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Seeking Safety

Seeking Safety is a present-focused treatment for clients with a history of trauma and substance abuse. The treatment was designed for flexible use: group or individual format, male and female clients, and a variety of settings (e.g., outpatient, inpatient, residential). Seeking Safety focuses on coping skills and psychoeducation and has five key principles: (1) safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions); (2) integrated treatment (working on both posttraumatic stress disorder (PTSD) and substance abuse at the same time); (3) a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse; (4) four content areas: cognitive, behavioral, interpersonal, and case management; and (5) attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues).

Descriptive Information

Areas of Interest	Mental health treatment Substance abuse treatment Co-occurring disorders
Outcomes	Review Date: October 2006 1: Substance use 2: Trauma-related symptoms 3: Psychopathology 4: Treatment retention
Outcome Categories	Alcohol Drugs Mental health Trauma/injuries Treatment/recovery
Ages	13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Inpatient Residential Outpatient
Geographic Locations	No geographic locations were identified by the developer.
Implementation History	Since 1992, Seeking Safety has been implemented in more than 3,000 clinical settings and as part of statewide initiatives in Connecticut, Hawaii, Oregon, Texas, and Wyoming. It has been implemented in programs for substance abuse, mental health, domestic violence, homelessness, women and children, and veterans and in correctional, medical, and school settings in the United States and internationally, including in Argentina, Australia, Canada, France, Germany, Italy, Japan, the Netherlands, New Zealand, Scotland, and Sweden.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	Seeking Safety has been tested with dually diagnosed women, men, and adolescent girls. Samples have included clients in outpatient and residential settings, low-income urban women, incarcerated women, and veterans (both men and women). The treatment manual is available in both English and Spanish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Review Date: October 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Hien, D. A., Cohen, L. R., Miele, G. M., Litt, L. C., & Capstick, C. (2004). Promising treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry, 161, 1426-1432.

Study 2

Holdcraft, L. C., & Comtois, K. A. (2002). Description of and preliminary data from a women's dual diagnosis community mental health program. Canadian Journal of Community Mental Health, 21, 91-109.

Study 7

Weller, L. A. (2005). Group therapy to treat substance use and traumatic symptoms in female veterans. Federal Practitioner, 27-38.

Study 8

Zlotnick, C., Najavits, L. M., Rohsenow, D. J., & Johnson, D. M. (2003). A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: Findings from a pilot study. Journal of Substance Abuse Treatment, 25, 99-105.

Supplementary Materials

Cook, J. M., Walser, R. D., Kane, V., Ruzek, J. I., & Woody, G. (2006). Dissemination and feasibility of a cognitive-behavioral treatment for substance use disorders and posttraumatic stress disorder in the Veterans Administration. Journal of Psychoactive Drugs, 38, 89-92.

Najavits, L. M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press.

Poster of the Safe Coping Skills

Seeking Safety Adherence Scale and Score Sheet

Video Training Series on Seeking Safety

Outcomes

Outcome 1: Substance use
Description of Measures	Substance use was indicated by urinalysis. Some studies used the Substance Use Inventory, a self-report of quantity and frequency over the past week. Outcomes were based on mean rating of use over previous 4 weeks. One study used the Clinical Global Impression (CGI), a 7-point interviewer-rated scale characterizing abuse severity and improvement. Some studies used the Addiction Severity Index (ASI) self-report of problem severity in last 30 days. One study with adolescent girls used the Personal Experiences Inventory.
Key Findings	A randomized controlled trial of 107 women assessed the severity of substance use in participants assigned to Seeking Safety, Relapse Prevention, or a usual care control condition. Compared with women in the usual care control condition, women who participated in Seeking Safety significantly reduced their substance use at the end of treatment (p < .001) and at the 6-month follow-up (p < .05). In a randomized controlled trial with 33 adolescent girls, Seeking Safety participants significantly improved on 7 of 10 Personal Experience Inventory subscales compared with participants who received usual care (p < .05), with effect sizes that ranged from small (Cohen's d = 0.37) to large (Cohen's d = 1.17). At the 3-month follow-up assessment, Seeking Safety participants continued to show a significant improvement on the Loss of Control subscale (p < .05), with a small effect size (Cohen's d = 0.37). In five studies with small samples and no control groups, Seeking Safety participants showed pre- to posttreatment reductions in substance use (p < .05). In one of the five studies, Seeking Safety participants significantly increased their substance abstinence (p < .008). In another study, weekly urinalyses suggested that three of five participants were abstinent throughout treatment. In a study of incarcerated women, 11 of 17 participants in the Seeking Safety program did not report using drugs 3 months after release.
Studies Measuring Outcome	Study 1, Study 2, Study 3, Study 4, Study 5, Study 6, Study 7, Study 8
Study Designs	Experimental, Preexperimental
Quality of Research Rating	2.1 (0.0-4.0 scale)

