Ethnic Match, Therapeutic Alliance, and Treatment Outcomes among Women with Trauma and Addictions Lesia M. Ruglass, Ph.D. 1,2, Denise Hien, Ph.D. 1, 2, Mei-Chen Hu, Ph.D. 2, Nathilee Caldeira, Ph.D. 2,3, Aimee Campbell, Ph.D. 2, Huiping Jiang, Ph.D. 3, Gloria Miele, Ph.D. 2, Edward V. Nunes, M.D. 2,3, Doris Chang, Ph.D. 4 1: CUNY - City College, 2: Columbia University, 3: New York State Psychiatric Institute, 4: New School for Social Research Treatment interventions for comorbid PTSD and substance use disorders (SUD) have shown promising results (Hien, Cohen, Miele, Litt & Capstick, 2004; Najavits, 2002) and provide alternatives to traditional relapse prevention. However, given high dropout rates and difficulties with retention among this population, the questions remain as to the specific conditions under which more women can become engaged, remain in and benefit from treatment. Studies indicate the therapeutic alliance is one of the most salient predictors of positive treatment outcome, regardless of treatment content and theoretical orientation (Connors, Carroll et al., 1997; Horvath & Luborsky, 1993). However, the alliance may be fragile among those with trauma and addictions for a host of reasons. Moreover, when there is an ethnic match or mismatch between clients and therapists, the therapeutic alliance and treatment outcomes may additionally be impacted. The aim of the present study was to examine the relationship between ethnic match, therapeutic alliance, and treatment outcomes among women with comorbid PTSD and SUD. Despite the potential for mistrust that can occur because of a trauma history and racial/ethnic differences, clients were able to engage with their therapists during treatment and develop a positive helping alliance. It is possible that variables other than racial/ethnic matching, such as perceptions of therapist credibility or competence, may have been more relevant during the course of treatment. Results also suggest that, under specific conditions, racial/ethnic matching may provide additional benefits. Racial/Ethnic matching may facilitate communication, enhance trust and rapport, and increase clients’ ability to participate in and benefit from treatment. Future studies need to qualitatively address how clients and therapists experience racial/ethnic differences in the therapeutic relationship. A total of 353 women were recruited at seven outpatient CTPs across the United States. The study used a randomized, controlled, repeated measures design to assess the effectiveness of Seeking Safety (SS) plus standard substance abuse treatment in comparison to a control treatment (Women’s Health Education, WHE) plus standard substance abuse treatment. Recruitment occurred over a 21-month period in Participants received an eligibility assessment and a comprehensive baseline assessment and, if eligible, were randomized into SS or WHE in rolling admission groups for 6 weeks (12 sessions) stratified by alcohol use disorders. Participants were assessed weekly during treatment, and at 1- week, 3-, 6-, and 12-months post treatment. Measures included the Addiction Severity Index (ASI-Lite), Clinician Administered PTSD Scale (CAPS) and the Helping Alliance questionnaire II (HAq-II). Four racial/ethnic match and mismatch conditions were created: 1) Black and Latina Clients/Racially-Ethnically Matched Therapists (N = 56); 2) White Clients/White Therapists (N = 80); 3) Black or Latina Clients /Racially-Ethnically Mismatched Therapists (N = 87); 4) White Clients/Racially-Ethnically Mismatched Therapists (N=81). Support The research reported in this article was supported by grants from the National Institute on Drug Abuse (NIDA): U10 DA13035 (Edward V. Nunes, MD, PI) and K24 DA (Edward V. Nunes, MD). The Clinical Trial Identification Number is NCT (NIDA). Contact: Lesia M. Ruglass, Ph.D. Research Center for Trauma and Addictions Department of Psychology CUNY - City College 160 Convent Avenue NAC Building, 8/132A New York, NY Tel: Fax: ABSTRACT BACKGROUND METHODS RESULTS Alliance ratings