Abstract

The study reported in this article examines the associations between service users’ hope, the social worker–service user working alliance, and social worker burnout as perceived by service users, on the one hand, and perceived change in the service users’ presenting problems, on the other. The study was conducted with 342 service users of a large municipal welfare agency. Consistent with the study hypotheses, the findings show (a) positive associations between the working alliance and service users’ hope, on the one hand, and between the working alliance and the perceived effectiveness of the intervention, on the other, and (b) negative associations between perceived social worker burnout and perceived intervention effectiveness. They also show that hope and social worker burnout, as perceived by service users, mediate the association between the working alliance and the perceived effectiveness of the intervention.

The issue of the effectiveness of professional intervention has occupied scholars and practitioners in the helping professions since at least the mid-20th century. Since then, Eysenck’s (1952) claim that there was no empirical evidence to indicate the effectiveness of such intervention has been refuted by numerous empirical studies (Franklin, Kim, & Tripodi, 2009; Norcross & Lambert, 2011). What makes such intervention effective or ineffective, however, remains an open question. Answering this question is important because of the responsibilities that professionals bear: to try to alleviate their clients’ distress and help them to resolve the problems and, for those who work in the public sector, to make effective use of the financial resources channeled to this endeavor. For decades now, scholars have invested considerable effort in trying to understand what promotes and what detracts from intervention effectiveness (Lambert, 2011; Reading, 2013). The research has focused on the type of intervention (Bachelor & Horvath, 1999; Bergin & Garfield, 1994), the features and resources of the service provider (Becker, 2013; Hersoug, 2009) and service user (Yeryomenk, 2012), and the professional–client interaction (Martin, Garske, & Davis, 2000; Muran & Barber, 2010). The present study focuses on the working alliance between social worker and service user.

Literature Review

Working Alliance

The working alliance refers to the quality and strength of the relationship and cooperation between service user and service provider. According to Bordin (1979) it consists of three components: (1) agreement on the goals of the intervention, (2) agreement on the means of attaining the goals, and (3) the relationship between the service user and the service provider. A good working alliance is characterized by the development of bonds and by agreement on goals and the assignment of tasks. It is not bound to any particular theoretical orientation (Horvath & Bedi, 2002) but is viewed as an essential component in the process of client change whatever the counseling orientation or technique (Taber, Leibert, & Agaskar, 2011). A good working alliance has been consistently associated with successful intervention outcomes (Bennett, Fuertes, Keitel, & Phillips, 2011; Horvath, Del Re, Flückiger, & Symonds, 2011; Horvath & Symonds, 1991; Howard, Turner, Olkin, & Mohr, 2006; Tryon, Blackwell, & Hammel, 2007).

Most studies of the working alliance have been conducted in the field of psychotherapy, where the concept originated (see, for example, Hatcher, 2010). The present study examines it in social work, specifically in the context of social welfare services. These services may or may not include psychotherapy, but their focus is generally on getting clients the benefits and services to which they are legally entitled. A working alliance in such services may well be difficult to establish. The working conditions under which social workers operate do not always provide them with the time, space, privacy, and quiet that facilitates building such an alliance. Whatever their good will toward their service users, social workers’ limited resources often constrain what they can do for them. Moreover, as representatives of the establishment, social workers are often viewed by service users with hostility and distrust (Hatfield, McCullough, Plucinski, & Krieger, 2010).

The present study addresses two issues. The first is whether there is any association between the working alliance and intervention effectiveness. The second, under the assumption that there is, concerns the dynamic of the association. To explore the second issue, we examine two potential mediating variables: the service users’ hope and their perceptions of their social workers’ burnout. Empirical evidence indicates that intervention effectiveness is associated with both (Deckard, Meterko, & Field, 1994; Gaba & Howard, 2002; Ho et al., 2011; Holtslander & Duggleby, 2009; Swift & Derthick, 2013). Moreover, both variables can be affected in the course of the intervention. Service users’ hope can be dashed or bolstered, and service providers’ burnout fostered or forestalled.

Hope

Hope has been conceptualized in numerous ways, stemming from a variety of conceptual approaches including psychodynamic (Mitchell, 1993), philosophical (Scioli, Ricci, Nyugen, & Scioli, 2011), and cognitive (Snyder et al., 2000). For the purpose of this study, we used the conceptualization of Snyder (Snyder et al., 1991): Hope consists of the sense that one has the means to attain one’s goals and the ability and determination to do so. It is regarded as an effective psychosocial resource for coping with difficult life experiences and as essential to individuals’ well-being (Ho et al., 2011; Holtslander & Duggleby, 2009). There is broad agreement on the value of hope for people in general and for individuals in crisis in particular (Cheavens, Michael, Snyder, & Eliott, 2005).

