Helping Alliance, Retention, and Treatment Outcomes: A Secondary Analysis From the NIDA Clinical Trials Network Women and Trauma Study

Abstract

We examined the association between the therapeutic alliance and treatment outcomes among 223 women with posttraumatic stress disorder (PTSD) and substance use disorders who participated in a multisite clinical trial of group treatments for trauma and addictions in the United States throughout 2004 and 2005. General linear models indicated that women who received Seeking Safety, a cognitive-behavioral treatment, had significantly higher alliance ratings than those in Women's Health Education, a control group. Alliance was related to significant decreases in PTSD symptoms and higher attendance in both interventions. Alliance was not related to substance use outcomes. Implications and limitations of the findings are discussed.

RÉSUMÉ

Aider l'alliance, de rétention, et les résultats du traitement: Une analyse secondaire de la femme NIDA Clinical Trials Network et l’étude de traumatologie

Nous avons examiné l'association entre l'alliance thérapeutique et les résultats du traitement chez 223 femmes toxicomanes souffrant du SSPT qui ont participé aux États-Unis de 2004 à 2005 à un essai clinique multi site de traitements en groupe pour des traumatismes et des toxicomanies. Nos modèles linéaires généraux ont démontré que les femmes ayant reçu En Quête de Sécurité, un traitement cognitivo-comportemental, avait des évaluations d'alliance thérapeutique significativement plus élevées que les femmes dans le groupe control, Education de la Santé des Femmes. L'alliance thérapeutique était associée à la diminution significative de symptômes du SSPT et à une plus forte assiduité dans les deux interventions. L'alliance thérapeutique n’était pas associée aux résultats de l'usage de substances. Les implications et les limites des résultats sont discutées.

RESUMEN

Ayudando a la Alianza, Adherencia, y los Resultados del Tratamiento: Un análisis secundario del Estudio de la Mujer y el Trauma de la Red de Ensayos Clínicos del NIDA (Instituto Nacional de Abuso de Drogas)

Estudiamos la relación entre la alianza terapéutica y los resultados del tratamiento de 223 mujeres con trastorno por estrés post-traumatico (TEPT) y trastorno por uso de sustancias que participaron en un ensayo clínico multi-centrico de tratamientos de grupo para víctimas de trauma y adicciones en Estados Unidos entre el año 2004 y 2005. Los modelos lineales generalizados indicaron que las mujeres que recibieron “Seeking Safety” (Buscando Seguridad), un tratamiento cognitivo-conductual, tuvieron indices de alianza significativamente superiores que las mujeres en “Women's Health Education” (Educación para la Salud de la Mujer), el grupo control. La alianza estuvo relacionada con una disminución significativa de los síntomas del trastorno por estrés post-traumático (TEPT) y una mayor asistencia a ambas intervenciones. La alianza no tuvo relación con los resultados en el uso de sustancias. Se analizan las implicaciones y limitaciones de estos hallazgos.

Keywords :

• helping alliance
• posttraumatic stress disorder
• substance use disorders
• retention
• treatment outcomes

THE AUTHORS

Lesia M. Ruglass, Ph.D., is an assistant professor of psychology at the City College of New York, The City University of New York, New York, New York, USA, and a research scientist in the Trauma and Addictions Project at City College. Dr. Ruglass received her bachelor's degree from New York University, her master's degree from Boston University, and her Ph.D. in clinical psychology from the New School for Social Research. Her research interests center on understanding the influence of race and ethnicity on the diagnosis and treatment of individuals with PTSD and addictions and understanding and reducing risk factors that contribute to the HIV/AIDS epidemic among African Americans. Dr. Ruglass has authored/coauthored several peer-reviewed articles and presented her work at national and international conferences. Dr. Ruglass also maintains a private practice based in Manhattan, NY.

