“Keeping It Real”: The Relational Effects of Trauma Among African American Women and Their Substance Abuse Treatment Counselors

Abstract

African American women experience disproportionately high rates of trauma. Interpersonal forms of trauma often make it much more difficult for trauma survivors to initiate and maintain positive, healthy relationships with others. This study examined the kinds of relationships women with extensive histories of trauma and substance had with their substance abuse treatment counselors and the characteristics that they believe contributed to connected and disconnected client–counselor relationships. Using the case study method, 26 in-depth interviews were conducted with African American women. Data analysis revealed three primary kinds of relationships women had with their substance abuse treatment counselors: reparative, damaging, and transactional. Eighteen (69%) of the 26 women had reparative relationships with their counselors. Reparative relationships had two primary characteristics: empowering and mattering. Two (8%) of the 26 women had damaging relationships with their substance abuse treatment counselors. Damaging relationships had two primary characteristics: unimportant and untrustworthy. Six of the women (23%) had transactional relationships with their substance abuse treatment counselors. Transactional relationships were task-focused and superficial. Healing from interpersonal experiences of trauma is possible only within the context of trusting relationships. Substance abuse treatment counselors have an opportunity to help African American women with histories of trauma heal and recover. Creating positive, therapeutic relationships between clients and professionals is essential.

Keywords

relational effects trauma relationships substance abuse treatment counselors

Introduction

African American women experience disproportionately higher rates of interpersonal trauma than other racial groups (Alim, Charney, & Mellman, 2006; Center for Substance Abuse Treatment [CST], 2009; Sacks, McKendrick, & Banks, 2008; Savage, Quiros, Dodd, & Bonavota, 2007). Studies report that 65% to 88% of African Americans have had exposure to trauma (e.g., an experience or event that is so emotionally painful and distressing that it overwhelms individuals’ ability to cope, often leaving them powerless) in their lifetime (Alim et al., 2006; Goldmann et al., 2011). More specifically, among African American women, rates of interpersonal trauma (i.e., intentional acts of harm or abuse by one human being to another human being) are particularly alarming, especially when the abuse was perpetuated by someone they knew and trusted. Harrell (2011) found that almost 50% of African American women were victims of rape, sexual assaults, robberies, and aggravated assaults. Among African American women, 25% to 31% have experienced intimate partner violence (Harrell, 2011) and 34% were sexually abused as children (Amodeo, Griffin, Fassler, Clay, & Ellis, 2006). Commonly, most women (79%) experience two or more traumatic events (Farley, Golding, Young, Mulligan, & Minkoff, 2004; Sacks et al., 2008; Savage et al., 2007). Trauma is a profound experience that affects many aspects of African American women’s lives.

Exposure to trauma, especially childhood abuse, often leads to the initiation and development of substance abuse disorders (CST, 2009; Farley et al., 2004). In fact, women with histories of substance abuse report even higher rates of trauma, with lifetime estimates between 55% and 100% as compared with women without a history of substance abuse (Blakey & Hatcher, 2013; Sacks et al., 2008; Savage et al., 2007). Moreover, women who have histories of trauma, particularly childhood trauma, have poorer substance abuse treatment outcomes such as strained social relationships, shorter lengths of stay in treatment, higher rates of relapse, continued drug use, and criminality (Amaro et al., 2007; Joe, Simpson, Dansereau, & Rowan-Szal, 2001; Sacks, et al., 2008). A variety of factors can influence treatment outcomes—such as readiness to change, self-efficacy, social support, and the clinical profile (i.e., depression and anxiety stress levels) of clients (Flora & Stalikas, 2013). Nevertheless, the client–counselor relationship is the strongest predictor of positive outcomes during and posttreatment (Barber et al., 2006; Joe et al., 2001).

The purpose of this study was to identify the kinds of relationships that African American women with extensive histories of trauma had with their substance abuse treatment counselors and the ways those relationships affected their recovery. The therapeutic relationship between a therapist and client could easily be considered the most important component of the recovery process (Barber et al., 2006; Joe et al., 2001; Martin, Garske, & Davis, 2000). Therapeutic relationships can be a vehicle for emotional change and growth, as well as begin to repair damage resulting from interpersonal traumatic experiences (Herman, 1997; Liang, Williams, & Siegel, 2006; Shattell, Starr, & Thomas, 2007). Although studies regarding the client–drug counselor relationship are limited, stronger alliances have been associated with better outcomes (Barber et al., 2006). This study provides an opportunity to increase our knowledge of the ways in which trauma can affect the client–counselor relationship.

Relational Cultural Theory (RCT)

RCT is a theoretical model that is based on the fundamental principle that relationships are the foundation of growth and human development. Traditional models of mental health grew out of the premise that human development and psychological well-being are achieved through separation and individuation (Duffey & Somody, 2011; Jordan, 2004a; Miller & Stiver, 1997). However, the underlying premise of RCT is that women change, grow, and heal through relationships and connections with others, which are critical to their human development and psychological well-being (Jordan, 2004a). RCT has led to a greater understanding of what women and people of color need from treatment to maximize participation and positive outcomes (Jordan, 2004a). Therapists who embrace RCT principles can increase individuals’ vitality, ability to promote their self-interests, provide individuals with a more positive picture of themselves and others, enhance their self-worth, and help clients feel more connected to others (Miller & Stiver, 1997).

RCT is about understanding the powerful role connection and disconnection play in the recovery process (Miller & Stiver, 1997). The primary concepts central to RCT are connection, growth-fostering relationships, the central relational paradox, disconnections, and traumatic disconnections. Connection refers to an interaction between two or more people that is mutually empathic and mutually empowering, which leads to “five good things”: zest, worth, productivity, clarity, and desire for more connection (Jordan, 2004a, 2004b). Connections create growth-fostering relationships. They are fundamental and complex processes of active participation in relationships that result in mutual growth and development between the counselor and client (Miller & Stiver, 1997).

Although these connections and growth-fostering relationships are ideal, there are points of disconnection because of the dynamic nature of relationships. Disconnections are those interactions in relationships in which mutual empathy and mutual empowerment do not occur; typically because of disappointment, a sense of being misunderstood, and sometimes a sense of danger, violation, and/or impasse. Disconnections may be acute, chronic, or traumatic (Jordan, 2004a, 2004b). In the face of repeated disconnections, people yearn even more for relationship, but their fear of engaging with others causes individuals to hide who they are and what they feel. Using RCT, this study seeks to identify the kinds of relationships that lead to connection or disconnection for African American women with extensive histories of trauma.

Understanding Trauma From a Relational Perspective

Trauma has a profound effect on individuals’ relationship with others often influencing the quality and depth of the relationship (Covington, Burke, Keaton, & Norcott, 2008; Rosenbaum & Varvin, 2007). Experiences of interpersonal trauma, particularly childhood abuse, often serve as a template that affects the ways that individuals form connections with others, often interfering with their ability to relate in meaningful ways (Zorzella, Muller, & Classen, 2014). Trauma survivors are more likely to form insecure attachments, which can lead to relational problems such as hostility, antisocial behavior, impulsivity, passivity, helplessness, a lack of empathy, and difficulty forming and maintaining relationships (Liang et al., 2006; Zorzella et al., 2014).

Moreover, traumatic experiences can shatter individuals’ sense of trust, safety, hope, and belief in people, which can lead to ambivalent relationships that compel individuals to vacillate between withdrawing from and clinging to relationships with others (Courtois & Ford, 2013; Herman, 1997). Individuals with histories of trauma may be reluctant to invest in close relationships, because doing so requires facing fears associated with closeness as well as potentially opening themselves up to the possibility of retraumatization, which can exacerbate trauma symptoms such as flashbacks, somatic memories, and other symptoms (Herman, 1997). Cohen and Hien (2006) found that 52% of women with histories of trauma avoided close relationships because they feared repeated victimization. Finally, traumatic experiences often disrupt individuals’ abilities to engage and maintain trusting relationships with social service providers (Covington et al., 2008; Herman, 1997). Herman (1997) argued that supportive responses from professionals could mitigate the effects of trauma, whereas hostile, negative responses can compound the damage, often aggravating trauma symptoms.