Several studies have shown that hope is a powerful predictor of positive intervention outcomes (Hubble & Miller, 2004; Irving et al., 2004) and a buffer against negative outcomes (Rand & Cheavens, 2009; Swift & Derthick, 2013). Hope has also been associated with recovery from serious illnesses, injuries (Hartley, Vance, Elliott, Cuckler, & Berry, 2008; Kathleen et al., 2012), and trauma (Brooksbank & Cassell, 2005; Snyder, Lehman, Kluck, & Monsson, 2006); with reduced symptoms of depression (Dominguez, 2013); and with successful coping with stress (Chang & DeSimone, 2001). In consequence, researchers and theoreticians have developed intervention approaches in which hope is a core feature.

Burnout

Burnout in human services work is generally viewed as a prolonged response to chronic emotional and interpersonal stressors on the job (Maslach, 2003). Its main symptoms are emotional exhaustion, lack of sense of personal achievement, and depersonalization. Emotional exhaustion refers to the sense that one’s emotional resources are depleted and that one has nothing left to give. Lack of personal accomplishment refers to feelings of unhappiness about oneself and one’s work-related achievements. Depersonalization refers to negative, often cynical attitudes and feelings about one’s clients. Burnout may impair the quality of care provided to clients and may directly affect the provider’s ability to enter into and maintain a quality working alliance (McCarthy & Frieze, 1999).

Burnout is a serious hazard in the helping professions, resulting from the emotionally demanding nature of the work (Hombrados-Mendieta & Cosano-Rivas, 2013; Kirk-Brown & Wallace, 2004), high caseload and work demands, and insufficient resources or time in which to complete assignments. Studies show that symptoms of burnout impair the physical and emotional well-being of service providers (Kim, Ji, & Kao, 2011), result in their impersonal treatment of service users, and undermine the quality of their performance and the effectiveness of their interventions (Deckard et al., 1994; Gaba & Howard, 2002).

Burnout has been extensively studied among an array of human services workers, including social workers (Guerin, Devitt, & Redmond, 2010; Koritsas, Coles, & Boyle, 2010; Padyab, Chelak, Nygren, & Ghazinour, 2012; Savaya, 2014). Generally, the workers themselves provide information about their burnout. Very few studies (for example, McCarthy & Frieze, 1999) have examined service users’ perceptions of worker burnout. In view of the impact of burnout on the quality of social workers’ work and their relationship with their clients, the present study asks service users to assess the burnout of their social workers.

The present study examines the following two hypotheses: (1) There are (a) positive associations between the working alliance and service users’ hope, on the one hand, and between the working alliance and the perceived effectiveness of the intervention, on the other, and (b) negative associations between perceived social worker burnout and perceived intervention effectiveness. (2) Hope and social worker burnout, as perceived by service users, mediate the association between the working alliance and the perceived effectiveness of the intervention.

The hypotheses are examined among service users of a large municipal social welfare service in Israel. Basing the study on service users’ reports is an important corrective in view of the fact that very little place has been given to service users as a source of information. For example, a recent study by Hatfield, and colleagues (2010) found that service users’ reports of deterioration of their situations do not appear in either written or oral summaries of their treatment outcomes, even if the service users consistently reported a deterioration in their situation in the course of their meetings with the therapist. Indeed, it has come to be understood that treatment evaluation that does not include the service user’s perspective is partial and unsatisfactory (Bloom, 2010; Moore, 2013).

Method

Sample

Sampling Procedure

The target population was the intensive service users of the social welfare department of a large city in Israel. Intensive service users were defined as those who had at least 18 interventions in 2011. The sample was drawn in the following five stages: (1) We received a list of all the department’s 1,766 intensive service users, identified by number. Their names remained with the head of the research unit in the department. (2) We used Excel 2010 to obtain a probability sample from the list. The sample consisted of 640 service users, 80 from each of the department’s eight branches. (3) We submitted the numbers of the sampled 640 service users to the head of the research unit, who then identified them by name. (4) The identified service users were contacted by the department’s secretarial staff, who explained the purpose of the study and asked them whether they would be willing to participate in it. Those who agreed were asked for their permission to pass their names and phone numbers on to the researchers. (5) Service users who gave permission were contacted by the interviewers, and a date and place for the data collection were arranged.

The study was approved by the ethics committee of Tel Aviv University, and the interviews began after the interviewees signed an informed consent form.

Sample Characteristics

The sample consisted of 342 service users. About two-thirds of the sample were women (see Table 1). The mean age was 43.9 years (SD = 10.38). About a third of the sample were married; almost half were separated or divorced. About a third had no more than a junior high school education, and under half completed high school. A little over a half were employed.

