Patient- and therapist-rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment.

Abstract

Concurrent Treatment of Posttraumatic Stress Disorder (PTSD) and Substance Use Disorders Using Prolonged Exposure (i.e., COPE) is an efficacious, integrated, psychotherapy that attends to PTSD and substance use disorders simultaneously. No study has examined how therapeutic alliance functions during the provision of COPE and how this compares to non-integrated treatments, such as relapse prevention (RP) for substance use disorders. Understanding the role of alliance in COPE versus RP could inform treatment refinement and ways to enhance treatment outcomes. Participants (N = 55 veterans) were randomized to 12, individual, weekly sessions of COPE or RP in a randomized clinical trial. Piecewise linear mixed effect models examined how mid-treatment (1) patient-rated alliance, (2) therapist-rated alliance, and (3) the convergence between patient- and therapist-rated alliance as measured by a difference score predicted reductions in PTSD symptoms and substance use across treatment and follow-up periods. Both patient- and therapist-rated alliance predicted reductions in PTSD symptoms in COPE. Higher patient-rated alliance predicted lower percent days using substances in RP. Difference score models showed higher patient-rated alliance relative to therapist-rated alliance scores predicted symptom reductions in COPE whereas higher therapist-rated alliance scores relative to patient-rated alliance scores predicted symptom reductions in RP. Preliminary findings show a unique relationship between the rater of the alliance and treatment modalities. Patient-rated alliance may be important in trauma-focused, integrated treatments whereas therapist-rated alliance may be more important in skills-focused, substance use interventions.