Therapeutic Relationships

Some researchers argue that the quality of the therapeutic relationships is more significant than any other part of treatment (Martin et al., 2000; Safran & Muran, 2000). Studies have found that strong therapeutic alliances between clients and therapists are more important and impactful than any psychological intervention (Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Ilgen, McKellar, Moos, & Finney, 2006; Martin et al., 2000). Barber et al. (2006) proposed that clients who had a strong alliance with their therapist improved regardless whether their counselor adhered to a particular modality. Whereas, counselors who had weak relationships with their clients needed to adhere to particular modalities for their clients to improve. Essentially, strong therapeutic relationships are vital to the success of treatment, particularly for clients with histories of addiction (Meier, Barrowclough, & Donmall, 2005; Orlinsky, Ronnestad, & Willutzki, 2004).

The vast majority of studies have found that the quality of therapeutic relationships between clients and professionals is predictive of improved therapeutic outcomes (Shin, Marsh, Cao, & Andrews, 2011). These outcomes include increased engagement (Ruglass et al., 2012; Simpson et al., 2009), substantial improvement in self-efficacy (Hartzler, Witkiewitz, Villarroel, & Donovan, 2011; Simpson et al., 2009), reduced drug use (Gibbons et al., 2010; Joe et al., 2001; Meier et al., 2005), better posttreatment behaviors such as decreased criminality (Simpson et al., 2009), favorable changes in symptomology (Simpson et al., 2009), higher overall functioning (Simpson et al., 2009), longer retention in treatment (Barber et al., 2006; Joe et al., 2001; Ruglass et al., 2012), and higher rates of treatment completion (Breshears, Yeh, & Young, 2009).

Nonetheless, there is a paucity of research regarding clients who have complex histories of trauma and their relationships with helping professionals such as substance abuse treatment counselors. Exploring clients’ experiences in treatment can lead to a greater understanding of how professionals can build more effective relationships with clients who have histories of trauma (Ruglass et al., 2012). Given that the therapeutic relationship is a significant predictor of treatment engagement and completion, it is vital that we understand more about therapeutic interactions between women with histories of trauma and their substance abuse treatment counselors. This study seeks to fill this gap.

The goal of this study was to understand the kinds of relationships that African American women with extensive histories of trauma had with their substance abuse treatment counselors and how those relationships affected the recovery process. The main research questions guiding this study were as follows:

Research Question 1: What types of relationships did African American women with histories of trauma have with their substance abuse treatment counselors?

Research Question 2: How did these relationships affect the recovery process?

Method

The women were recruited from Trillium Health and Wellness (THW), a substance abuse treatment agency in a large, urban Midwestern city. THW is a nonprofit gender-specific substance abuse treatment agency. THW provides a continuum of care ranging from medically monitored detox, intensive residential services, to recovery home/transitional living programs. In addition, THW provides women with methadone maintenance, health and mental health screening, and monitoring services such as physicals conducted by on-site nurses, mental health evaluations, and medication monitoring. This is the only facility of its kind in the state.

Participant Characteristics

The ages of the 26 African American women ranged from 19 to 43 years (average = 36 years of age). The women had used alcohol and other drugs (e.g., marijuana, heroin, and/or crack cocaine) between 3 and 37 years. On average, the women had used alcohol and other drugs for 22 years. The youngest age at which they started using was 5 years old, and the oldest age was 20 years old. On average, the women had started using alcohol and/or other drugs at 14 years of age. The women participated in treatment from 14 to 661 days (average = 99 days). They had from zero to 13 previous treatment episodes (10 women = zero to two previous treatment episodes; 12 women = three to five previous treatment episodes; four women = six to 13 previous treatment episodes), with an average of three previous treatment episodes. Moreover, during the study time frame, five women relapsed and three women completed another treatment episode. Finally, 19 women were diagnosed with a mental health disorder, the most common disorders of which were depression, bipolar, and anxiety (see Table 1).

Table 1.

Demographics of Sample.

Name of Mother	Type of Relationship	Name of Counselor	Length of Time in Treatment	No. of Traumatic Events	Age	No. Years Using Alcohol/Drugs	No. of Previous TX Episodes	Mental Health Diagnosis
Candace—4	Damaging	Karen	91 days—relapse	9	39	26	5	Depression
Dawn—2	Damaging	Nancy	102 days	6	39	24	3	Depressive disorder Not Otherwise Specified Anxiety
Barbara—4	Transactional	Lucy Quinn	95 days—relapsed	8	38	27	6	Bipolar Depression Suicide attempt
Darcy—3	Transactional	Gwen Tonya	86 days	6	20	6	1	Depression
Evelyn—2	Transactional	Lucy	14 days	3	33	17	1	None reported
Lisa—3	Transactional	Gwen	101 days—relapsed	12	37	30	13	None reported
Vickie—3	Transactional	Christopher Gabriela	110 days	7	26	15	2	PTSD Depression Anxiety Self-mutilation
Victoria—4	Transactional	Karen	111 days	6	37	23	3	None reported
Bailey—3	Reparative	Lucy	25 days/11 days	4	32	15	3	None reported
Belinda—1	Reparative	Sarah	661 days	3	26	13	2	None reported
Dallas—2	Reparative	Linda	84 days	4	42	30	7	Depression
Dana—3	Reparative	Francis	82 days	12	19	3	0	Depression
Darla—4	Reparative	Beatrice	95 days	10	43	29	3	Depression Nervous breakdown
Edith—1	Reparative	Gwen	85 days	10	42	26	9	Depression Anxiety
Harriet—2	Reparative	Linda	90 days	5	39	25	3	Depression Anxiety Auditory hallucinations
Kai—3	Reparative	Karen	39 days—relapsed	8	40	35	4	Depression
Lashaun—3	Reparative	Gwen	86 days	5	41	21	5	Depression
Mackenzie—3	Reparative	Linda	90 days	8	39	22	4	None reported
Natalie—3	Reparative	Francis	85 days	10	31	18	1	Depression
Tabitha—3	Reparative	Linda	96 days/90 days	4	37	18	1	Anxiety Depression Attachment disorder
Tahlia—3	Reparative	Francis	96 days	2	37	19	1	Antisocial behavior Depression
Tammy—4	Reparative	Lucy	33 days	7	43	25	4	Depression
Tasha—2	Reparative	Francis	36 days	2	30	16	0	Depression Suicide attempt
Tonia—3	Reparative	Linda	71 days	5	34	21	3	Depression
Vanessa—3	Reparative	Linda	105 days/90 days	5	40	26	4	None reported
Vivian—4	Reparative	Karen	122 days—relapsed	7	33	19	1	Depression

Note. PTSD = posttraumatic stress disorder.

According to self-reports, counselors’ reports, and documents in the women’s file, all 26 women (100%) experienced some form of interpersonal trauma. Seven women (27%) experienced two to four traumatic/adverse traumatic events. Ten women (38%) experienced five to seven traumatic/adverse traumatic events. Nine women (35%) experienced eight to 12 traumatic/adverse traumatic events.

Myriad forms of interpersonal trauma were reported. Fourteen women (54%) reported childhood sexual abuse. Eight women (31%) experienced childhood physical abuse. Ten women (38%) reported they were raped. Twenty-one women (81%) reported intimate partner violence. Five women (19%) indicated that they were sex trafficked. Finally, 13 women (50%) had witnessed or experienced some kind of violence (e.g., being kidnapped, tied up and severely beaten, witnessing close family members or friends being shot and killed).