Table 1:

Demographics (N = 342)

Variable M (SD
Age 43.95 (10.38)  
Number of children 2.58 (2.06)  
Gender   
 Male  33.6 
 Female  66.4 
Marital status   
 Widowed  2.3 
 Divorced/separated  46.2 
 Married  34.2 
 Single  17.3 
Employment   
 Employed  55.0 
 Not employed  45.0 
Education   
 Junior high school education or less  36.0 
 High school education  45.4 
 Matriculated  8.5 
 University degree  10.1 
Variable M (SD
Age 43.95 (10.38)  
Number of children 2.58 (2.06)  
Gender   
 Male  33.6 
 Female  66.4 
Marital status   
 Widowed  2.3 
 Divorced/separated  46.2 
 Married  34.2 
 Single  17.3 
Employment   
 Employed  55.0 
 Not employed  45.0 
Education   
 Junior high school education or less  36.0 
 High school education  45.4 
 Matriculated  8.5 
 University degree  10.1 

Variables

Background Information

Gender, age, family status, number of children, education, and employment were queried.

Perceived Change

To ascertain perceived change, respondents were asked to name the main problem for which they sought help from the welfare department and to indicate its severity at the time of their initial help seeking on a 10-point scale, with 1 = not at all serious and 10 = extremely serious. Then, they were asked to indicate the amount of change they perceived in this problem on a 10-point scale, with 1 = a lot worse, 5 = no change, and 10 = much better. Perceived change was determined by the ratings on the second question.

Type of Problem

Type of problem was introduced as a variable after we saw that the service users had named various types of problems. Content analysis of the main problem for which the respondents sought help revealed four types: (1) instrumental (for example, financial, letters of referral to other services), (2) physical or mental health, (3) children and school, and (4) family (for example, domestic violence). For the purpose of this study, the categories were reduced to two: instrumental problems (43.2% of the total) and noninstrumental problems (56.8%). Perceived change was assessed separately for each category.

Working Alliance

Working alliance was measured by the short version of the Working Alliance Inventory (Horvath & Greenberg, 1986). This 12-item questionnaire measures service user–service provider agreement on three dimensions: (1) goals (for example, “My social worker and I are working toward mutually agreed-on goals”), (2) tasks (for example, “My social worker and I agree about the things I will need to do in therapy to help improve my situation”), and (3) bond (for example, “I believe my social worker likes me”). Factor analysis yielded two factors. One consisted of 11 items, which explained 64.2% (α = .95) of the variance. The other contained only one item (“My social worker and I have different ideas on what my problems are”), which explained 8.9% of the variance. Being only a single item, the second factor was removed from the analysis. A working alliance score was calculated as the mean of the responses on the 11 items. The higher the score, the stronger the perceived working alliance.

Perceived Social Worker Burnout

Perceived social worker burnout was assessed by the Maslach Burnout Inventory (Maslach & Jackson, 1986), a 21-item questionnaire that asks respondents to indicate how often they experience feelings pointing to burnout (ranging from 0 = never to 6 = every day). The items cover three factors: emotional exhaustion, depersonalization, and personal accomplishment. For the present study, respondents were asked to indicate their perceptions of their social worker’s burnout. Factor analysis with varimax rotation carried out for the present study yielded the same three factors reported by Maslach and Jackson (1986). The first, consisting of 11 items indicating personal accomplishment (for example, “I feel that my social worker positively influences my life through her work”), explained 31.8% of the variance. The second, consisting of six items indicating emotional exhaustion (for example, “My social worker is emotionally drained by her work”), explained 22.7% of the variance. The third, consisting of four items pointing to depersonalization (for example, “I feel my social worker treats me like an impersonal object”), explained 14.6% of the variance. Reliabilities were as follows: personal accomplishment, α = .94; emotional exhaustion, α = .94; and depersonalization, α = .85. Based on these reliabilities, we calculated three scores, one for each factor, based on the mean response to the items in the factor. To calculate the score on the personal accomplishment factor, we reversed the ratings so that the score indicated lack of personal accomplishment. The higher the overall score, the greater the burnout in each factor.

Hope

Hope was assessed using eight statements from Snyder and colleagues’ (1991) Hope Scale, after the four distracting statements were removed. Four of the statements measure sense of agency (for example, “I energetically pursue my goals”). The other four refer to sense of pathways (for example, “There are lots of ways around any problem”). Participants were asked to indicate the extent to which each statement applied to them on a five-point scale, ranging from 1 = not at all to 5 = entirely. Factor analysis with varimax rotation yielded one factor, which explained 31.9% of the variance. Reliability was α = .84. Scores were calculated as the mean of the responses. The higher the score, the greater the sense of hope.

Findings

Descriptive Findings

Of the problems reported by the respondents, 146 (43.2%) were instrumental and 196 (56.8%) were noninstrumental. Service users reported high severity of both types of problem (see Table 2). Along with this, they rated the severity of their financial problems significantly higher than that of their nonfinancial problems. Analogously, they reported almost no change in their financial problems, but moderate improvement in their nonfinancial ones. The respondents reported a better-than-average working alliance, a moderately high level of hope, and a low level of perceived social worker burnout (see Table 3).

