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. Author manuscript; available in PMC: 2023 Aug 1.
Published in final edited form as: J Subst Abuse Treat. 2022 Mar 22;139:108766. doi: 10.1016/j.jsat.2022.108766

Predictors of Therapeutic Alliance, Treatment Feedback, and Clinical Outcomes among African American Women in Treatment for Co-Occurring PTSD and SUD

Alexandria G Bauer 1, Lesia M Ruglass 1,2, Alina Shevorykin 3, Tanya C Saraiya 4, Gabriella Robinson 2, Kechna Cadet 5, Lovelyne Julien 6, Thomas Chao 7, Denise Hien 1
PMCID: PMC9187592  NIHMSID: NIHMS1792968  PMID: 35346534

Abstract

Introduction:

Black women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women.

Methods:

This study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women’s Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire.

Results:

Stepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = .411, p = .021 and β = .383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group.

Conclusions:

Education and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

Keywords: Women, African American, Post-traumatic stress disorder, Substance use, Alliance

1. Introduction

Black women may be at elevated risk for developing post-traumatic stress disorder (PTSD) due to experiencing trauma, particularly sexual assault and interpersonal violence, combined with gender- and race-based discrimination and other sociocultural stressors (Brooks Holliday et al., 2020; Sibrava et al., 2019). Indeed, racial discrimination amplified the relationship between lifetime trauma exposure and increased risk of PTSD symptom severity among Black women (Mekawi et al., 2021). A robust body of literature links PTSD and substance use. For example, the self-medication hypothesis suggests that substances are used to ameliorate symptoms of PTSD, such as hyperarousal and negative cognitions and mood (Haller & Chassin, 2014; Hawn et al., 2020; Khantzian, 1997).

Compared to individuals with either a substance use disorder (SUD) or PTSD, individuals with co-occurring PTSD and SUD (PTSD+SUD) are at greater risk for polysubstance use; poorer mental, physical, and psychosocial health; worse treatment outcomes; and a greater likelihood of relapse (Back et al., 2009). Racial/ethnic minorities may experience even greater disability from co-occurring PTSD+SUD, in part due to a lower likelihood of seeking and accessing treatment (Cheng & Robinson, 2013; Harris et al., 2005; Keyes et al., 2008; Mulvaney-Day et al., 2012; Roberts et al., 2011; Snowden, 2012; Wang et al., 2005). Attending all treatment sessions offered has also been a particular challenge for Black women (Davis & Ancis, 2012) and women in treatment for co-occurring PTSD+SUD (Resko & Mendoza, 2012).

Black women with co-occurring mental health problems and substance use are less likely to be engaged and retained in treatment compared to White women (Blitz et al., 2006; Grella & Greenwell, 2007). In samples of predominately Black women, PTSD symptoms and drinking motives (e.g., drinking to cope) mediated the relationship between trauma and alcohol/drug use behaviors (Cross et al., 2015; Kaysen et al., 2007). Furthermore, trauma exposure can have long-term negative impacts on physical and psychological well-being for Black women in substance use treatment (Tracy et al., 2012). Thus, crucially, we must understand and address factors that impede treatment engagement and retention among Black women with PTSD+SUD.

1.1. Therapeutic alliance

Therapeutic alliance is an important predictor of treatment retention and outcomes (Campbell et al., 2015; Horvath & Symonds, 1991; Janeiro et al., 2018; Roos & Werbart, 2013; Schottenbauer et al., 2008). Therapeutic alliance is often defined as the relational bond between the client and therapist with agreement on the treatment-related goals and tasks in therapy. The alliance is a dynamic process that plays a differential role throughout the course of treatment (Ardito & Rabellino, 2011). Research has established that a therapeutic alliance developed early in treatment can be a stronger predictor of clinical outcomes than an alliance developed during mid-to late stages of treatment (Hilsenroth et al., 2004; Horvath, 2001; Horvath & Luborsky, 1993; Horvath & Symonds, 1991; Meier et al., 2005; Walling et al., 2012). This is due, in part, to greater opportunities to repair therapeutic ruptures (i.e., disagreements or misunderstandings between the therapist and patient; Horvath & Luborsky, 1993; Muran et al., 2021). Alliance also plays a strong role in group-based therapies, where additional alliance dimensions include relationships between group members and between the group members and the group therapist (Ardito & Rabellino, 2011; Holmes & Kivlighan, 2000; Urbanoski et al., 2012).

The positive impact of alliance on outcomes has been documented across a variety of treatments (Ardito & Rabellino, 2011). For example, stronger alliance in early treatment has been associated with decreased PTSD symptoms following treatment (Cloitre et al., 2004; Wagner et al., 2012) and improved mindfulness after a mindfulness-based relapse prevention trial (Bowen & Kurz, 2012). A recent systematic review of 34 studies also found that patient-rated therapeutic alliance predicted post-treatment PTSD outcomes across diverse trauma treatment approaches (Howard, Berry, & Haddock, 2021).