Outcome 2: Trauma-related symptoms
Description of Measures	In some studies, trauma-related symptoms were measured using the Clinician-Administered Post Traumatic Stress Disorder Scale, a structured clinical interview that assesses frequency, intensity, severity of DSM-IV PTSD symptoms and impact of symptoms on social and occupational functioning. The Impact of Event Scale, a 15-item self-report of symptoms of intrusion and avoidance, was used for some research. Other studies used the Posttraumatic Symptom Scale (PSS), a 17-item self-report that indicates frequency of problems following a traumatic event. Some studies used the Trauma Symptom Checklist 40, a self-report measure. The Clinician-Administered PTSD Scale was used to determine lifetime and current diagnosis of PTSD, and intensity and severity of symptoms in the last month for some studies. The World Assumptions Scale, a measure of cognitions related to PTSD, was also used.
Key Findings	In a study that randomly assigned 107 women to Seeking Safety, Relapse Prevention, or a usual care control condition, the Seeking Safety participants showed a significant improvement on measures of trauma symptoms compared with usual care participants at the end of treatment (p < .01), at the 6-month follow-up (p < .05), and at the 9-month follow-up (p < .05). Among those participants with severe baseline trauma-related symptoms, 30% of Seeking Safety participants experienced a moderately improved to a better level of functioning at the 12-month follow-up compared with their baseline pretreatment assessment. By contrast, only 21% of the participants in the usual care control group experienced an improvement in trauma-related symptoms at the 12-month follow-up. Thoughts related to PTSD also decreased in the Seeking Safety participants compared with the usual care participants. In a randomized controlled trial with a sample of 33 adolescent girls, those in Seeking Safety had fewer sexual concerns (p = .002) and less sexual distress (p < .001) 2 months after intake compared with the girls in the usual care control condition. In a study of incarcerated women, 9 of 17 participants in Seeking Safety no longer met the diagnostic criteria for PTSD at the end of treatment. The Seeking Safety sample as a whole showed significant decreases in PTSD symptoms from pre- to posttreatment (p = .002) and from pretreatment to 3 months after release (p = .04). A pilot study of 17 women exposed to Seeking Safety also showed decreases in trauma-related symptoms from pre- to posttreatment (p < .05). In three additional studies with small samples and no control groups, Seeking Safety participants showed a pre- to posttreatment reduction in PTSD symptoms. In a study of veterans exposed to the Seeking Safety program, PTSD symptoms on the PTSD Checklist decreased significantly from pre- to posttreatment. This study on male veterans who participated in Seeking Safety also showed significant decreases in trauma-related symptoms.
Studies Measuring Outcome	Study 1, Study 3, Study 4, Study 5, Study 6, Study 8
Study Designs	Experimental, Preexperimental
Quality of Research Rating	2.3 (0.0-4.0 scale)