In terms of adverse traumatic experiences, four women (15%) witnessed domestic violence as children. Eleven women (42%) reported extreme emotional abuse as children. Eight of the 11 women (73%) also reported emotional abuse as adults. Seventeen women (65%) engaged in prostitution, of which violence was a common part of the experience. Eighteen women (69%) had been neglected and abandoned as children, often because of parental substance abuse. Seventeen women (65%) had a biological parent or parents who abused drugs. Thirteen women (50%) indicated that loss of children through their involvement with child protection was traumatic. Finally, four women indicated that their involvement with the foster care system as children was traumatic; all four had been abused while in foster care (e.g., sexual abuse, physical abuse, extreme neglect, and emotional abuse).

Data Collection Procedures

Two data collection methods were utilized in this study: (a) in-depth, semistructured interviews and (b) documents from the women’s file. The interviews were conducted at THW, the substance abuse treatment center, and lasted between 1 and 2 hr. The interviews took place in separate offices/rooms throughout the building. The participants were reminded that any information provided was confidential. All the interviews were recorded digitally and transcribed verbatim by a professional transcription service. Pseudonyms were used to protect the confidentiality of the women and the substance abuse treatment agency. The interview protocol explored specific details about each woman’s substance abuse history, questions about their relationship with their substance abuse treatment counselor, and their overall experiences in treatment.

The women’s interview protocol included the following questions:

Describe your relationship with your current substance abuse treatment counselor.

In what ways does your relationship with your substance abuse counselor affect your experience at THW?

What does your substance abuse counselor do that makes you feel supported?

What does your substance abuse counselor do that makes you feel unsupported?

What are some ways by which your relationship with your substance abuse counselor could be improved?

What do you like most about your relationship with your substance abuse counselor?

You said that you’ve been here since ______ (date). Has your relationship with your treatment counselor changed since you’ve been here? If so,

How has it changed?

What do you think has caused the change?

Would you say it is worse or better? How so?

In addition, notes were taken from documents contained in each woman’s file. The documents included case notes written by substance abuse treatment professionals, biopsychosocial assessments, psychological evaluations, and homework assignments completed by the women. In this study, the documents were used primarily for demographical purposes. The in-depth interviews and notes from documents were uploaded into NVIVO 10, a qualitative software program that allows researchers to code and categorize narrative text, make connections between codes, and develop themes. The women received US$25 for their participation in the study. The university institutional review board that oversees research with human participants approved all study protocols.

Data Analysis

Data analysis includes several steps that took place throughout the duration of the study. The first step of data analysis included transcribing the interviews, which were completed by a professional transcription company. As the interviews were completed, they were reviewed and analyzed to ensure accuracy and confirm that the desired information was being collected. Memos also were kept to organize, make sense of, and document early analytic reflections of the interview process and data being collected (Gillham, 2000; Miles & Huberman, 1994).

The next step in the analytic process involved typing up and organizing the documents, which were collected from each woman’s file. The third step of data analysis consisted of coding the interviews and documents from the women’s files. Initially, the data were coded using open coding, which entailed coding line-by-line to allow the codes to emerge from the data (Miles & Huberman, 1994; Padgett, 2008). Open coding generated a list of codes (Miles & Huberman, 1994). The codes were reviewed to identify salient themes, using a case study technique of looking within and between cases to disconfirm, corroborate, and identify alternative explanations (Yin, 2009). The final step of data analysis consisted of thematic analysis, which is a way of dissecting the data and grouping codes to identify and understand patterns emerging from the data, which provides plausible explanations across cases to answer the research questions (Fereday & Muir-Cochrane, 2006; Miles & Huberman, 1994; Yin, 2009).

During data collection and analysis, several strategies were used to enhance the rigor and trustworthiness of the findings. Several strategies helped increase credibility and confidence in the research findings. Credibility is concerned with the level of confidence someone can place in the research findings (Padgett, 2008). The first step taken to ensure credibility was prolonged engagement. It is based on the belief that the more time researchers spend in the field, the better understanding they have of an organization and the more time they have to establish a relationship of trust with participants (Padgett, 2008; Shenton, 2004). Data were collected over 14 months through multiple interactions with participants. Another step taken to increase credibility was peer debriefing. This allows researchers to obtain feedback from others regarding the conclusions and interpretations that are being made, thus decreasing the possibility of researcher bias (Padgett, 2008). The use of negative case analysis (i.e., giving equitable attention to divergent viewpoints) was another step taken to increase credibility. During data analysis, looking for differing viewpoints and alternative explanations ensures findings are based on participants’ responses and not the researcher’s biases. Thick description and purposive sampling (interviewing key informants who are knowledgeable about a particular issue) were used to increase transferability, which ensures the research findings can be applied to other contexts. Finally, an audit trail through memos and field notes based on participant observation was created to increase dependability. These steps were taken to strengthen the study.

Findings

The purpose of this study was to identify the kinds of relationships that African American women with histories of trauma had with their substance abuse treatment counselors, and how those relationships affected their engagement in substance abuse treatment. Data analysis revealed three primary kinds of relationships women had with their substance abuse treatment counselors: reparative, transactional, and damaging. Eighteen (68%) of the 26 women had reparative relationships with their counselors. Six women (43%) had transactional relationships with their substance abuse treatment counselors. Two (8%) of the 26 women had damaging relationships with their substance abuse treatment counselors.

Reparative Relationships

Reparative relationships consisted of positive characteristics that seemed to contribute to women’s restoration and healing from interpersonal traumatic experiences. Reparative relationships made the women feel powerful, that they were in control, and that they were important and mattered. Reparative relationships had two primary characteristics: empowering and mattering.

Empowering

The first characteristic of the women’s reparative relationship with substance abuse treatment counselors was that these relationships were empowering. The counselors provided women with information that allowed them to make informed decisions. In these relationships, the professionals told the unadulterated truth and gave women choices that enhanced their ability to make informed decisions.

Keeping it real

The primary way in which the women felt empowered was what they described as “keeping it real.” Counselors kept it real when they were honest and did not sugar-coat anything, telling women the unadulterated truth. Darla, a 43-year-old woman with a history of childhood sexual and physical abuse, multiple rapes, and an extensive history of intimate partner violence, confirmed that honesty is an essential component of keeping it real:

What I like most about my counselor is she’s honest. She keeps it real. I know where I stand . . . I trust that what she’s telling me is the truth. She’s really honest, and I appreciate that because it’s hard to know when everyone wants something from you. You’re always thinking: What’s their angle? What do they want from me? She’s not like that. She keeps it real.

Neither did the counselors give mixed messages, nor were they ambiguous about their position. Tahlia, a 37-year-old woman with an extensive history of domestic violence and emotional abuse, confirmed that clear communication is an important part of keeping it real, saying,

Ms. Francis gives it to us in the raw—you know, just like a mother figure. I want somebody to tell me what I need to hear and not try to butter it up, you know. She says what she says, and she means it, and they know she means it, you know. And she lets us know to save the bullshit for somebody else. A lot of us need to hear that, you know. Instead of somebody always being passive and stuff like that. She comes in the group and lays it down. It makes me realize what I need to do for me and my children.

Another component of keeping it real was that the substance abuse treatment counselors were upfront about the pros and cons of the women’s actions and gave them the freedom to make their own choices. Kai, a 40-year-old woman with a history of physical abuse, neglect, intimate partner violence, and rape, stated,

Ms. Karen is going to keep it real with me. She ain’t going to tell me nothing that you know that’s going to twist me in no kind of way. You know she’s going to show tough love and she’s going to do her job. You know she ain’t going to hide nothing from my worker, and that’s what I like . . . She lets me know the importance of being honest. She said if I can learn to be honest about the little things, something little I can make it . . . What I like is she puts it out there and lets me make my own choice.