Previous research has shown alliance is also a significant predictor of treatment outcomes (e.g., symptom improvement, attendance) in group-based therapies (Johnson et al., 2008; Joyce et al., 2007). Furthermore, greater alliance in early treatment was associated with improved retention and reductions in PTSD symptoms for diverse women in Seeking Safety, a group-based treatment for co-occurring PTSD+SUD (Pinto et al., 2011; Ruglass et al., 2012). This evidence suggests that strengthening therapeutic alliance early in treatment may improve retention and other treatment-related outcomes.

1.2. Predictors of early alliance in individual and group therapy

Despite significant evidence of the associations between alliance and treatment outcomes, we know little about predictors of early alliance among Black women in treatment for PTSD+SUD. Black women may experience greater barriers to development of early alliance than other racial/ethnic groups, given stigma related to mental illness, negative attitudes toward mental health treatment, and mistrust of mental health providers, stemming from historical and ongoing mistreatment (e.g., therapists ignoring concerns, minimizing symptoms, exhibiting bias or microaggressions) of Black/African American communities by medical and research institutions (Carpenter-Song et al., 2010; Conner, Copeland, Grote, Koeske, et al., 2010; Constantine, 2007; Harris et al., 2020; Vasquez, 2007).

Demographic (e.g., age, education), psychosocial (e.g., interpersonal problems, motivation, self-efficacy), and pre-treatment clinical factors (e.g., alcohol dependence) have been related to the development of early alliance in some studies of individual therapy for SUD and other mental health disorders (Barrowclough et al., 2010; Connors et al., 2000; Hser et al., 1999; Keller et al., 2010; Lawson et al., 2020; Meier et al., 2005; Renner et al., 2012; Urbanoski et al., 2012; Wolfe et al., 2013). Likewise, among patients in PTSD treatment, with and without co-occurring disorders, social support and anxiety symptom severity significantly predicted greater early alliance, while racial/ethnic minority status (i.e., combined group of African American, Hispanic, American Indian/Alaska Native, Asian/Pacific Islander) predicted weaker early alliance (Chen et al., 2019; Knaevelsrud & Maercker, 2006; Koo et al., 2015).

Studies have examined individual demographic and group-level characteristics as predictors of alliance among predominately male or White young adults in group-based substance use therapy, finding that older age, baseline motivation for treatment, and commitment to therapy predicted greater early- and mid-treatment alliance (Garner et al., 2008; Urbanoski et al., 2012). However, the systematic review by Howard and colleagues (2021) revealed that fewer studies have examined alliance in group-based treatments. And no studies, to our knowledge, have investigated determinants of alliance in group therapy specifically among Black women enrolled in treatment for PTSD+SUD.

1.3. Mediating influence of alliance

Research has examined alliance as a mediator for symptom change throughout the course of mental health treatments (Baier, Kline, & Feeny, 2020). For example, alliance was a significant mediator between microaggressions and interpersonal problems with treatment outcomes (Lawson et al., 2017; Owen et al., 2011), and between treatment expectations and outcomes after brief group-based therapy (Abouguendia et al., 2004). In each of these studies, greater alliance was associated with better treatment outcomes. Conversely, Sullivan, Lawson, and Akay-Sullivan (2020) found that among individuals with and without childhood trauma, alliance did not mediate the relationship between early-treatment distress and later-treatment interpersonal problems. No studies have examined alliance as a mediator for group-based PTSD+SUD treatment outcomes among Black women.

1.4. The current study

Although limited, the previous research on the role of race and/or ethnicity in treatment retention (McClendon, Dean, & Galovski, 2020; Spoont et al., 2015) and the therapeutic relationship (Gurpinar-Morgan et al., 2014; Walling et al., 2012) has noted the importance of, and need for, further investigation of alliance among Black women and underrepresented populations (Davis & Ancis, 2012). Yet no studies to date have examined these effects in Black women with co-occurring PTSD+SUD. A recent review highlighted the extensive contributions of the Women and Trauma Study, a clinical trial that compared Seeking Safety to Women’s Health Education, with two dozen publications on the impacts on implementation and dissemination of trauma-focused therapy in community-based substance use treatment centers. Still, no studies have examined the impact of alliance and related factors on treatment feedback among Black women in this influential study. Investigation of these important treatment-related perceptions would provide insight into the experiences and viewpoints of Black women following participation in PTSD+SUD treatments, such as Seeking Safety. Thus, the current exploratory study aimed to: 1) investigate predictors of alliance (i.e., demographics, interpersonal problems, and clinical characteristics) among Black women participating in a PTSD+SUD clinical trial and 2) explore the mediating role of therapeutic alliance on treatment outcomes and treatment feedback among Black women in treatment for PTSD+SUD.

2. Method

2.1. Participants

This study is a secondary analysis of 353 women from the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study (CTN-0015). Original inclusion criteria included women who: were aged 18–65, had been diagnosed with drug/alcohol misuse or dependence according Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR; American Psychiatric Association, 2000), had used alcohol or an illicit drug in the past 6 months, had previously experienced one or more traumatic events, and met criteria for DSM-IV-TR (American Psychiatric Association, 2000) full or subthreshold PTSD. The study defined subthreshold PTSD as meeting Criterion A, B, either C or D, and E and F (Grubaugh et al., 2005). For the purposes of the current study, the analysis included only nonHispanic Black women who completed the early alliance measure, resulting in a subsample of N = 88 participants.

