counseling. Results from an initial sample of recruited participants working with novice counselors (N = 38) revealed 3 patterns of alliance development labeled stable alliance, linear alliance growth, and quadratic alliance growth. Results from a replication sample (N = 41) of recruited participants also working with novice counselors, revealed 3 identical patterns of alliance development, which offered strong support for the validity of these growth patterns. As predicted by Gelso and Carter (1994), a pattern of quadratic alliance development was associated with greater improvement on measures of counseling benefit when compared to other patterns of alliance development. The discussion underscores the importance of examining both the strength (level) and pattern of development when examining the effects of the working alliance.

No abstract

It is feasible to integrate the programmatic, data collection, data transmission, and outcome enhancement components of OBQI into the day-to-day operations of home health agencies. The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients. OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare settings.

To evaluate the effects of Medicare's prospective payment system and Medicaid's preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicare's prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaid's policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.