Table 2:

Type and Severity of Problems

Variable M SD 
Severity of problems 8.77 2.14 
Severity of instrumental problems 9.00 1.93 
Severity of noninstrumental problems 8.57 2.29 
Perceived change 6.51 2.42 
Perceived change in instrumental problems 5.83 2.36 
Perceived change in noninstrumental problems 7.03 2.35 
Variable M SD 
Severity of problems 8.77 2.14 
Severity of instrumental problems 9.00 1.93 
Severity of noninstrumental problems 8.57 2.29 
Perceived change 6.51 2.42 
Perceived change in instrumental problems 5.83 2.36 
Perceived change in noninstrumental problems 7.03 2.35 
Table 3:

Predictor Variables

Variable M SD 
Hope 3.62 0.84 
Working alliance 4.92 1.86 
Perceived social worker burnout 2.63 1.18 
Variable M SD 
Hope 3.62 0.84 
Working alliance 4.92 1.86 
Perceived social worker burnout 2.63 1.18 

With the exception of problem severity, all the predictor variables were significantly, albeit moderately, correlated with perceived change (see Table 4). The correlations were all in the expected direction. Hope and working alliance were positively correlated with perceived change, such that more hope and a better working alliance were associated with the desired changes. Perceived social worker burnout and type of problem were negatively correlated. That is, the more social worker burnout the respondents perceived, the less positive change they reported. Those who reported that their main problem was instrumental reported less change than those who reported that it was not instrumental.

Table 4:

Correlation Matrix

 Perceived Change Hope Working Alliance Perceived Social Worker Burnout Type of Problem Severity of Problem 
Perceived change      
Hope .26**     
Working alliance 31** .16**    
Perceived social worker burnout –.31** –.16** –.78**   
Type of problem –.25** –.15** –.07 .07  
Severity of problem .05 –.02 –.00 .05 .10 
 Perceived Change Hope Working Alliance Perceived Social Worker Burnout Type of Problem Severity of Problem 
Perceived change      
Hope .26**     
Working alliance 31** .16**    
Perceived social worker burnout –.31** –.16** –.78**   
Type of problem –.25** –.15** –.07 .07  
Severity of problem .05 –.02 –.00 .05 .10 

**p < .01.

Analysis of the Model

We hypothesized that hope and perceived social worker burnout mediate the associations between the working alliance and perceived change. To test this proposition, we applied process procedure (Preacher & Hayes, 2008) for testing indirect effects. More specifically, the indirect effect of working alliance through hope and perceived social worker burnout was bootstrapped. Then we constructed 95% confidence intervals (CIs), using 1,000 bootstrap samples. Problem type and severity and the socioeconomic variables of age, gender, family status, years of schooling, and number of children were entered into the regression as control variables. The findings are presented in Table 5.

Table 5:

Regression Analysis: Findings

 Model 1: Outcome = Perceived Burnout
 
Model 2: Outcome = Hope
 
Model 3: Outcome = Perceived Change
 
Variable β SE β SE β SE 
Constant 5.85*** 0.377 3.70*** 0.42 5.35*** 1.59 
Burnout     –0.39* 0.16 
Hope     0.55*** 0.14 
Working alliance –0.51*** 0.02 0.07** 0.02 0.144 0.10 
Type of problem 0.03 0.08 –0.21* 0.09 –1.02*** 0.24 
Marital status: married –0.15 0.09 –0.02 0.10 –0.14 0.28 
Marital status: single –0.12 0.12 0.05 0.13 0.01 0.35 
Age –0.00* 0.00 –0.00 0.00 –0.02 0.01 
Gender –0.10 0.09 –0.06 0.10 0.41 0.27 
Education –0.02* 0.01 0.01 0.01 –0.05 0.03 
Number of children 0.01 0.02 0.00 0.02 –0.03 0.06 
Problem severity 0.01 0.01 –0.00 0.02 0.09 0.05 
Summary Model 1: R2 = .64, F = 0.07, p < .000 
Model 2: R2 = .07, F = 2.80, p < .005 
Model 3: R2 = .23, F = 8.90, p < .000 
 Model 1: Outcome = Perceived Burnout
 
Model 2: Outcome = Hope
 
Model 3: Outcome = Perceived Change
 
Variable β SE β SE β SE 
Constant 5.85*** 0.377 3.70*** 0.42 5.35*** 1.59 
Burnout     –0.39* 0.16 
Hope     0.55*** 0.14 
Working alliance –0.51*** 0.02 0.07** 0.02 0.144 0.10 
Type of problem 0.03 0.08 –0.21* 0.09 –1.02*** 0.24 
Marital status: married –0.15 0.09 –0.02 0.10 –0.14 0.28 
Marital status: single –0.12 0.12 0.05 0.13 0.01 0.35 
Age –0.00* 0.00 –0.00 0.00 –0.02 0.01 
Gender –0.10 0.09 –0.06 0.10 0.41 0.27 
Education –0.02* 0.01 0.01 0.01 –0.05 0.03 
Number of children 0.01 0.02 0.00 0.02 –0.03 0.06 
Problem severity 0.01 0.01 –0.00 0.02 0.09 0.05 
Summary Model 1: R2 = .64, F = 0.07, p < .000 
Model 2: R2 = .07, F = 2.80, p < .005 
Model 3: R2 = .23, F = 8.90, p < .000 

*p < .05. **p < .01. ***p < .001.