2.2. Procedures

The CTN Women and Trauma Study was a two-arm, randomized clinical trial conducted across seven community-based substance use treatment programs (CTPs). Interested individuals completed eligibility screening and written informed consent prior to baseline assessment and randomization. The CTN study randomized participants to either Seeking Safety (SS, Arm 1; Najavits, 2002), a cognitive-behavioral intervention targeted for both trauma and substance use, or Women’s Health Education (WHE, Arm 2; Miller et al., 1998), an active psychoeducation program that served as a comparison condition. Topics covered in WHE (e.g., sexual behavior, sexually transmitted diseases, pregnancy and childbirth) were unrelated to trauma or substance use. Both arms involved twice-weekly, group-based sessions over 6 weeks, for a total of 12 sessions. Study therapists were all female, and approximately half were White. Black and Latina therapists represented 28% and 22% of the therapist pool, respectively. The majority of therapists (56%) had a master’s or more advanced degree.

An independent assessor administered measures assessing symptoms, risk behaviors, other psychosocial and health history characteristics at baseline and at four follow-up time points (i.e., one-week, 3-month, 6-month, and 12-month). Study procedures have been described in detail elsewhere. Each Institutional Review Board and the review boards associated with each CTP reviewed and approved this study.

2.3. Measures

Baseline demographics included age, race, ethnicity, marital status, level of education completed, and monthly income from multiple sources (e.g., employment; unemployment compensation; welfare; pensions, benefits, or Social Security).

2.3.1. Alliance

The CTN study assessed alliance using the 19-item Revised Helping Alliance Questionnaire-Patient version (HAq-II; Luborsky et al., 1996) in week 2 (early alliance) and week 6 (late alliance). Items asked participants to rate agreement with each statement (e.g., I feel I can depend on the counselor, I like the counselor as a person, the counselor appears to be experienced in helping people). Response options ranged from 1 = Strongly disagree to 6 = Strongly agree. The study reverse scored negatively worded items, so that higher scores reflected greater alliance. The study calculated mean scores for all participants at week 2 and week 6. The HAq-II-P has shown excellent psychometric properties in samples of Black and White participants with substance use (Luborsky et al., 1996). The HAq-II-P demonstrated good internal consistency in the current sample: Cronbach’s α = .84.

2.3.2. Substance use

The study administered the Addiction Severity Index-Lite (ASI-Lite; Cacciola et al., 2007; McLellan et al., 1997) by semi-structured interview at baseline and all follow-up time points. The ASI-Lite has demonstrated good reliability and validity among predominately Black and female samples (Cacciola et al., 2007; McLellan et al., 2006). The study assessed substance use by the mean number of days in the past 30 days using alcohol (to intoxication), illicit drugs (heroin, methadone, opiates, barbiturates, sedatives, cocaine, amphetamines, cannabis, hallucinogens, inhalants), and/or nicotine. The research team calculated mean scores for baseline and one-week post-treatment.

2.3.3. PTSD symptoms

The study used the Clinician-Administered PTSD Scale for DSM-IV (CAPS; Blake et al., 1995; Weathers et al., 2001), a widely used structured interview, to assess PTSD symptom frequency and severity over the past 30 days. The study team administered the CAPS at baseline and all follow-up time points. Total scores were calculated by summing subscales of the three symptom clusters of (1) re-experiencing, (2) avoidance and numbing, and (3) hyperarousal. Total scores ranged from 0 to 136, with higher scores indicating greater PTSD symptom severity. The CAPS has demonstrated excellent consistency, reliability, and convergent validity (Blake et al., 1995). The CAPS demonstrated good internal consistency in the current sample: Cronbach’s α = .83. Our secondary analyses use only the baseline and one-week post-treatment follow-up scores.

The PTSD Symptom Scale-Self Report (PSSR; Foa et al., 1993) is a 17-item measure of frequency and intensity of PTSD symptoms, which the study administered during each treatment session. Total scores were used to determine early PTSD symptom improvement, demonstrated by ≥ 30% reduction in total scores between baseline and week 2 (Ruglass et al., 2012). The PSSR has demonstrated good to excellent reliability and validity (Foa et al., 1993). The PSSR had excellent internal consistency in the current sample: Cronbach’s α = .94.

2.3.4. Session attendance

The study defined session attendance as the total number of sessions (0–12 sessions) attended across all six weeks of the intervention.

2.3.5. Seeking Safety treatment feedback

The study used the 16-item Seeking Safety Feedback Questionnaire (SSQ; Najavits, 2002) to assess treatment feedback at one-week post-treatment. Four items asked participants to rate how helpful the treatment was overall, for PTSD and substance use, for PTSD alone, and for substance use alone. Twelve additional items asked participants to rate how helpful each of the topics were. Response options ranged from –3 = Greatly harmful to 3 = Greatly helpful on a 7-point scale. The study calculated mean scores for topic feedback ratings. Only participants assigned to Seeking Safety (n = 40) completed this measure.