The last component of keeping it real was forecasting, which involved the counselors’ informing the women about possible future scenarios and preparing them ahead of time to make some difficult decisions if it came to that. Belinda, a 35-year-old woman with a history of domestic violence, related,

We have a really open, honest relationship. She keeps it real. I mean, she’s brutally honest . . . It’s good . . . Sometimes I don’t wanna hear it because it hurts, but she prepares you for things that you wouldn’t think of. She helps you—like with the hospitalization of my son. I didn’t even think about the possibility of him needing to be hospitalized. But even before he was hospitalized, she said, “You might need to consider that Tyrell isn’t making it and he needs more help. You need to think about that if the time comes, you need to be ready to make that decision.” She kept it really real with me, and I felt like I was in control, that I was able to make the best decision for my son.

Keeping it real was the most important characteristic of a reparative relationship. It made the women feel empowered and in control. It gave the women honest feedback and also helped them make informed decisions for the future.

Mattering

The second characteristic of reparative relationships is “mattering”—the belief and evaluation that someone is important to another person (Marshall, 2001). In this study, mattering was the extent to which the women believed that their substance abuse treatment counselor conveyed that they were important, thought about and were concerned about them, and took an interest in or paid attention to them (Rosenberg & McCullough, 1981). In this study, mattering took several forms: listens to me, makes time for me, keeps their word, and goes above and beyond.

Listens to me

The first form of mattering was that the women believed that their counselors took time to listen and hear them. Dana, a 19-year-old with a history of childhood physical and sexual abuse, neglect, rape, and intimate partner violence, said “The reason I like Ms. Francis is because she sits down and gives me time to conversate with her. She listens to me and hears what I have to say.”

Bailey, a 32-year old-woman with a history of domestic violence and neglect, confirmed the importance of her counselor’s listening, tracking, and recalling things that she said in her one-to-one sessions:

I love that she listens. She actually listens to you and she doesn’t forget what you tell her. So if you go to her with some BS and then try to flip it because you forget that it’s something that you said, she’s gonna call you on it.

Listening to clients made the women feel that they mattered because the counselors used this information to help them get more out of recovery. Dallas, a 44-year-old with a history of domestic violence and prostitution, reported,

I have an open, honest relationship with her. I felt like I could talk to her about anything, you know . . . She will listen. She gives constructive criticism, and that’s great, you know. She’s not judgmental towards me. She pointed out to me that I was emotionally unbalanced. So she studied me, which meant she had been watching me and paying attention and she showed concern and care for me. For real. And let me get something out of being here: She served a purpose for me being here. Because I’m telling you if it wasn’t for her, ain’t no telling when I would of found out what the real problem was [being bi-polar]. You know, I would of still been running around blind, you know, but the Lord decided to use her.

Keeps their word

Another factor that the counselors did that conveyed to the women that they mattered was when the counselors kept their word. This made the women feel that they were important and valued. For example, Dana indicated “Ms. Francis does whatever she promises. She’s gonna do it. And that’s why I like her. She keeps her word. It’s something I can count on.”

A crucial part of keeping their word was that the counselors provided an explanation to the women when they were unable to do something. Darla explained why this mattered to her:

We got a good relationship ‘cause she called me today, this morning, to let me know that her schedule had a conflict in it and she wouldn’t be able to make it for the session with my daughter today. You know, and she didn’t want me to feel like she was blowing me off. Whatever we plan to do, if she can’t make it, she always let me know . . . and she only works three days a week, but sometimes she comes in on Friday and Sundays, you know, just to see you know if anything is going on and if I need anything. She’s a good counselor. I know when someone cares about me. There are so many ways she shows me that she cares.

This made the women feel that the counselors respected them. Often, the women felt stigmatized and devalued because they had histories of addiction and were involved with child protection. Consequently, people treated them as if they were not important or worthy of respect. Letting the women know when they were unable to keep their word meant a lot to the women.

Goes above and beyond

In the final form of mattering, the counselors went above and beyond their regular work responsibilities and came in on their days off to keep a promise. Harriet, a 34-year-old who stabbed her father after years of watching him beat her mother, said,

She’s [Her counselor] going to school, but she’ll come in here and check on us. Did you do this? Did you do that? How did group go? So I’m like, ooh, she really do care! That kinda touched me a lot. I would write down stuff that I wanted to ask her, and she remembered stuff I had already told her. So I know she had to be really listening to me and she’d just give it to me. And I was like no matter what, I’ll stick with this woman. I don’t care how I grit my teeth and all that. I’ll stick with her.

The women felt that the counselors went above and beyond by making time to talk to them even when they were busy, particularly when the women were struggling with issues that arose while in treatment. According to Bailey,

No matter where she’s at, she could just be walking through the door. I could be like, “Lucy, I need to talk to you.” She’ll say, “Okay, come on.” She ain’t made it up the stairs yet . . . I mean, she’ll take the time to talk to you even if she got a million other things on her caseload or a lot of paperwork to do . . . She stays late when she don’t have to, and she comes in. Like one day last week, she was truly sick but because she had promised me a one-on-one, it was her day to work, but she still came in and gave me that one-on-one and went through my service plan.

Another way in which counselors went above and beyond for the women was when they advocated for them. Tammy, a 43-year-old with a history of childhood sexual abuse, neglect, rape, and witnessing friends and relatives murdered stated,

I got a good relationship with Ms. Linda . . . She really understands me, and she knows what I’m going through. She talks to my worker, my DCFS worker . . . Today was her day off—and she came in just to meet with us . . . What I like the most about her is that she believes in me. She thinks that I can do anything. She thinks I’m smart, and I like stuff like that—positive stuff because that gives me more motivation, you know, to do what I need to do.

Mattering, the second characteristic of a reparative relationship was significant because it demonstrated to the women that they were valued, that someone cared about them, and that they were important enough to be heard, have someone make time for them, and have someone go above and beyond for them.

Reparative characteristics of the counselors consisted of empowerment and mattering, which helped the women begin to heal from their traumatic experiences because the women felt close to and attached to their counselor. Darla said,

Ms. Beatrice is more to me than just a counselor—it’s just something about her . . . I feel attached to her. When I finally get my daughter back, I want her to see and let her know you know you played a part in this, you know, and I’m grateful for that. I’m grateful for her.

Trauma often makes individuals feel powerless, hopeless, unimportant, and alone (Copeland, 2002). Empowerment and validation through mattering go a long way toward helping women heal and seem to be an important part of therapeutic relationships. Moreover, survivors need validation and to be heard. These experiences often negate past experiences and create new, affirming, connections (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005).

Transactional Relationships

Transactional relationships have a scope of work limited to specific, short-term tasks (completed paperwork, treatment plans, required weekly one-on-one meetings), which are accomplished with limited, planned commitments (Enos & Morton, 2003). The professionals work within the system. The parties maintain separate identities and have limited closeness (Clayton et al., 2010; Enos & Morton, 2003). The relationship between women and their counselors primarily were based on accomplishing personal and institutional goals (e.g., the women want to complete treatment, and it is the counselors’ job to help them). According to Clayton et al. (2010), “Persons come together on the basis of an exchange, each offering something that the other desires. One or both parties benefit from the exchange, and no long-term change is expected” (p.7). Consequently, there was not much depth in the relationship between clients and counselors because the goal of the relationship was to complete the necessary tasks, not develop a deeper relationship (Clayton et al., 2010).

Task focused

The main characteristic of transactional relationships is that they are task focused. When the women described their relationship with their counselor, they focused mainly on the tasks that the counselors helped them complete. Barbara, a 38-year-old woman with a history of neglect, childhood sexual abuse, intimate partner violence, and rape, reported,

Ms. Lucy, she was easy to work with ‘cause of a lot of things. I have a lot of difficulties with like spelling and some things with reading, and she has become a great help, there. And she helped me with filling out the paper things I needed to do. She’s a cool person . . . Ms. Lucy shows me that she is there for me by helping me with a lot of my paper work . . . Sometimes it’s like I’m brain dead . . . and I couldn’t think like the goals that I wanted. She would help me think of my goal with the paperwork.

