Enhancing the Therapeutic Relationship Between Mental Health Case Managers and Individuals With Serious Mental Health Conditions: A Participatory Action Research Study in Community-Based Services

Abstract

This study examined how community mental health case managers, most of whom were mental health nurses, modified their day-to-day practice to strengthen the therapeutic relationship within community services. Using a participatory action research design across 10 centres in Catalonia, Spain, 24 case managers and 105 patients engaged in two action-reflection cycles. Data from reflective diaries and focus groups were analyzed using inductive thematic analysis. Through cyclical observation and collaborative reflection, participants identified key facilitators and barriers to developing the therapeutic relationship and co-designed two practice innovations: (1) jointly-created informational materials clarifying case-management scope and expectations, and (2) regular mixed patient-professional reflective groups focused on the therapeutic process. Despite structural pressures, heavy workloads, service fragmentation, and limited opportunities for professional reflection, the participatory approach supported sustainable, relationally focused practice change grounded in patient-provider dialogue. Embedding structured reflective spaces within routine care emerged as a practical mechanism to consolidate therapeutic alliance and advance recovery-oriented practice. While findings apply across disciplines, they are particularly relevant to nursing-led and nurse-participating case-management teams, in which continuous therapeutic contact, coordination functions and relational expertise intersect. The study offers a replicable framework for enhancing person-centred care in community mental health settings, and it underscores the value of nurse-involved co-creation and structured reflection to maintain therapeutic presence, align expectations and integrate lived experience into ongoing quality improvement.