2.3.6. Planned predictors

The ASI-Lite included measures of psychosocial and health history, including nine dichotomous (yes/no) items that asked whether participants had significant periods in which they experienced serious problems getting along with parents, siblings, children, partners, and others. To create a single score for “lifetime interpersonal problems,” the study team created a sum score for these items that ranged from 0 to 9, with higher scores indicating more interpersonal problems. The ASI-Lite also includes measures of mental health treatment history, including number of times in mental health treatment (e.g., hospital/inpatient or outpatient/private setting) and how many times they had been treated for alcohol or drug use. Three ASI-Lite items assessed problems related to alcohol, drug use, or psychological or emotional problems in the past 30 days. The study summed these items to create a total score for “mental health problems,” ranging from 0 to 90. Three additional items asked participants how much they were troubled or bothered by alcohol, or psychological or emotional problems in the past 30 days on a 5-point scale (0 = Not at all, 1 = Slightly, 2 = Moderately, 3 = Considerably, 4 = Extremely). Items were summed to create a total score for “mental health burden” (range = 0 to 12, higher scores indicating greater distress). Finally, the ASI asked participants, “How important to you now is treatment for these [alcohol, drug, or psychological or emotional] problems?” Response options were 0 = Not at all, 1 = Slightly, 2 = Moderately, 3 = Considerably, and 4 = Extremely. The study created sum scores for “treatment importance” (range = 0 to 12, higher scores indicating greater perceived importance).

2.3.7. Planned mediators

Predictors of alliance (i.e., ASI-Lite items) that were significant were selected as candidates for mediation models, treated as the causal variable (X) of treatment outcomes (Y), with mediating influence of alliance (M). This resulted in a series of mediation models. The first series tested pathways between: education and alliance (path a), alliance and treatment outcomes (i.e., session attendance, PTSD symptom severity, substance use; each representing a path b, respectively), and between education and treatment outcomes (paths c and c’). The second series tested pathways between: previous alcohol/drug treatment attempts and alliance (path a), alliance and treatment outcomes (i.e., session attendance, PTSD symptom severity, substance use; each representing path b, respectively), and between previous alcohol/drug treatment attempts and treatment outcomes (paths c and c’).

The study also performed exploratory mediation analyses to assess the impact of significant predictors of alliance on SS treatment feedback, as mediated by early alliance, among participants in the SS group. Similar to the primary mediation models, education and previous alcohol/drug treatment attempts were entered as causal variable (X) of treatment feedback (Y), with mediating influence of alliance (M). These mediations tested pathways between education and alliance (path a), alliance and treatment feedback (path b), and alliance and treatment feedback (paths c and c’).

2.4. Interrater reliability

During the original RCT, independent assessors, who held at least a master’s degree with clinical experience including diagnostic skills, received a 1-day expert-led training on administering and scoring relevant measures (i.e., CAPS and ASI-Lite) and had weekly conference calls with the lead team to maintain competency and interrater reliability on the measure. The team conducted reliability of diagnoses by reviewing 10% of all baseline and 10% of all follow-up assessments. The research team computed Kappas on diagnosis and intraclass correlations on severity ratings between the independent assessors and expert raters. The study expected raters to have a .70 level of agreement. If agreement levels fell below .70, the supervisor conducted joint rated interviews with the independent assessors until they achieved a .70 level in three consecutive interviews. Independent assessors were blind to the treatment condition of any participant at any time during the study.

2.5. Data analysis

The study performed descriptive statistics and bivariate correlations to describe baseline characteristics and relationships between predictor variables. Continuous variables with skewness or kurtosis values greater than ±2 (i.e., total income, number of times in any mental health treatment, and number of times in alcohol/substance use treatment) were transformed for normality using the two-step approach by Templeton (2011). The team conducted two stepwise, hierarchical linear regressions to separately examine predictors of early alliance (model 1) and late alliance (model 2). For both models, the study entered age, education, and income in block 1; and baseline clinical symptoms (i.e., PTSD symptoms, SUD scores, early PTSD symptom improvement), intervention group, and site in block 2. Block 3 retained these variables as covariates, and the team entered stepwise all planned predictor variables (e.g., interpersonal problems, mental health problems, alcohol/drug treatment attempts, and treatment importance), with alliance as the dependent variable (either early or late alliance). Multiple imputation accounted for 33% missing data in late alliance (week 6), using fully conditional specification for m = 10 imputations (Rubin, 1987). The missing data in alliance was missing completely at random (Little’s MCAR test, χ2 = 121.181, p = .814). The study team used PROCESS v3.5.3 macro for SPSS (Hayes, 2018) to examine whether alliance mediated the associations among significant predictors and attendance, PTSD symptoms, and SUD outcomes at one-week post-treatment. The research team ran all analyses with IBM SPSS Version 27.