All three models were significant. Model 1 explained 64% of the service users’ perceptions of social worker burnout. In this model, perceived burnout was predicted by a poor working alliance, as well as by older age and more education. That is, older and better-educated service users tended to view their social workers as more burned out. Model 2 explained 7% of the service users’ hope. Hope was predicted by the working alliance and type of problem. The stronger the working alliance, the greater the hope. Service users whose main problem was instrumental expressed less hope than those whose main problem was not instrumental.

Model 3 explained 23% of the variance in perceived change. Perceived social worker burnout was negatively associated with perceived change. The more burned-out the service users viewed their social workers as being, the less improvement the service users reported. Service users’ hope was positively associated with their perceived change, such as the greater the hope they reported, the greater the improvement in their presenting problem. Finally, service users who presented instrumental problems reported less improvement than those who presented noninstrumental problems.

When hope and perceived social worker burnout were entered in the equation along with working alliance, the impact of working alliance disappeared, so that it no longer predicted the perceived changes with which it was correlated in Table 4. Finally, because the bootstrap CIs differed from zero (CI for perceived burnout = 0.02, 39; p < .01; CI for hope = 0.01, 0.08; p < .05), the findings showed a significant indirect effect of working alliance on perceived change through hope and perceived social worker burnout. This finding provides further confirmation for the hypothesized model.

Discussion

The study findings support both research hypotheses. With respect to the first hypothesis, all the predictor variables—working alliance, hope, and perceptions of social worker burnout—were significantly correlated with perceived change in the expected directions. The stronger the respondents’ reported working alliance and hope, the greater their reported improvement. The more they regarded their social worker as burned out, the less improvement they reported.

The findings regarding the associations between perceived treatment effectiveness and the service users’ hope and working alliance with their social workers are consistent with previous studies. They provide yet further evidence of the importance of hope and a good working alliance to the attainment of positive treatment outcomes. Service users’ perceptions of positive change in their situation may also augment their hope and improve their working alliance with their social workers.

The findings regarding the deleterious effect of perceived social worker burnout are consistent with the extensive findings showing that such burnout impairs the quality of professional intervention (Golshani, 2012; Green, Albanese, Shapiro, & Aarons, 2014; Maslach, 2012; Weekes, 2014). Unlike previous findings based on professionals’ reports, the current findings are based on service users’ reports. The service users’ reports not only corroborate the well-known findings but add urgency to them, especially given that the study was carried out in a public welfare services agency. The work conditions in public welfare services, including emergency situations that require rapid responses and overlarge caseloads of service users with multiple persistent problems, are conducive to burnout (Bradley & Sutherland, 1995). Under such conditions, social workers cannot provide optimal service. As is frequently noted in the literature, workers who suffer from burnout are exhausted and tend to objectify their clients (Shirom, Nirel, & Vinokur, 2006; Weekes, 2014). Because users of public welfare services simply do not have the means to purchase assistance from alternative sources, the findings mean that the weakest populations, who are most in need of quality social services, are the ones at greatest risk for not getting them.

With respect to the second hypothesis, the findings show that hope and perceived social worker burnout both mediated the association between the working alliance and the perceived effectiveness of the intervention. These findings may be explained by the likelihood that the working alliance is severely undermined by social worker burnout. They do not contradict the abundant findings in the literature of the relation between the working alliance and intervention effectiveness (see, for example, Bennett et al., 2011; Eubanks-Carter, Muran, & Safran, 2010; Horvath et al., 2011; Taber et al., 2011), even though the direct impact of the working alliance disappeared after hope and perceived social worker burnout were added to the equation. Rather, they suggest that service users’ hope and their perception that their service provider is not burned out but is attentive and caring are what matter in the attainment of positive change.

A major study finding concerns the corrosive impact of severe financial problems. Service users who presented with financial problems reported greater problem severity, less hope, and less improvement in their situations than those who presented with nonfinancial problems. This finding is not surprising. For one thing, social workers have very limited resources for alleviating service users’ financial distress. For another, although social workers’ training prepares them to counsel people with emotional and family problems, it does not train them to deal with service users’ financial difficulties.

Limitations

The main limitation of the study is that, despite our efforts, we were unable to obtain a representative sample of service users, as many of those we approached refused to participate in the study. Nonetheless, there was considerable variance in all the variables, which suggests lack of bias. Given the importance of being able to generalize from findings, we urge that efforts be made to obtain representative samples of service users for future studies.

