Education and Prior Treatment Attempts Predict Stronger and Earlier Therapeutic Alliance for Black Women with PTSD and SUD, But Not Treatment Outcomes

Addiction Science Made Easy
May 2022
CTN Dissemination Library

Key points:

• Black women are at higher risk for co-occurring PTSD and SUD and also experience disparities in treatment engagement and retention
• Therapeutic alliance, the bond between the provider and client, has been found to predict outcomes, but little is known about its impact for Black women in care
• Greater education and more prior treatment attempts were tied to stronger and earlier alliance in treatment for Black women in this study, but none of these factors influenced treatment outcome 

Black women are at higher risk for exposure to trauma, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), and disparities in treatment engagement and retention persist, especially for Black women with co-occurring PTSD and SUD.

Therapeutic alliance – the bond between the provider and client, formed in part through agreement on treatment-related goals and tasks in therapy – predicts and impacts treatment retention and outcomes, but we still know very little about what predicts strong alliance for Black women and how alliance affects their PTSD and SUD outcomes.

To try to better understand these connections, researchers examined data from the NIDA Clinical Trials Network Women and Trauma study (CTN-0015), focusing on the 88 Black/African American women who had participated in the original trial, a study comparing Seeking Safety, a cognitive-behavioral intervention for PTSD and SUD, to Women's Health Education, the control group.

Looking at responses to surveys administered during the study that measured therapeutic alliance, PTSD, and SUD symptoms, as well as participants' feelings about the Seeking Safety intervention (for women in that arm of the trial), researchers found that:

• Years of education and previous alcohol/drug treatment attempts significantly predicted higher and earlier alliance during therapy
• Late alliance in the last week of therapy was not significantly predicted by any study variable, but it also didn't differ significantly from early alliance, suggesting stability in alliance over time
• Though education and previous treatment attempts predicted stronger alliance, none of these factors predicted outcomes like session attendance or PTSD/SUD symptoms 
• Black women with higher levels of education had less favorable opinions of the Seeking Safety intervention

Conclusions: Education and prior treatment attempts predicted higher and earlier therapeutic alliance among Black/African American women in PTSD and SUD group treatment, but how alliance functions in terms of treatment outcomes among these women remains an open question. When treating Black women who have lower levels of education or are relatively new to treatment, clinicians may want to consider integrating more alliance-building strategies in the early stages of care. 

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