All assumptions for homogeneity of variance and linearity were met. We examined standardized residuals for homoscedasticity and outliers (residual of ±3 or greater). Durbin-Watson tests supported independence of errors across all models (range = 1.717 to 2.209). Tolerance and VIF were within the range of acceptable values (≥ .562 and ≤ 1.635, respectively). The study excluded listwise cases with missing data. Those excluded from the analyses (n = 14, across all analyses) did not differ significantly from those included (n = 74) on any demographic, clinical, or predictor variable. The study used an alpha level of 0.05 for all statistical tests.

3. Results

Table 1 displays participant demographics. The study randomized a total of 40 Black female participants to SS, and 48 to WHE. The study found no significant differences between SS and WHE in demographics, baseline clinical characteristics, session attendance, or patient-rated alliance at either time point (all ps > .05). No significant differences existed between patient-rated early alliance and late alliance in the overall sample, t(58) = 1.11, p = .314) or by treatment group (SS: t(26) = .707, p = .486; WHE: t(31) = .724, p = .475).

Table 1.

Demographics and descriptive statistics for predictor variables among a sample of Black women in PTSD/SUD treatment (n = 88)

Overall (n = 88) Seeking Safety (n = 40) Control (n = 48)
M SD M SD M SD
Age 41.90 7.72 40.68 8.29 43.22 7.33
Total income in past 30 days 554.83 651.39 581.82 670.03 522.41 637.97
Years of education 12.13 2.09 12.39 2.37 11.89 1.79
Marital statusa
  Married 6 6.8 2 5.0 4 8.3
  Remarried 1 1.1 1 2.5 0 0.0
  Widowed 6 6.8 4 10.0 2 4.2
  Separated 19 21.6 7 17.5 12 25.0
  Divorced 14 15.9 9 22.5 5 10.4
  Never married 42 47.7 17 42.5 25 52.1
Baseline substance use (number of days) 3.04 1.73 3.17 1.52 2.93 1.88
Baseline PTSD severityb 62.40 17.02 63.08 17.10 61.98 16.98
Interpersonal problems 4.20 2.11 4.48 2.15 4.00 2.08
Mental health treatment experiences 3.09 7.26 2.90 6.11 3.19 8.10
Alcohol/drug treatment attempts 6.29 11.36 5.38 5.93 6.94 14.36
Days experiencing mental health problems (past month) 26.51 21.44 26.75 21.95 26.42 21.02
Burden of mental health problems (past month) 5.68 3.22 5.60 3.48 5.71 3.00
Treatment importance 7.28 3.55 7.10 3.55 7.44 3.55
Patient-rated early alliance (week 2, n = 88) 5.21 .499 5.30 .44 5.15 .54
Patient-rated late alliance (week 6, n = 59) 5.11 .757 5.12 .78 5.10 .74
Sessions attended (out of 12) 9.01 2.50 9.42 2.6 8.70 2.4
Treatment feedbackc
  Treatment overall 2.86 .59
  PTSD and substance use 2.82 .61
  PTSD alone 2.71 .66
  Substance use alone 2.71 .66
  Topic ratings 2.77 .59
  Entire scale 2.77 .582
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a

Values provided in this category represent n and % of sample.

b

Range = 26 to 104.

c

Only completed by Seeking Safety participants (n = 28). Possible range of scores: −3 to 3.

3.1. Predictors of patient-rated alliance

Table 2 presents correlations between predictor variables, and early and late alliance. No significant correlations occurred between the predictor variables and the alliance variables at the bivariate level. The overall linear regression model predicting early alliance was significant in block 1 (predictors: age, education, and income), F(3, 41) = 3.126, p = .04, and accounted for 19.8% of the variance (Table 3). Education was a significant predictor across all blocks (βs > .411, ps < .03), controlling for all other variables in the model. Age and income were not related to early alliance. Block 2 did not represent a significant improvement over block 1; and baseline substance use and PTSD symptoms, intervention group, site, and early PTSD symptom improvement were not significant predictors of early alliance. In block 3, only the number of previous alcohol/drug treatment attempts was a significant predictor of early alliance (β = .38, p = .01), holding all other variables constant. Interpersonal problems, number of previous mental health treatment experiences, number of days experiencing alcohol/drug or psychological/emotional problems, burden of alcohol/drug or psychological/emotional problems, and perceived treatment importance did not significantly predict early alliance (ps ≥ .376) and we excluded them from the model (Table 4). All linear regression models predicting late alliance were not significant in the original data or across ten imputed models (ps ≥ .06), as Supplemental Table 1 shows.

Table 2.

Correlations between predictor variables with early and late alliance

1 2 3 4 5 6 7 8
1. Interpersonal problems -
2. Mental health treatment experiences .216* -
3. Alcohol/drug treatment attempts .231* .144 -
4. Days experiencing mental health problems −.043 −.102 .005 -
5. Burden of mental health problems .120 −.020 .068 .595* -
6. Treatment importance −.003 −.052 .113 .525* .767* -
7. Early alliance (at Week 2) .192 .016 .116 −.054 −.009 −.055 -
8. Late alliance (at Week 6) −.029 .046 .004 −.072 −.015 −.019 .120 -
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*

p < .05

Table 3.