Implications

The study findings have both theoretical and practical implications. On a theoretical level, they reveal the mediating effects of service user hope and perceived social worker burnout on intervention effectiveness. To the best of our knowledge, these effects have not been reported in previous studies. Future study is recommended to determine the replicability of the findings. Future study is also recommended to compare service users’ perceptions of their providers’ burnout with the perceptions of the providers themselves. It would also be beneficial to conduct these examinations not only within social welfare agencies, but also in a variety of social work settings.

On a practical level, the findings suggest the possible value of developing strategies to encourage service user hope and to create intervention approaches and programs focusing on financial problems. The findings also suggest that public welfare organizations would do well to implement strategies to mitigate the risk of burnout, both for the workers’ sake and so that they can provide better service to their clients. Because heavy workload and poor remuneration are known to foster burnout, ideally efforts should be made to reduce social workers’ workload and increase their pay. Where this is not possible, efforts should be made to implement practices that may mitigate burnout, such as increased supervision and peer group support, which would enable social workers to vent their frustrations and share their feelings and experiences with their colleagues.

References

Bachelor
A.
Horvath
A.
(
1999
).
The therapeutic relationship
. In
Hubble
M. A.
,
Duncan
B. L.
Miller
S. D.
(Eds.),
The heart and soul of change: What works in therapy
  (pp.
123
176
).
Washington, DC
:
American Psychological Association
.
Becker
A. L.
(
2013
).
The barriers to treatment: Clinicians’ perceptions.
 
New Haven
:
Southern Connecticut State University
.
Bennett
J. K.
Fuertes
J. N.
Keitel
M.
Phillips
R.
(
2011
).
The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment
.
Patient Education and Counseling
 ,
85
1
,
53
59
.
Bergin
A. E.,
,
Garfield
S. L.
(Eds.). (
1994
).
Handbook of psychotherapy and behavior change
  (
4th ed.
).
New York
:
John Wiley & Sons
.
Bloom, M
. (
2010
).
Client-centered evaluation: Ethics for 21st century practitioners
.
Journal of Social Work Values and Ethics
 ,
7
1
.
Bordin
E. S.
(
1979
).
The generalizability of the psychoanalytic concept of the working alliance
.
Psychotherapy: Theory, Research & Practice
 ,
16
,
252
260
.
Bradley
J.
Sutherland
V.
(
1995
).
Occupational stress in social services: A comparison of social workers and home help staff
.
British Journal of Social Work
 ,
25
,
313
331
.
Brooksbank
M. A.
Cassell
E. J.
(
2005
).
The place of hope in clinical medicine
. In
Eliott
J. A.
(Ed.),
Interdisciplinary perspectives on hope
  (pp.
241
256
).
New York
:
Nova Science Publishers
.
Chang
E. C.
DeSimone
S. L.
(
2001
).
The influence of hope on appraisals, coping, and dysphoria: A test of hope theory
.
Journal of Social and Clinical Psychology
 ,
20
,
117
129
.
Cheavens
J. S.
Michael
S. T.
Snyder
C. R.
Eliott
J. A.
(
2005
).
The correlates of hope: Psychological and physiological benefits
. In
Eliott
J. A.
(Ed.),
Interdisciplinary perspectives on hope
  (pp.
119
132
).
New York
:
Nova Science Publishers
.
Deckard
G.
Meterko
M.
Field
D.
(
1994
).
Physician burnout: An examination of personal, professional and organizational relationships
.
Medical Care
 ,
32
,
745
754
.
Dominguez
J.
(
2013
).
All together now: Toward a systemic understanding of hope in family therapy
 .
San Diego
:
Alliant International University
.
Eubanks-Carter
C.
Muran
J. C.
Safran
J. D.
(
2010
).
Alliance ruptures and resolution
. In
Muran
J. C.
Barber
J. P.
(Eds.),
The therapeutic alliance: An evidence-based guide to practice
  (pp.
74
94
).
New York
:
Guilford Press
.
Eysenck
H. J.
(
1952
).
The effects of psychotherapy: An evaluation
.
Journal of Counseling Psychology
 ,
16
,
319
324
.
Franklin
C.
Kim
J. S.
Tripodi
S. J.
(
2009
).
A meta-analysis of published school social work practice studies
.
Research on Social Work Practice
 ,
19
,
667
677
.
Gaba
D. M.
Howard
S. K.
(
2002
).
Fatigue among clinicians and the safety of patients
.
New England Journal of Medicine
 ,
347
,
1249
1255
.
Golshani
A.
(
2012
).
Personality traits, and self-care strategies in licensed marriage and family therapists and marriage and family therapist trainees and interns.
 