Victoria, a 37-year-old woman with a history of childhood sexual abuse, intimate partner violence, and witnessing the murder of her friend, described her relationship in similar ways. She was able to identify positive things that she liked about her counselor, but these things often were canceled out by her counselors’ unpredictability. Victoria stated,

She is so strict with rules and stuff. But now we’re just fine because she’s basically been helping me out a lot with parenting and getting a sponsor . . . She helped me find a recovery home. She talked to my caseworker. If it wasn’t for her, the caseworker wouldn’t have even complied with a lot of the stuff they supposed to do concerning me and my case . . . I didn’t like her at first, but I feel more comfortable with her. I can tell she kinda bi-polar, but I know not to talk to her at certain times, you know . . . It’s PMS, it’s bi-polar or menopause or something. Something’s wrong with her. I know to stay my distance from her when she acts like that . . . It’s time to move around.

Superficial

Another characteristic of transactional relationships was that the relationships were superficial. The women did not to get too personal, and they kept the relationship strictly professional. Lisa, a 37-year-old woman with a history of childhood sexual and physical abuse, neglect, rape, and intimate partner violence, as well as her partner killed her brothers, remarked,

I think she’s [her counselor] a very open-minded person. Very busy. Personally, I utilize her for what she’s here for. That’s it. I’m not trying to get personal or anything like that . . . She’s very nice. Sometimes I think too nice. Very passive, sort of . . . Professional thing, and that’s the relationship . . . When I’m having a stress thing, it’s like she hears me and she don’t hear me. But I understand when her hands are tied. That’s all she can do . . . When I need to talk or if it’s something’s going, she tells me we’re going to get together. We don’t get together. That’s cool. I understand some patients require more than others. I’m a big girl. I can stand up. I’ll pray about or cry or take another approach to it.

Vickie, a 26-year-old woman, had been sexually abused by her father for many years until she was placed in the foster care system, where she also was sexually abused after seeing her parents murdered. She confirmed that her relationship with her counselor was strictly professional, stating,

Strictly professional. Very clear boundaries intact, which makes me feel comfortable . . . What I’ve seen so far when he says he’s going to do something, he does it . . . You know, he’s real to the chase but polite and just to the point. When he say something and when he want it done, just go ahead and do it and you won’t have a problem . . . He does his part by helping me with what I need, and I do what he asks of me . . . We don’t have a problem . . . It’s about business. I know what I’m here for, and it ain’t to make friends.

In this study, transactional relationships existed solely to serve a function—to focus on the tasks that allowed the women to complete treatment. These relationships did not seem to have a lot of depth. Many of the women described them as strictly professional in nature. The women and the counselors alike did not want to get too personal. Other than accomplishing specific goals, the women kept their distance. Transactional relationships were not bad; however, they did not seem to lead to deeper level healing that took place with women who had reparative relationships.

Damaging Relationships

Damaging relationships consisted of negative characteristics that made women feel unimportant, disempowered, and unsafe. These characteristics were opposite of reparative relationships as they reinforced the women’s belief that people cannot be trusted or counted on when they need help. Two characteristics contributed to damaging relationships: unimportant and untrustworthy.

Unimportant

“I’m not important” was a characteristic of a damaging relationship because it made the women feel like they did not matter because their counselor was not there or did not have time for them. Dawn, a 39-year-old woman with a history of childhood sexual abuse, domestic abuse, and general violence, explained,

I used to be jealous of my counselor and another client, because every time I looked around, she was in with this client. They were in there for hours. I was trying to get help, and I couldn’t because she was too busy with somebody or something else. Every time I needed her, she never had time. Then when I would meet with her, she was always in a rush. She would ask me questions . . . and I would never just answer the question. I would always give her a little bit more. She would say, “I didn’t ask you that. Hurry up. I got something else to do.” Every day I questioned whether I wanted to stay in treatment . . . The only thing that kept me there was knowing I had to do this for my kids. I clearly was not a priority and often went to other counselors for help.

Dismissive

Another characteristic that made the women feel unimportant was when the counselors were dismissive of them, failed to address their concerns or include things they wanted as part of their treatment plan. This made the women feel like they could not trust or count on their counselor. Dawn said,

After thirty days or so, I tried to talk to my counselor about housing. “No, Dawn, this isn’t the time to worry about that.” . . . She kept putting it off, and now DCFS is telling me if I don’t have a place by Friday, by the time I get ready to leave here, they’re going to take my kids . . . I mean, these are my kids . . . Every time I would bring it up, she would dismiss me and talk about what she wanted to talk about . . . I just don’t trust her. I don’t feel like she has my back.

Doesn’t listen

A final characteristic opposite from a reparative relationship was when their counselor did not listen to them. Dawn described a situation like this:

There were many times when I had to really get aggressive with my counselor . . . I want her to listen to what I’m saying . . . It got to the point that no matter what I said, she wouldn’t listen or would do the opposite . . . She said it was because she was afraid that I would go out and use, but it made me feel like what I wanted and needed didn’t matter . . . There are so many things she does that shows me that my needs aren’t a priority . . . I tried to get another counselor because it has gotten to the point that I don’t trust her. I don’t want to talk to her. What’s the point when she’s going to do what she wants anyway?

Untrustworthy

The second characteristic that leads to damaging relationships was untrustworthiness. In these instances, the women felt uncertain about whether their counselor would lie or falsify reports to their child protection caseworkers or probation officers. In general, they did not trust their counselors, which resulted in strained relationships. Candace, a 39-year-old woman with a history of childhood sexual and physical abuse, domestic violence, and general acts of violence, is an example:

I don’t know what that lady might do or say . . . I’m just hoping and praying she tells the truth. I don’t care how she acts . . . She throws her power around . . . That’s her own stuff, as long as she tells the truth . . . She’s like a sadist. You never know when she’s gonna lash out . . . I don’t know if she going to do this or that . . . I’m hoping that this lady tells the truth and does what’s required in terms of the job she holds.

Not doing their part

Another factor that made their counselors untrustworthy was that they failed to do their part or keep their word. As Candace described it,

Every time I come to our one-to-one sessions to discuss my homework, she isn’t ready. I bring all this homework to her. I’m showing my progress . . . I’m doing whatever she tells me to do. No matter what it is, I do it . . . I’m supposed to be able to go to my counselor with any problem I’m having . . . I told her, “I can’t work with you.” I’m not getting nothing out of treatment . . . I no longer want her to be my counselor . . . She’s not doing her part. I just don’t trust that she has my best interest at heart.

Dawn also indicated that her counselor did not do her part, so she felt let down by her counselor and said,

I feel like she let me down with my housing part. Because when I was trying to talk to my counselor about it earlier, she would always tell me, “It’s not time.” She should have been on it . . . I trusted her with my sobriety and to help me get my kids back . . . So far, she’s threatening both by not doing her part. I came to treatment for help, but I feel like they’re hurting me more than helping me.

The damaging characteristics made these women feel that they were unimportant and that their counselors were untrustworthy, which made them feel unsafe with their counselors. Both of them asked for a new counselor, but it was against agency policy to switch unless something egregious happened. Damaging relationships also resulted from personality clashes or ongoing battles for power between the women and their counselors.

Damaging relationships caused the women to question whether they wanted to remain in treatment and seriously contemplated leaving treatment. Both women remained in treatment despite wanting to leave, though, because they knew that leaving would adversely affect their ability to regain custody of their children. Dawn and Candace both thought that treatment was a waste of time because it was not helping them reach their desired goals.

Discussion

The purpose of this study was to understand the kinds of relationships that African American women with extensive histories of trauma had with their substance abuse treatment counselors and how those relationships influenced their experiences in treatment. The women had three primary kinds of relationships with their substance abuse treatment counselors: reparative, transactional, and damaging. Eighteen women (69%) had reparative relationships with their substance abuse treatment counselors. Reparative relationships are relationships in which individuals have experiences or receive messages that refute previously held beliefs about and/or validate who they are and the value they add to the world. Reparative relationships made the women in this study feel empowered and heard. These kinds of relationships also conveyed to the women that someone cared about them and that they mattered. The counselors did this by making themselves available, going above and beyond, and acting in caring and supportive ways toward the women. This type of relationship was critical, given the importance of the counselors’ role, as the women had to complete treatment successfully and remain abstinent as part of their child protection case plan.