Predictors of early and late therapeutic alliance in hierarchical stepwise linear regression models

95% CI
R 2 F df β SE p LL UL
Early alliance
 Block 1 .198 3.126* 3, 38
  Age −.242 .010 .161 −.036 .006
  Education .411 .003 .021 .001 .014
  Income .075 < .001 .660 < .001 < .001
 Block 2 .257 1.428 8, 33
  Baseline substance use (number of days) .050 .043 .771 −.075 .100
  Baseline PTSD symptom severity −.061 .004 .727 −.010 .007
  Early PTSD symptom improvement .281 .568 .132 −.277 2.035
  Intervention group (SS vs WHE) .052 .164 .762 −.284 .384
  Site .055 < .001 .731 −.001 .001
 Block 3 .394 2.315* 9, 32
  Number of alcohol/drug treatment attempts .383 .006 .011 .004 .028
Late alliancea
 Block 1 .012 .089 3, 32
  Age .008 .025 .757 −.043 .059
  Education < .001 .008 .997 −.015 .015
  Income < .001 < .001 .651 < .001 .001
 Block 2 .282 1.066 7, 28
  Baseline substance use (number of days) .077 .087 .375 −.093 .247
  Baseline PTSD symptom severity .004 .009 .674 −.014 .022
  Early PTSD symptom improvement .768 1.282 .551 −1.786 3.322
  Intervention group (SS vs WHE) .255 .312 .413 −.357 .868
  Site −.002 .001 .061 −.003 < .001
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*

p < .05

a

Late alliance values for R2, F, and degrees of freedom (df) are presented from original data. Values for individual variables presented are pooled unstandardized Betas and test statistics.

Note. SS = Seeking Safety; WHE = Women’s Health Education. Variables excluded for early and late alliance models: lifetime interpersonal problems, number of mental health treatment experiences, experiencing alcohol/drug or psychological/emotional problems, burden of alcohol/drug or psychological/emotional problems, and perceived treatment importance. Also excluded from late alliance model: number of alcohol/drug treatment attempts.

Table 4.

Excluded variables for early and late therapeutic alliance in block 3 of hierarchical stepwise linear regression models

Beta In t p
Early alliance
  Lifetime interpersonal problems −.006 −.033 .974
  Number of mental health treatment experiences −.033 −.213 .833
  Experiencing mental healtha problems .149 .898 .376
  Burden of mental health problems .041 .209 .836
  Treatment importance .119 .663 .512
Late allianceb
  Lifetime interpersonal problems −.310 −1.154 .263
  Number of mental health treatment experiences −.242 −1.173 .256
  Number of alcohol/drug treatment attempts −.058 −.265 .794
  Experiencing mental healtha problems −.134 −.515 .613
  Burden of mental healtha problems .072 .266 .793
  Treatment importance < .001 −.002 .999
  Early alliance −.081 −.364 .720
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a

Alcohol/drug, psychological or emotional problems.

b

Values for late alliance predictors are using original data.

3.2. Mediation analyses

Neither education or previous alcohol/drug treatment attempts had significant indirect effects on session attendance, PTSD symptoms or substance use at post-treatment (Table 5). Exploratory mediation analyses on alliance as a mediator for treatment feedback (among participants in the SS group, n = 40) revealed that neither education or previous alcohol/drug treatment attempts had significant indirect effects on treatment feedback ratings for treatment overall, PTSD and substance use, PTSD alone, or substance use alone. Previous alcohol/drug treatment attempts did not have a significant indirect effect on topic ratings, but education had a significant indirect effect, where greater education was related to higher early alliance, but worse feedback topic ratings.

Table 5.

Path coefficients of predictor variables on attendance, treatment outcomes, and feedback with mediating influence of alliance

Education
 Treatment attempts
Path estimates 95% CI
(cʹ)		 Path estimates 95% CI
(cʹ)
a b c cʹ LL UL a b c cʹ LL UL
Session attendance .005* .259 −.01 −.012 −.035 .012 .009 −.038 .017 .018 −.043 .078
Posttreatment outcomes
  PTSD symptoms .006* −8.86 −.12 −.065 −.311 .181 .006 −9.50 −.169 −.109 −.669 .450
  Substance use .007* .21 .006 .005 −.011 .019 .006 .214 .028 .026 −.008 .061
Treatment feedback
  Overall .006* .116 −.005 −.006 −.014 .003 .008 −.016 −.004 −.004 −.026 .019
  PTSD alone .006* .267 −.002 −.004 −.013 .005 .008 .233 −.013 −.014 −.038 .010
  Substance use alone .006* .207 −.004 −.005 −.015 .004 .008 .088 −.003 −.004 −.029 .021
  PTSD + substance use .006* .119 −.005 −.006 −.015 .003 .008 −.031 −.002 −.002 −.025 .021
  Other topics .006* .270 −.006* −.008* −.013 −.002 .008 .017 .010 .010 −.007 .026
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*