Chicago
:
Chicago School of Professional Psychology
.
Green
A. E.
Albanese
B. J.
Shapiro
N. M.
Aarons
G. A.
(
2014
).
The roles of individual and organizational factors in burnout among community-based mental health service providers
.
Psychological Services
 ,
11
1
,
41
49
.
Guerin
S.
Devitt
C.
Redmond
B.
(
2010
).
Experiences of early-career social workers in Ireland
.
British Journal of Social Work
 ,
40
,
2467
2484
.
Hartley
S. M.
Vance
D. E.
Elliott
T. R.
Cuckler
J. M.
Berry
J. W.
(
2008
).
Hope, self-efficacy, and functional recovery after knee and hip replacement surgery
.
Rehabilitation Psychology
 ,
53
,
521
529
.
Hatcher
R. L.
(
2010
).
Alliance theory and measurement
. In
Muran
J. C.
Barber
J. P.
(Eds.),
The therapeutic alliance: An evidence-based guide to practice
  (pp.
7
29
).
New York
:
Guilford Press
.
Hatfield
D.
McCullough
L.
Plucinski
A.
Krieger
K.
(
2010
).
Do we know when our clients get worse? An investigation of therapists’ ability to detect negative client change
.
Clinical Psychology and Psychotherapy
 ,
17
,
25
32
.
Hersoug
A. H.
(
2009
).
Therapist characteristics influencing the quality of alliance in long-term psychotherapy
.
Clincal Psychology and Psychotherapy
 ,
16
,
100
110
.
Ho
S.
Rajandram
K. R.
Chan
N.
Samman
N.
McGrath
C.
Zwahlen
A. R.
(
2011
).
The roles of hope and optimism on posttraumatic growth in oral cavity cancer patients
.
Oral Oncology
 ,
47
,
121
124
.
Holtslander
L.
Duggleby
W. D.
(
2009
).
The hope experiences of older bereaved women who cared for a spouse with terminal cancer
.
Qualitative Health Research
 ,
19
,
388
400
.
Hombrados-Mendieta
I.
Cosano-Rivas
F.
(
2013
).
Burnout, workplace support, job satisfaction and life satisfaction among social workers in Spain: A structural equation model
.
International Social Work
 ,
56
,
228
246
.
Horvath
A. O.
Bedi
R. P.
(
2002
).
The therapeutic alliance
. In
Norcross
J. C.
(Ed.),
Psychotherapy relationships that work: Therapist relational contributions to effective psychotherapy
  (pp.
37
69
).
New York
:
Oxford University Press
.
Horvath
A. O.
Del Re
A. C.
Flückiger
C.
Symonds
D.
(
2011
).
Alliance in individual psychotherapy
.
Psychotherapy
 ,
48
1
,
9
16
.
Horvath
A. O.
Greenberg
L.
(
1986
).
The development of the Working Alliance Inventory
. In
Greenberg
L.
Pinsoff
W.
(Eds.),
The psychotherapeutic process: A resource handbook
  (pp.
529
556
).
New York
:
Guilford Press
.
Horvath
A. O.
Symonds
B. D.
(
1991
).
Relation between working alliance and outcome in psychotherapy: A meta-analysis
.
Journal of Counseling Psychology
 ,
38
,
139
149
.
Howard
I.
Turner
R.
Olkin
R.
Mohr
D. C.
(
2006
).
Therapeutic alliance mediates the relationship between interpersonal problems and depression outcome in a cohort of multiple sclerosis patients
.
Journal of Clinical Psychology
 ,
62
,
1197
1204
.
Hubble
M. A.
Miller
S. D.
(
2004
).
The client: Psychotherapy’s missing link for promoting a positive psychology
. In
Linley
P. A.
Joseph
S.
(Eds.),
Positive psychology in practice
  (pp.
335
353
).
Hoboken, NJ
:
John Wiley & Sons
.
Irving
L. M.
Snyder
C. R.
Cheavens
J.
Gravel
L.
Hanke
J.
Hilberg
P.
Nelson
N.
(
2004
).
The relationships between hope and outcomes at the pretreatment, beginning, and later phases of psychotherapy
.
Journal of Psychotherapy Integration
 ,
14
,
419
443
.
Kathleen
B.
Kortte
K. B.
Stevenson
J. E.
Hosey
M. H.
Castillo
R.
Wegener
S. T.
(
2012
).
Hope predicts positive functional role outcomes in acute rehabilitation populations
.
Rehabilitation Psychology
 ,
57
,
248
255
.
Kim
H.
Ji
J.
Kao
D.
(
2011
).
Burnout and physical health among social workers: A three-year longitudinal study
.
Social Work
 ,
56
,
258
268
.
Kirk-Brown
A.
Wallace
D.
(
2004
).
Predicting burnout and job satisfaction in workplace counselors: The influence of role of stressors, job challenge, and organizational knowledge
.
Journal of Employment Counseling
 ,
41
,
29
37
.
Koritsas
S.
Coles
J.
Boyle
M.
(
2010
).
Workplace violence towards social workers: The Australian experience
.
British Journal of Social Work
 ,
40
, ’
257
271
.
Lambert
M. J.
(
2011
).
What have we learned about treatment failure in empirically supported treatments? Some suggestions for practice
.
Cognitive and Behavioral Practice
 ,
18
,
413
420
.
Martin
D. J.
Garske
J. P.
Davis
M. K.
(
2000
).
Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review
.
Journal of Consulting Clinical Psychology
 ,
68
,
438
450
.
Maslach
C.
(
2003
).
Job burnout: New directions in research and intervention
.
Current Directions in Psychological Science
 ,
12
,
189
192
.
Maslach
C. L.
(
2012
).
Making a significant difference with burnout interventions: Researcher and practitioner collaboration
.
Journal of Organizational Behavior
 ,
33
,
296
300
.
Maslach
C.
Jackson
S. E.
(
1986
).
The Maslach Burnout Inventory.
 