Gloria M. Miele, Ph.D., is an instructor of clinical psychology in Department of Psychiatry at the College of Physicians and Surgeons, Columbia University. Since 1990, she has been involved in research, treatment, and training in the areas of substance use and comorbid mental disorders. She is the training director for the Greater New York Node of NIDA's Clinical Trials Network (CTN) and has been a regional trainer for the American Psychological Association's HIV Office for Psychology Education (HOPE) for nearly 10 years. Her most recent work involves the use of technology, specifically Web-based interventions and new media, in substance abuse research. Dr. Miele is primary or coauthor of dozens of articles on the evaluation and treatment of substance abuse, HIV, and co-occurring mental health problems. She is also coauthor of the book, Trauma services for women in substance abuse treatment: An integrated approach (Hien et al., 2008). Dr. Miele is also a business development and leadership coach, working with entrepreneurs and other business leaders to sharpen their skills and optimize their success in their personal and professional lives. She provides training and coaching in strengths-based leadership, effective communication, emotional intelligence, and other areas that increase business success. She lives and works in Southern California.

Denise A. Hien, Ph.D., is a professor of clinical psychology at The City College of New York and maintains an appointment as a senior research scientist in the Department of Psychiatry at the College of Physicians and Surgeons, Columbia University. She is the founding executive director of the Women's Health Project. Over the past 16 years with funding from the National Institute on Drug Abuse, Office of Research on Women's Health, and National Institute on Alcoholism and Alcohol Abuse, she and her team have conducted research that has helped to characterize the psychosocial and diagnostic correlates of interpersonal violence among innercity minority women and their families. She has also contributed to science on the treatment of trauma-related disorders with substance comorbidities, conducting single and multisite clinical trials across the United States in community-based substance abuse treatment settings. She has authored, coauthored, and presented extensively in scientific journals, and at national and international conferences. Dr. Hien is considered a leader in the field of women's trauma and addiction treatment. She has been a member of NIDA's Asian Pacific Islanders Scholars Workgroup since 1999, and she has sponsored and mentored numerous predoctoral and postdoctoral minority researchers in their long-term health disparities career development. She is coauthor of the book entitled Trauma services for women in substance abuse treatment: An integrated approach.

Dr. Aimee Campbell, Ph.D., M.S.S.W., received her doctorate in social work and is a research scientist in the Substance Abuse Division of the New York State Psychiatric Institute (NYSPI) and an assistant professor of clinical psychiatric social work in the Department of Psychiatry at the College of Physicians and Surgeons, Columbia University. Her expertise centers on behavioral interventions for substance use disorders and HIV prevention intervention research, with a specific interest in the study of dissemination and implementation strategies to increase the use and effectiveness of empirically supported treatments in community settings.

Mei-Chen Hu obtained her Ph.D. in social welfare from the University of Wisconsin-Madison (discipline: social work) and is associate research scientist in the Department of Psychiatry, Columbia University. Areas of interest include drug dependence, psychiatric disorder, and child development.

Nathilee A. Caldeira, Ph.D., in clinical psychology and is a psychologist at the School of Medicine, New York University, New York, NY. Areas of interest include trauma and addictions.

Dr. Huiping Jiang, Ph.D., received his bachelor's degree in mathematics in 1998 from Nankai University, China, and received his Ph.D. in statistics from Southern Methodist University in 2003. From September 2003 to May 2009, Dr. Jiang was employed by the Research Foundation for Mental Hygiene, Inc., as a research biostatistician at the Biostatistics Division of the New York State Psychiatric Institute (NYSPI). From May 2009 to now, Dr. Jiang works as a statistical consultant at the Substance Abuse division of the New York State Psychiatric Institute. Dr. Jiang's research is focused on conducting independent methodological research in statistical analysis of brain imaging data, estimation and diagnosis for longitudinal data, and time series data analysis. Dr. Jiang also collaborates with NYSPI researchers and undertakes the solution of nonstandard statistical problems related to the field of neuroscience and psychiatry.