Reparative relationships are a type of growth-fostering relationship. Similar to RCT, empowerment was a vital component of reparative relationships, as it helped individuals overcome fear and helplessness that often result from traumatic experiences (Elliott et al., 2005). Empowerment also gave the women control over their lives by making conscious choices thereby increasing their power personally, interpersonally, politically, and societally (Gutierrez, Parsons, & Cox, 1998). The authenticity displayed by the counselor in terms of “keeping it real” resulted in the counselors’ increased ability to engage the women in a therapeutic relationship that fostered their growth, as asserted in RCT (Jordan, 2008). Mattering—one of the primary means of creating and maintaining growth-fostering relationships according to RCT—leads to increased desire to relate, increased energy, and an increase in overall sense of self-worth (Jordan, 2004a, 2004b).

Reparative relationships are similar to what Saakvitne et al. (2000) refer to as RICH (respect, information, connection, and hope) relationships. RICH relationships can heal interpersonal trauma and facilitate safety and trust, which are essential components of trauma survivors’ relationships with professionals, and fundamental to the development of healing connections (Courtois & Ford, 2013; Elliott et al., 2005; Herman, 1997).

Six women (23%) had transactional relationships with their substance abuse treatment counselors. These relationships were short term, task focused, limited in scope, and strictly professional with limited personal connection or involvement (Clayton et al., 2010; Enos & Morton, 2003). Transactional relationships did not get too personal or lead to long-term growth. Transactional relationships were women’s strategy of survival, a method that women used to stay out of relationship or limit the connection with their counselor (Miller & Stiver, 1997). Transactional relationships were a mutual response by the women and their substance abuse treatment counselor.

Several reasons could have contributed to women having transactional relationships.

Three of them had to switch counselors. One woman had to switch because she relapsed. Another woman’s counselor was in a car accident and took leave. The final woman’s counselor left the treatment center. These interruptions in treatment did not allow them to adequately bond with their new counselor.

One of the women had an infant who was in the intensive care unit. Almost every day, Vickie went to visit her daughter, which limited her involvement in treatment groups and individual meetings with her counselor.

Evelyn was in treatment for only 14 days, which was not enough time for her to connect with her counselor.

Five of the six women were on the same unit, which had more turnover, in that two counselors left during the course of the study. The other unit had no turnover. Stability of the unit also could affect the counselors’ ability to engage and connect with clients.

Transactional relationships had both negative and positive aspects. The unfortunate aspect was that deeper level processing and working through trauma and substance abuse histories did not take place. Most of the research has found that it is through this deeper level connection that healing, recovery, and growth is fostered (Courtois & Ford, 2013; Herman, 1997; Miller & Stiver, 1997). Transactional relationships resemble aspects of the central relational paradox in that the women altered themselves to meet the expectations of their counselor and/or the agency. Mutuality was not possible, and became a source of disconnection for the women. The positive aspect was that these women were able to form a relationship, albeit superficial and did what they needed to do to get their needs met. Transactional relationships are promising because they have tremendous potential, and with some work, these relationships could become more growth fostering or even reparative, which is consistent with RCT (Miller & Stiver, 1997).

Only two of the women (8%) had damaging or negative relationships with their substance abuse treatment counselor. Damaging relationships were those in which harm occurred or the potential for harm was present. Damaging relationships made the women feel that they were unimportant. The counselors tended to be dismissive of the women’s needs and desires, often did not listen to them, and did not do their part. This behavior made the women feel that they could not trust or count on their counselor, that the counselors did not have their best interest at heart, could not help them, and ultimately made them question the utility of treatment.

The dynamics present in damaging relationships were in many ways similar to, and had the potential to reinforce, negative effects of trauma. Interpersonal forms of trauma, particularly trauma starting in childhood, can make individuals feel powerless, helpless, and out of control. Trauma often makes people feel that they are not important, do not matter, and that the world is against them (Herman, 1997; Miller & Stiver, 1997). Because of abuse, many trauma survivors do not feel that they have someone to trust, lean on, or be an ally who will support, encourage, and advocate for them. In this sense, damaging relationships could exacerbate the trauma that many of the women experienced by reacting similarly to the people in their past.

Damaging relationships are consistent with the RCT concept of traumatic connections, in that these relationships often trigger the women to return to strategies of disconnection and old ways of self-protection (Jordan, 2004a, 2004b). Both Dawn and Candace indicated that they would have left treatment if it had not been for their involvement with child protection. In essence, their counselor had power over them. With respect to damaging relationships, the more unequal the relationship, the greater potential for harm (Miller & Stiver, 1997). Because Dawn and Candace had less power in the relationship, they had less ability to alter the relationship. Damaging relationships can jeopardize clients’ treatment and recovery. Often, when individuals drop out of treatment or leave against medical advice, it is believed that it is because they are not ready to change. The findings in this study, however, highlight the reality that damaging relationships also could contribute to the reasons individuals leave treatment early.

Although all trauma can have devastating effects, the women who had damaging and transactional relationships had more experiences of childhood sexual abuse, intimate partner violence, and general violence, which sometimes involved their being kidnapped, tied to a bed, beaten, and raped repeatedly, and/or witnessing loved ones being murdered or assaulted more often than women who had reparative relationships. One could argue that these are among the most egregious forms of interpersonal violence, and consequently had a greater impact on their ability to form positive, trusting relationships with their substance abuse treatment counselors.

Contributions of the Study

This study makes several contributions. The major contribution of this study is that it highlights the impact that African American women’s histories of trauma have on their relationships with their substance abuse treatment counselors. Focusing on African Americans, a cultural group that tends to have higher exposure to trauma, provides a greater opportunity to understand the ways in which trauma can affect the client–counselor relationship. Moreover, studies report that African Americans have a greater need for substance abuse and mental health treatment, but are less likely to gain access to care and if they enter treatment, often receive a poorer quality of care (Wells, Klap, Koike, & Sherbourne, 2001). However, Areán, Alvidrez, Nery, Estes, and Linkins (2003) reported that treatment programs that took clients’ preferences into account and allowed them to have some control over services were successful in retaining African Americans and other people of color. In this study, African American women identified characteristics that they believe lead to transformative, transactional, and damaging client–counselor relationships. Knowing characteristics that lead to different kinds of relationships can help counselors and other mental health professionals be intentional about creating more effective relationships with clients who have histories of trauma as these relationships can lead to healing as well as contribute to longer retention in substance abuse treatment (Ruglass et al., 2012). Given that the therapeutic relationship is a significant predictor of treatment engagement and completion, it is critical that we understand more about therapeutic interactions between African American women with histories of trauma and their substance abuse treatment counselors.

A second contribution of the study was the focus on substance abuse treatment counselors. Most studies have concentrated on client–therapist relationships (Bedi, Davis, & Williams, 2005; Littauer, Sexton, & Wynn, 2005; Shattell et al., 2007). Although very few studies have examined client–substance abuse treatment counselor relationships, there were similarities between therapists and treatment counselors. Some of the reparative and damaging characteristics identified in this study have been found to influence therapeutic relationships in other studies. Studies found that therapists who listened attentively, validated clients’ experiences, were honest, could relate to them, made them feel special, knew them as a person, and showed genuine concern and care, were important characteristics (Bedi et al., 2005; Littauer et al., 2005; Shattell et al., 2007). This is important as treatment counselors’ formal training is different from that of therapists. Nonetheless, characteristics that were identified and highlighted in this study are similar to what other studies have reported.