Palo Alto, CA
:
Consulting Psychologists Press
.
McCarthy
W. C.
Frieze
I. H.
(
1999
).
Negative aspects of psychotherapy: Client perceptions of psychotherapists’ social influence, burnout, and quality of care
.
Journal of Social Issues
 ,
55
,
33
50
.
Mitchell
S. A.
(
1993
).
Hope and dread in psychoanalysis
 .
New York
:
Basic Books
.
Moore
S. J.
(
2013
).
Theraputic relationship influences on treatment effectivness
 
(Unpublished doctoral dissertation)
.
Purdue University
,
West Lafayette, IN
.
Muran
J.
Barber
P.
(
2010
).
The therapeutic alliance: An evidence-based guide to practice
 .
New York
:
Guilford Press
.
Norcross
J. C.
Lambert
M. J.
(
2011
).
Evidence-based therapy relationships
. In
Norcross
J. C.
(Ed.),
Psychotherapy relationships that work: Evidence-based therapy relationships
  (pp.
3
25
).
New York
:
Oxford University Press
.
Padyab
M.
Chelak
H. M.
Nygren
L.
Ghazinour
M.
(
2012
).
Client violence and mental health status among Iranian social workers: A national survey
.
British Journal of Social Work
 ,
42
,
111
128
.
Preacher
K. J.
Hayes
A. F.
(
2008
).
Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models
.
Behavior Research Methods
 ,
40
,
879
891
.
Rand
K. L.
Cheavens
J.
(
2009
).
Hope theory
. In
Lopez
S.
Snyder
C. R.
(Eds.),
The Oxford handbook of positive psychology
  (pp.
323
335
).
New York: Oxford
University Press
.
Reading
R. A.
(
2013
).
Investigating the role of therapist reflective functioning on psychotherapy process and outcome
 .
New York
:
New School for Social Research
.
Savaya
R.
(
2014
).
Social worker burnout: Contribution of daily stressors identified by social workers
.
British Journal of Social Work
 ,
44
,
1268
1283
.
Scioli
A.
Ricci
M.
Nyugen
T.
Scioli
E. R.
(
2011
).
Hope: Its nature and measurement
.
Psychology of Religion and Spirituality
 ,
3
,
78
97
.
Shirom
A.
Nirel
N.
Vinokur
A. D.
(
2006
).
Overload, autonomy, and burnout as predictors of physicians’ quality of care
.
Journal of Occupational Health Psychology
 ,
11
,
328
342
.
Snyder
C. R.
Harris
C.
Anderson
J. R.
Holleran
S. A.
Irving
L. M.
Sigmon
S. T.
et al
(
1991
).
The will and the ways: Development of an individual-differences measure of hope
.
Journal of Personality and Social Psychology
 ,
60
,
570
585
.
Snyder
C. R.
Ilardi
S. S.
Cheavens
J.
Michael
S. T.
Yamhure
L.
Simpson
S.
(
2000
).
The role of hope in cognitive–behavior therapies
.
Cognitive Therapy and Research
 ,
24
,
747
762
.
Snyder
C. R.
Lehman
K. A.
Kluck
B.
Monsson
Y.
(
2006
).
Hope for rehabilitation and vice versa
.
Rehabilitation Psychology
 ,
51
,
89
112
.
Swift
J. K.
Derthick
A. O.
(
2013
).
Increasing hope by addressing clients’ outcome expectations
.
Psychotherapy
 ,
50
,
284
287
.
Taber
B. J.
Leibert
T. W.
Agaskar
V. R.
(
2011
).
Relationships among client–therapist personality congruence, working alliance, and therapeutic outcome
.
Psychotherapy
 ,
48
,
376
380
.
Tryon
G. S.
Blackwell
S. C.
Hammel
E. F.
(
2007
).
A meta-analytic examination of client–therapist perspectives of the working alliance
.
Psychotherapy Research
 ,
17
,
629
642
.
Weekes
J. D.
(
2014
).
The relationship of self-care to burnout among social workers in health care settings.
 
Pittsburgh
:
Walden University
.
Yeryomenk
N.
(
2012
).
Does the depth of client experiencing predict good psychotherapy outcomes? A meta-analysis of treatment outcomes
 .
Ontario, Canada
:
University of Windsor
.