were generally high across all four racial/ethnic match and mismatch conditions (M = 5.1 to 5.4). No significant differences emerged among the racial/ethnic match conditions in their ratings of the alliance at Week 2, [F (4, 218) = 0.37, p >.05] or Week 6 [F (4, 218) = 0.59, p >.05]. Moreover, there were no significant associations between client-therapist racial/ethnic match or mismatch and number of sessions attended [F (4, 348) = 1.33, p >.05]. However, depending on clients’ pre-treatment presentation, racial/ethnic match predicted positive treatment outcomes. White clients with severe PTSD symptoms at baseline were more likely to have reduced PTSD symptoms at follow-up when matched with White therapists [β = -0.43; SE = 0.14; p <.01]. Black and Latina clients who were light substance users at baseline were less likely to use substances heavily at follow-up when matched with therapists from the same racial/ethnic background [β =1.47; SE =0.72; p <.05]. CONCLUSIONS Distribution of Ethnic Match and Mismatch among Study Therapists and Participants The authors examined the relationship between racial/ethnic match, therapeutic alliance and treatment outcomes among 353 women with PTSD and substance use disorders who participated in a multi-site clinical trial of group treatments for trauma and addictions. Results revealed there were no significant differences in alliance ratings or session attendance between clients who were treated by racially/ethnically similar therapists and clients treated by dissimilar therapists. However, depending on clients’ pre-treatment presentation, racial/ethnic match predicted positive treatment outcomes. White clients with severe PTSD symptoms at baseline were more likely to have reduced PTSD symptoms at follow-up when matched with White therapists. Black and Latina clients who were light substance users at baseline were less likely to use substances heavily at follow-up when matched with therapists from the same racial/ethnic background. The results suggest the common racial/ethnic mismatch between clients and therapists does not have to impede treatment engagement or alliance development. Moreover, under certain conditions, racial/ethnic matching may provide additional benefits. The authors discuss the implications of these findings for treating women with trauma and addictions. BL/LA clients /REM therapists (N = 56) White clients /White therapists (N = 80) BL/LA clients /REMM therapists (N = 87) White clients /REMM therapists (N = 81) VariablesM (SD) or %  2 or F-test Age (years)40.97 a (8.96)35.66 b (9.72)38.57 a (8.11)40.63 a (9.65)F(4,348) = 5.12*** Marital Status  2 (8) = 23.03** Married16.07% ab 28.75% a 9.20% b 18.52% ab Single44.64% a 25.00% a 51.72% a 28.40% a Divorce39.29% ab 46.25% c 39.08% a 53.09% bc Education  2 (8) = 37.78*** < High School37.50% ab 13.75% c 45.98% a 12.34% c High School32.14% ab 40.00% a 24.14% b 32.40% ab > High School30.36% ab 46.25% ac 29.89% b 55.56% c Baseline Sociodemographic Characteristics by Ethnic Match Conditions (N = 353) Note. BL = Black; LA = Latina; REM – Racially-ethnically matched; REMM = Racially-ethnically mismatched abc Groups with different superscripts are significant different at p <.05 *p < 0.05, **p < 0.01, *** p < Matching Conditionsn Alliance Week 2 Alliance Week 6 Session Attendance M (SD) Black and Latina Clients/REM Therapists565.3 (0.5)5.1 (0.9)5.1 (4.3) White Clients/White Therapists805.2 (0.5)5.3 (0.7)5.9 (4.7) Black and Latina Clients/REMM Therapists875.2 (0.5)5.2 (0.6)6.8 (4.3) White Clients/REMM Therapists815.2 (0.5)5.4 (0.6)6.0 (4.3) Therapeutic Alliance and Treatment Attendance among Four Client/ Therapist Racial/Ethnic Match Conditions* Note. REM = Racially-ethnically matached; REMM = Racially-ethnically mismatched; There are no significant differences among the racial/ethnic match conditions in alliance rating from Week 2 or Week 6 or in session attendance. *Data on the multiracial clients were omitted because they could not be classified as matched or mismatched based on race/ethnicity