A final contribution of this study is the use of RCT to understand women’s relationships with their substance abuse treatment counselors. Reparative, damaging, and transactional relationships are extensions of RCT’s growth-fostering connections, central relational paradoxes, and disconnections. Connections and disconnections describe the type of relationships individuals can have with professionals regardless of their trauma history. Counselors who treat the women similarly (unimportant, untrustworthy, dismissive, does not listen) to the individuals who traumatized them reinforce and often worsen the damage resulting from trauma. Although counselors treat the women differently (empowering, mattering, listen to me, makes time for me, keeps their word, goes above and beyond) than people who traumatized, these relationships can be transformative and healing for individuals who have histories of trauma.

Limitations

Although the study here makes a noteworthy contribution to the literature—in that it brings together research on relational effects of trauma and therapeutic relationships between clients and substance abuse treatment counselors—several limitations should be noted. Most significant is that the client–counselor relationship is only considered from the woman’s point of view and did not include the counselors’ perspective. Possibly, if the relationship had been examined from both vantage points, the findings of this study might be different.

A related limitation is that the women were interviewed about their relationship with their counselor at different points in time. Some of the women had been in treatment for 30 days, and others had been in treatment for 60 days. Most of the women had been in treatment at least for 2 weeks, because it was advised to wait at least 2 weeks before interviewing the women. Possibly, if all the women had been interviewed at the same point in time (e.g., the 60-day mark), the results of this study may have been different.

Another limitation is that this study involved clients and their counselors at only one substance abuse treatment agency—albeit the only one of its kind in the state. Clients and counselors in another substance abuse treatment program may have identified other factors that positively and negatively affect therapeutic relationships.

Finally, the study findings included only African American women with histories of trauma. Although it is unclear whether other women in treatment have had histories of trauma, studies report that 31% to 99% of women with histories of addiction also have been exposed to trauma (Sacks et al., 2008). Nonetheless, women from other racial groups and ethnicities may have had different experiences with their substance abuse treatment counselors. Race did not come up as a factor, even though the women were asked whether they thought racial differences between them and their counselor had any effect on their relationship with their counselor.

Implications for Practice

Within substance abuse treatment settings, high recidivism is commonly believed to be a regular part of doing business. Although readiness to change and motivation are certainly essential factors, believing that these factors solely explain high recidivism rates negates the importance of counselor–client relationships and the ways in which these relationships can be transformative or damaging, which will affect outcomes related to engagement, retention, and longer periods of abstinence (Amaro et al., 2007).

Many substance abuse treatment agencies are incorporating trauma-specific interventions into their current practices, as well as creating trauma-informed systems of care (Blakey & Bowers, 2014). Nonetheless, this study found that the client–counselor relationship was an effective tool that facilitated women’s healing and empowerment, confirming that “if a proper alliance is established between a patient and a therapist, the patient will experience the relationship as therapeutic, regardless of other psychological interventions” (Martin et al., 2000, p. 446). This is not to suggest that substance abuse treatment agencies should not become trauma informed or move toward integrated practice (simultaneously addressing substance abuse and trauma in a coordinated, intentional way) because studies have found that integrated practice is the most effective way to address clients who have co-occurring disorders (Elliott et al., 2005). Enhancing and improving counselor–client relationships, however, can be done immediately and requires very little money to begin.

Reparative relationships between counselors and clients may be the first positive, transformative relationship that many women have had. These relationships have the power to help clients establish new ways of relating to others; increase women’s power in personal, interpersonal, and political realms; and empower them to direct their own lives by giving them more choices over important life decisions (Elliott et al., 2005; Meier et al., 2005; Orlinsky et al., 2004). Healing from interpersonal experiences of trauma is possible only within the context of trusting relationships (Herman, 1997). Substance abuse treatment counselors have an opportunity to help African American women with histories of trauma heal and recover. Creating safe, positive, supportive, therapeutic relationships between clients and professionals is essential.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Joan M. Blakey receive dissertation funding from SAMHSA, the Council on Social Work Education, Diversifying Faculty in Illinois, and The Center for Gender Studies at the University of Chicago.

Author Biographies

Joan M. Blakey, MSW, PhD, is an associate professor and department chair in the Helen Bader School of Social Welfare’s Department of Social Work at the University of Wisconsin–Milwaukee. She received her PhD in social work from the University of Chicago. She received her master of social work and bachelor of science in African American studies, sociology, and youth studies degrees from the University of Minnesota–Twin Cities. Her practice and research experiences have primarily been with women and families with histories of trauma and substance abuse. Her primary research interests include trauma and substance abuse among women who are involved with the child protection and criminal justice systems. She is interested in understanding the process of healing from trauma, creating trauma-informed systems of care, and testing the effectiveness of trauma-informed interventions.

Kimberly B. Grocher, MSW, MA, LCSW, is a doctoral student at Fordham University. She also is a staff associate in psychiatry, Weill Cornell Medical College. She has extensive experience working with women who have histories of trauma in private practice.

References

Alim

T. N.

Charney

D. S.

Mellman

T. A.

(2006). An overview of posttraumatic stress disorder in African Americans. Journal of Clinical Psychology, 62, 801-813.

Amaro

Dai

Arevalo

Acevedo

Matsumoto

Nieves

Prado

(2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban community-based substance abuse treatment. Journal of Urban Health, 84, 508-522. doi:10.1007/s11524-007-9160-z

Amodeo

Griffin

M. L.

Fassler

I. R.

Clay

C. M.

Ellis

M. A.

(2006). Childhood sexual abuse among Black women and White women from two-parent families. Child Maltreatment, 11, 237-246.

Areán

P. A.

Alvidrez

Nery

Estes

Linkins

(2003). Recruitment and retention of older minorities in mental health services research. The Gerontologist, 43, 36-44.

Barber

J. P.

Gallop

Crits-Christoph

Frank

Thase

M. E.

Weiss

R. D.

Beth Connolly Gibbons

(2006). The role of therapist adherence, therapist competence, and alliance in predicting outcome of individual drug counseling: Results from the National Institute Drug Abuse Collaborative Cocaine Treatment Study. Psychotherapy Research, 16, 229-240.

Bedi

Davis

Williams

(2005). Critical incidents in the formation of the therapeutic alliance from the client’s perspective. Psychotherapy: Theory, Research, Practice, Training, 42, 311-323.

Blakey

J. M.

Bowers

P. H.

(2014). Barriers to integrated treatment of substance abuse and trauma among women. Journal of Social Work Practice in the Addictions, 14, 250-272.

Blakey

J. M.

Hatcher

S. S.

(2013). Trauma and substance abuse among child welfare involved African American mothers: A case study. Journal of Public Child Welfare, 7, 194-216.

Breshears

E. M.

Yeh

Young

N. K.

(2009). Understanding substance abuse and facilitating recovery: A guide for child welfare workers. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

10.

Center for Substance Abuse Treatment. (2009). Substance Abuse Treatment: Addressing the Specific Needs of Women (Treatment Improvement Protocol [TIP] Series, No. 51, HHS Publication No. [SMA] 15-4426). Rockville, MD: Center for Substance Abuse Treatment. Retrieved from http://store.samhsa.gov/shin/content/SMA15-4426/SMA15-4426.pdf

11.

Clayton

P. H.

Bringle

R. G.

Senor

Huq

Morrison

(2010). Differentiating and assessing relationships in service-learning and civic engagement: Exploitative, transactional, or transformational. Michigan Journal of Community Service Learning, 16, 5-22.

12.

Cohen

L. R.

Hien

D. A.

(2006). Treatment outcomes for women with substance abuse and PTSD who have experienced complex trauma. Psychiatric Services, 57, 100-106.

13.

Connors

G. J.

Carroll

K. M.

DiClemente

C. C.

Longabaugh

Donovan

D. M.

(1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65, 588-598.

14.

Copeland

M. E.

(2002). Dealing with the effects of trauma—A self-help guide. Washington, DC: U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services.

15.