p < .05

4. Discussion

This study is the first to conduct a focused analysis of predictors of alliance, and alliance as a mediator of outcomes, among Black women in treatment for co-occurring PTSD+SUD. The mean PTSD severity score in the current sample was consistent with a severe level of PTSD and similar to the full parent study sample (Hien et al., 2009). Participants attended 9 of 12 sessions, on average, a rate higher than the parent study and other similar treatment studies (Cui et al., 2016; Hien et al., 2012; Najavits et al., 2006; Ruglass et al., 2014). Despite the potential for stigma and mistrust (Carpenter-Song et al., 2010; Conner, Copeland, Grote, Rosen, et al., 2010; Harris et al., 2020), Black women in this trial demonstrated significant engagement with both treatments. Additionally, across both treatment groups, therapeutic alliance was high at week 2 and did not differ significantly from week 2 to week 6.

Education was a positive predictor of early alliance. Educational attainment and other measures of SES are important social determinants of health outcomes, particularly for racial/ethnic minority groups. Two studies of predominately White men in SUD treatment found a negative relationship between education and alliance (Connors et al., 2000) or no relationship between education and alliance (Urbanoski et al., 2012). Additionally, a study of predominately female and White participants in PTSD treatment found that education was unrelated to alliance ruptures (McLaughlin et al., 2014). Higher levels of education may allow Black participants who access PTSD+SUD treatment to engage in treatment-related tasks and goals more fully, and subsequently increase their bond with the group therapist. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education, through targeted discussions that serve to enhance the relational bond, understand the patient expectations and goals for treatment, and increase a sense of partnership as they embark on the treatment process (Asnaani & Hofmann, 2012).

Number of prior substance use treatments also positively predicted early alliance. Dennis and colleagues (2005) demonstrated that multiple treatment attempts are common for individuals with SUDs who later achieve long-term abstinence and recovery, and successes in prior treatment have been associated with positive SUD outcomes, including reduced substance use (Ruglass et al., 2019). These findings reinforce the relevance of SUD chronicity and demonstrate a cumulative latent benefit of having multiple prior treatment experiences, possibly preparing individuals for what to expect in therapy or increasing readiness to change. Findings strengthen the notion that multiple treatment attempts can be viewed positively, as Black women with more previous treatment attempts reported a stronger alliance with their therapists earlier in treatment (i.e., by week 2) than those with fewer previous treatment attempts.

Other demographic and baseline psychosocial factors (e.g., age, income, interpersonal problems) were not significant predictors of early alliance. Some studies have demonstrated a link between alliance and age (Connors et al., 2000; Garner et al., 2008; Urbanoski et al., 2012), or pre-treatment psychosocial factors (Lawson et al., 2020). However, several others have found no relationships between demographic factors or baseline clinical and psychosocial characteristics and alliance (Chen et al., 2019; Connors et al., 2000; Garner et al., 2008; Johnson et al., 2008; Walling et al., 2012). Furthermore, a systematic review of PTSD treatment studies found that demographic (e.g., age, gender), psychosocial, and pre-treatment symptom measures were inconsistently related to alliance, possibly due to significant variability in the constructs and measures utilized across studies (Howard et al., 2021). Our findings suggest that Black women in the current study formed a strong alliance with their group therapists, regardless of age, income, baseline symptoms, intervention arm, interpersonal problems, level of distress, and perceived importance of treatment. These findings provide support that group-based PTSD+SUD therapists can actively build a relational context that Black women perceive as positive, which is crucial for promoting treatment retention and improving outcomes (Amaro et al., 2007). And, given the documented barriers to treatment entry and alliance development among Black women (e.g., stigma, mistrust; Carpenter-Song et al., 2010; Constantine, 2007; Harris et al., 2020; Vasquez, 2007), clinicians can be encouraged by these findings.

Although a need remains for efforts to engage diverse and underserved populations in treatment, particularly for PTSD+SUD, the growing focus on multicultural therapy has led to numerous resources for working with diverse populations in treatment, including examples of specific strategies for therapists to enhance their ability to engage and build an alliance with diverse patient populations (e.g., Asnaani & Hofmann, 2012; Vasquez, 2007). Indeed, dimensions to consider when working with diverse patients may include the individual’s culture, traditions, spirituality, sexual and gender identity, immigration status, language preference and communication style, and health literacy (Tan-McGory 2020).