Dr. Lisa Litt, Ph.D., is a clinical psychologist and is clinical director of the Women's Health Project Treatment and Research Center and the Men's Center for Healing and Recovery, the Trauma Focused Programs at the Addiction Institute of New York at St. Luke's Hospital. There Dr. Litt oversees the programs’ clinical services and professional training. She is also an assistant clinical professor of medical psychology in Psychiatry at College of Physicians and Surgeons, Columbia University, and has served as an adjunct professor of psychology and education at Columbia University Teachers College. Dr. Litt has expertise working with individuals traumatized in childhood or adulthood and is trained in several methods developed specifically for the treatment of trauma. She has been director, trainer, and supervisor of numerous psychotherapy studies funded by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism exploring effective treatments for Posttraumatic Stress Disorder and cooccurring substance use disorders for women. She has recently coauthored a book entitled Trauma Services for Women in Substance Abuse Treatment. Also, experienced using integrated models of treatment for mental health and substance use issues. Dr. Litt maintains her private practice in New York City.

Therese K. Killeen, Ph.D., A.P.R.N. BC, discipline is nursing and is an associate professor at the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC. Areas of interest include addiction, comorbidity, PTSD, evidence-based practice, and motivational interviewing.

Mary Akiko Hatch-Maillette, Ph.D., clinical psychology, is a research scientist at the University of Washington Alcohol and Drug Abuse Institute; clinical instructor at the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA; and clinical psychologist in private practice. Areas of interest include treatment of addictions, PTSD, women's health, and depression.

Lisa M. Najavits, Ph.D., A.B.P.P., is professor of psychiatry at the School of Medicine, Boston University, Boston, MA; lecturer at the Harvard Medical School; clinical psychologist at VA Boston; and clinical associate at McLean Hospital. She is the author of Seeking Safety: A treatment manual for PTSD and substance abuse (2002) and A Woman's addiction workbook (2002), and over 140 professional publications. She is currently past-president of the American Psychological Association Division on Addictions. She has received various awards, including the 1997 Young Professional Award of the International Society for Traumatic Stress Studies; the 1998 Early Career Contribution Award of the Society for Psychotherapy Research; the 2004 Emerging Leadership Award of the American Psychological Association Committee on Women; and the 2009 Betty Ford Award of the Association for Medical Education and Research in Substance Abuse. She has received a variety of National Institutes of Health grants. She is a practicing therapist and psychotherapy supervisor.

Chanda Funcell Brown, Ph.D., L.M.S.W., obtained her Ph.D. in social work from the University of South Carolina, Charleston, SC, where biracial identity development was the research area; masters in social work from the State University of New York at Buffalo, NY, where clinical social work and addictions were the major areas; BA from the University of Pittsburgh at Bradford, PA, with human relations as major. Dr. Brown is currently the Director of the Charleston Center, Charleston County Department of Alcohol and Other Drug Abuse Services, Charleston, SC. Research interests include substance use disorders, co-occurring disorders, motivational incentives, biracial identity development, and racial socialization.

James A. Robinson, M.Ed., is the Director of Innovative Clinical Research Solutions and the Information Sciences Division at the Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY. He is also the Director of Clinical Research Informatics and Data Management at the New York University Langone Medical Center. Research interests are in developing innovative products and methodologies that will expedite the implementation and completion of clinical research studies.

Gregory S. Brigham, Ph.D., A.B.P.P., is a psychologist and chief research officer at Maryhaven, Inc., Columbus, OH, and research scientist at the Department of Psychiatry, University of Cincinnati, Cincinnati, OH. Area of interest includes treatment and prevention of chronic addiction disorders.

Edward V. Nunes, M.D., is professor of clinical psychiatry at the College of Physicians and Surgeons, Columbia University, New York, NY, and research psychiatrist at New York State Psychiatric Institute. Areas of interest include diagnosis and treatment of co-occurring psychiatric and substance use disorders.

Notes

1 Treatment can be briefly and usefully defined as a unique, planned, goal-directed, temporally structured, multidimensional change process of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help based (AA, NA, etc.), and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—which are not also used with nonsubstance users. Whether or not a treatment technique is indicated or contraindicated, and its selection underpinnings (theory-based, empirically-based, “principle of faith-based, tradition-based, etc.), continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and well-being treatment-driven models, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Each ideological model has its own criteria for success as well as failure. Treatment is implemented in a range of environments, ambulatory as well as within institutions, which can include controlled environments. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making that facilitates the collaboration between clinician and patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Editor's note.

2 The journal's style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor's note.