Courtois

C. A.

Ford

J. D

. (2013). Treatment of complex trauma: A sequenced, relationship-based approach. New York, NY: Guilford Press.

16.

Covington

S. S.

Burke

Keaton

Norcott

(2008). Evaluation of a trauma-informed and gender-responsive intervention for women in drug treatment. Journal of Psychoactive Drugs, 40(Suppl. 5), 387-398.

17.

Duffey

Somody

(2011). The role of relational-cultural theory in mental health counseling. Journal of Mental Health Counseling, 33, 223-242.

18.

Elliott

D. E.

Bjelajac

Fallot

R. D.

Markoff

L. S.

Reed

B. G.

(2005). Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. Journal of Community Psychology, 33, 461-477.

19.

Enos

Morton

(2003). Developing a theory and practice of campus community partnerships. In Jacoby

& Associates (Eds.), Building partnerships for service-learning (pp. 20-41). San Francisco, CA: Jossey-Bass, John Wiley & Sons.

20.

Farley

Golding

J. M.

Young

Mulligan

Minkoff

J. R.

(2004). Trauma history and relapse probability among patients seeking substance abuse treatment. Journal of Substance Abuse Treatment, 27, 161-167.

21.

Fereday

Muir-Cochrane

(2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5, 1-11.

22.

Flora

Stalikas

(2013) Factors affecting substance abuse treatment across different treatment phases. International Journal of Psychosocial Rehabilitation, 18, 27-42.

23.

Gibbons

C. J.

Nich

Steinberg

Roffman

R. A.

Corvino

Babor

T. F.

Carroll

K. M.

(2010). Treatment process, alliance and outcome in brief versus extended treatments for marijuana dependence. Addiction, 105, 1799-1808.

24.

Gillham

(2000). Case study research methods. New York, NY: Continuum.

25.

Goldmann

Aiello

Uddin

Delva

Koenen

Gant

L. M.

Galea

(2011). Pervasive exposure to violence and posttraumatic stress disorder in a predominantly African American Urban Community: the Detroit Neighborhood Health Study. Journal of Traumatic Stress, 24, 747-751.

26.

Gutierrez

L. M.

Parsons

Cox

(1998). Empowerment in social work practice: A sourcebook. Pacific Grove, CA: Brooks Cole.

27.

Harrell

(2011). Black victims of violent crime. Bureau of Justice Statistics Special Report (Report No. NCJ 214258). Retrieved from http://www.bjs.gov/content/pub/pdf/bvvc.pdf

28.

Hartzler

Witkiewitz

Villarroel

Donovan

(2011). Self-efficacy change as a mediator of associations between therapeutic bond and one-year outcomes in treatments for alcohol dependence. Psychology of Addictive Behaviors, 25, 269-278.

29.

Herman

(1997). Trauma and recovery: The aftermath of violence-from domestic abuse to political terror. New York, NY: Basic Books.

30.

Ilgen

M. A.

McKellar

Moos

Finney

J. W.

(2006). Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder. Journal of Substance Abuse Treatment, 31, 157-162.

31.

Joe

G. W.

Simpson

D. D.

Dansereau

D. F.

Rowan-Szal

G. A.

(2001). Relationships between counseling rapport and drug abuse treatment outcomes. Psychiatric Services, 52, 1223-1229.

32.

Jordan

J. V.

(2004a). Towards competence and connection. In Jordan

J. V.

Hartling

L. M.

Walker

(Eds.), The complexity of connection: Writings from the Stone Center’s Jean Baker Miller training institute (pp. 11-27). New York, NY: Guilford Press.

33.

Jordan

J. V.

(2004b). Relational resilience. In Jordan

J. V.

Hartling

L. M.

Walker

(Eds.), The complexity of connection: Writings from the Stone Center’s Jean Baker Miller training institute (pp. 28-46). New York, NY: Guilford Press.

34.

Jordan

J. V.

(2008). Recent developments in relational-cultural theory. Women & Therapy, 31, 1-4. doi:10.1080/02703140802145540

35.

Liang

Williams

L. M.

Siegel

J. A.

(2006). Relational outcomes of childhood sexual trauma in female survivors a longitudinal study. Journal of Interpersonal Violence, 21, 42-57.

36.

Littauer

Sexton

Wynn

(2005). Qualities clients wish for in their clients. Scandinavian Journal of Caring Science, 19, 28-31.

37.

Marshall

S. K.

(2001). Do I matter? Construct validation of adolescents’ perceived mattering to parents and friends. Journal of Adolescence, 24, 473-490.

38.

Martin

D. J.

Garske

J. P.

Davis

M. K.

(2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450.

39.

Meier

P. S.

Barrowclough

Donmall

M. C.

(2005). The role of therapeutic alliance in the treatment of substance misuse: A critical review of the literature. Addiction, 100, 304-316.

40.

Miles

M. B.

Huberman

A. M.

(1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage.

41.

Miller

J. B.

Stiver

I. P.

(1997). The healing connection: How women form relationships in therapy and life. Boston, MA: Beacon Press.

42.

Orlinsky

D. E.

Ronnestad

M. H.

Willutzki

(2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In Lambert

M. J.

(Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307-389). New York, NY: Wiley.

43.

Padgett

D. K.

(2008). Qualitative methods in social work research (2nd ed.). New York, NY: Sage.

44.

Rosenbaum

Varvin

(2007). The influence of extreme traumatization on body, mind and social relations. International Journal of Psychoanalysis, 88, 1527-1542.

45.

Rosenberg

McCullough

B. C.

(1981). Mattering: Inferred significance and mental health among adolescents. Research in Community and Mental Health, 2, 163-182.

46.

Ruglass

L. M.

Miele

G. M.

Hien

D. A.

Campbell

A. N.

M. C.

Caldeira

Nunes

E. V.

(2012). Helping alliance, retention, and treatment outcomes: A secondary analysis from the NIDA Clinical Trials Network Women and Trauma Study. Substance Use & Misuse, 47, 695-707.

47.

Saakvitne

Gamble

Pearlman

Lev

(2000). Risking connections. Baltimore, MD: Sidran Traumatic Stress Institute.

48.

Sacks

J. Y.

McKendrick

Banks

(2008). The impact of early trauma and abuse on residential substance abuse treatment outcomes for women. Journal of Substance Abuse Treatment, 34, 90-100.

49.

Safran

J. D.

Muran

J. C.

(2000). Resolving therapeutic alliance ruptures: Diversity and integration. Journal of Clinical Psychology, 56, 233-243.

50.

Savage

Quiros

Dodd

Bonavota

(2007). Building trauma informed practices: Appreciating the impact of trauma in the lives of women with substance abuse and mental health problems. Journal of Social Work Practice in the Addictions, 7, 91-115.

51.

Shattell

M. M.

Starr

S. S.

Thomas

S. P.

(2007). “Take my hand, help me out”: Mental health service recipients’ experience of the therapeutic relationship. International Journal of Mental Health Nursing, 16, 274-284.

52.

Shenton

A. K.

(2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22, 63-75.

53.

Shin

H. C.

Marsh

J. C.

Cao

Andrews

C. M.

(2011). Client–provider relationship in comprehensive substance abuse treatment: Differences in residential and nonresidential settings. Journal of Substance Abuse Treatment, 41, 335-346.

54.

Simpson

Rowan-Szal

G. A.

Joe

G. W.

Best

Day

Campbell

(2009). Relating counselor attributes to client engagement in England. Journal of Substance Abuse Treatment, 36, 313-320.

55.

Wells

Klap

Koike

Sherbourne

(2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry, 158, 2027-2032.

56.

Yin

R. K.

(2009). Case study research: Design and methods (4th ed.). Thousand Oaks, CA: Sage.

57.

Zorzella

K. P.

Muller

R. T.

Classen

C. C.

(2014). Trauma group therapy: The role of attachment and therapeutic alliance. International Journal of Group Psychotherapy, 64, 24-47.