The finding that late alliance was not significantly predicted by any study variable may be attributed to lower power at post-treatment. Alternately, alliance later in treatment may be influenced by different factors (e.g., shifts in motivation, symptom improvement) and/or other interpersonal processes that occur over the course of treatment. As noted, late alliance was not significantly different than early alliance, which suggests a stability in alliance over time within this sample. This finding is consistent with a recent review that revealed that most PTSD treatment studies have documented stability in alliance over time, although a few found significant increases in alliance (Howard et al., 2021). Nevertheless, some researchers have argued and shown that alliance at different timepoints in the treatment may have differential impacts on treatment outcomes (Ardito & Rabellino, 2011). For example, research has shown early alliance to be a stronger and more consistent predictor of treatment outcomes than late alliance (Hilsenroth et al., 2004; Horvath, 2001; Meier et al., 2005). Thus, understanding early alliance formation may be even more important than initially thought. Future research with a larger sample of Black women should replicate these findings and also consider assessing additional within-group treatment process variables (e.g., rupture-repair processes, group cohesion) or intrapersonal variables (e.g., stages of change, treatment readiness, level of motivation) that may shed light on how alliances are maintained throughout the course of group therapy for this subgroup (Garner et al., 2008).

Additionally, alliance did not mediate the associations between significant predictors (i.e., education and prior SUD treatment attempts) and retention and post-treatment PTSD and SUD symptoms. A systematic review of 37 studies (Baier et al., 2020) found that the therapeutic alliance was a significant mediator in many transdiagnostic studies, but none focused solely on Black women with PTSD or PTSD+SUD. Prior work with diverse female samples with trauma histories found that attachment style was more important in mediating treatment outcomes than the therapeutic alliance (Sullivan et al., 2020), but further investigations should examine mediators of change among Black women in PTSD+SUD treatment.

Early alliance was also not a significant mediator of the association between education and prior treatment attempts and SS treatment feedback. However, these models found that greater education was associated with higher early alliance, but poorer feedback on topics covered in SS. This finding suggests that women with greater educational attainment had higher alliance but rated the SS content as less helpful than women with lower educational attainment. Given that SS is meant to be accessible regardless of educational background, we speculate that women with more formal education may have experienced disinterest in some topics due to prior knowledge from personal experiences or prior treatment.

The current study has some limitations. First, limited information was available on previous substance use treatments (e.g., primary substances of concern, perception of experience, completion or reasons for dropout), and the study did not assess elements related to therapy process (e.g., treatment expectations) and group-based factors (e.g., group alliance, cohesion). Second, a recent study found significant measurement invariance between White and Black participants on the CAPS instrument (Ruglass et al., 2020). Although measurement invariance is possible among the Black women in this sample, the use of the CAPS among a sample of Black women without race-based comparisons may circumvent these issues. The sample size was limited, particularly for SS feedback. This, combined with the listwise deletion method, may have limited power for regression and mediation models. A related study found that racial/ethnic concordance between therapists and participants was related to SUD outcomes (Ruglass et al., 2014). However, our analyses did not include therapists’ race/ethnicity as a predictor of alliance, and the study did not assess measures of therapists’ and patients’ racial/ethnic identity. Thus, the influence of therapists’ race/ethnicity on development of alliance among Black women may be an area for continued investigation, with consideration for the complex heterogeneity among Black/African American and multiracial populations. Future research should also examine predictors of early alliance across PTSD+SUD treatment modalities.

4.1. Conclusions

Taken together, findings suggest that education and prior treatment attempts predict early alliance among Black women in PTSD+SUD group treatment, but how alliance functions in treatment outcomes among these women remains an open empirical question. We must continue to develop our understanding of the role of alliance among Black women to enhance the modification and delivery of these treatments, which have already shown equivocal efficacy among Black men and women (McClendon et al., 2019). This research can provide insight into key therapeutic factors and treatment perceptions among Black women with co-occurring PTSD+SUD who are at elevated risk for poor PTSD/SUD outcomes due to lack of access and engagement in care. Our overall findings contribute to the literature on Black women’s experiences in PTSD+SUD treatment, in the context of addressing health inequities in treatment engagement and retention. Our findings provide a lens into the relative impact of several important factors that influence early alliance, suggesting that addressing educational factors may be important to consider in implementing and culturally adapting PTSD+SUD interventions. Future research should identify key mediators among alliance, treatment feedback, and clinical outcomes among Black women, to promote PTSD+SUD recovery.

Supplementary Material

1

Highlights.

  • Higher education level predicted greater early alliance, controlling for age and income

  • Greater number of substance treatment attempts predicted higher early alliance

  • Alliance did not mediate relationships between predictors and PTSD/SUD outcomes

  • Alliance was not a mediator of feedback among Seeking Safety participants

  • Education level significantly predicted treatment feedback when controlling for alliance

Acknowledgements

This work was supported by the following grants from the National Institute on Drug Abuse (NIDA): U10 DA13035 (Edward Nunes, PI), U10 DA13714 (Dennis Donovan, PI), U10 DA13038 (Kathleen Carroll, PI), U10 DA13732 (Eugene Somoza, PI), U10 DA13727 (Kathleen Brady, PI), U10 DA013720 (Jose Szapocznik, PI), U10 DA013046 (John Rotrosen), T32 DA007288 (PI: McGinty), and 2R25DA035161-06 (Multiple PIs: Denise A. Hien and Lesia M. Ruglass).

Footnotes

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The authors declare no conflict of interest.

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