Outcome 3: Psychopathology
Description of Measures	In some studies, psychopathology was measured by the Global Assessment Scale of overall psychiatric functioning and impairment in the last 4 weeks. Some studies used the Brief Symptom Inventory (BSI) of general psychiatric symptoms. One study used psychiatric hospitalizations as well as responses to the Suicidal Behaviors Questionnaire as indications of psychopathology. Some studies assessed depression with the Hamilton Depression Rating Scale or the Beck Depression Inventory II. Adolescents were assessed with the Adolescent Psychopathology Scale (APS), 346 items on DSM disorders and psychosocial problems.
Key Findings	In a study that randomly assigned 107 women to Seeking Safety, Relapse Prevention, or a usual care control condition, Seeking Safety participants improved on measures of psychopathology from pre- to posttreatment (p < .01), whereas participants in the control condition worsened. At the 6- and 9-month follow-up assessments, Seeking Safety participants continued to show better functioning, but the difference was not statistically significant. In a study examining 12-month follow-up outcomes for women in Seeking Safety or treatment as usual, those in Seeking Safety improved more (p < .001), with a small effect size (Cohen's d = 0.18). In a randomized controlled trial of 33 adolescent girls, those in Seeking Safety showed greater improvement in their symptoms of anorexia, somatization, and major depression compared with the girls in the usual care control group. The effect sizes for anorexia (Cohen's d = 2.02) and somatization (Cohen's d = 1.27) were large, while the effect size for major depression (Cohen's d = 0.40) was small. A variety of improvements were found for Seeking Safety participants in three pilot studies. A sample of five dually diagnosed men improved pre- to posttreatment on the Global Assessment of Functioning (p < .02). A sample of women in a community mental health program showed pre- to posttreatment improvements in clinicians' ratings of psychiatric functioning (p < .01). In a pilot study of Seeking Safety, 17 women showed pre- to posttreatment reductions in suicidal thoughts and risk for future suicide.
Studies Measuring Outcome	Study 1, Study 2, Study 3, Study 4, Study 5, Study 6, Study 7
Study Designs	Experimental, Preexperimental
Quality of Research Rating	2.1 (0.0-4.0 scale)

Outcome 4: Treatment retention
Description of Measures	Treatment retention was measured by clinicians' records.
Key Findings	In a study of dually diagnosed men, all 5 participants completed 30 of 30 Seeking Safety sessions. In a pilot study of Seeking Safety, 17 of 27 women completed treatment (attended 6 or more sessions). In a study of adolescent girls, the average attendance was 11.78 of 25 sessions.
Studies Measuring Outcome	Study 4, Study 5, Study 6
Study Designs	Experimental, Preexperimental
Quality of Research Rating	2.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult)	100% Female	42.1% Black or African American 37.4% White 19.6% Hispanic or Latino 0.9% Race/ethnicity unspecified
Study 2	18-25 (Young adult) 26-55 (Adult)	100% Female	80% White 15% Black or African American 5% Asian
Study 3	26-55 (Adult)	100% Female	50% White 25% Black or African American 17% Hispanic or Latino 7% Race/ethnicity unspecified
Study 4	13-17 (Adolescent)	100% Female	78.8% White 12.1% Asian 3% Black or African American 3% Hispanic or Latino 3% Race/ethnicity unspecified
Study 5	26-55 (Adult)	100% Male	100% White
Study 6	26-55 (Adult)	100% Female	88.2% White 11.8% Black or African American
Study 7	26-55 (Adult)	100% Female	83.3% White 16.7% American Indian or Alaska Native
Study 8	26-55 (Adult)	100% Female	66.7% White 16.7% Race/ethnicity unspecified 11.1% Black or African American 5.6% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Substance use	2.3	2.3	2.3	2.0	1.6	2.0	2.1
2: Trauma-related symptoms	2.7	2.7	2.9	2.0	1.8	2.1	2.3
3: Psychopathology	2.4	2.4	2.1	2.0	1.7	2.1	2.1
4: Treatment retention	2.0	2.0	3.4	2.2	1.9	1.9	2.2

Study Strengths

Findings were consistently positive in a variety of domains. Some studies showed very careful attention to fidelity.

Study Weaknesses

Some studies used convenience samples. Sample size was often small, making it difficult to rule out confounds or make statistical inferences.

Readiness for Dissemination

Review Date: October 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Najavits, L. (2000). Training clinicians to conduct the Seeking Safety treatment for PTSD and substance abuse. Alcoholism Treatment Quarterly, 18, 83-98.

Najavits, L. (2002). Seeking Safety: A new psychotherapy for posttraumatic stress disorder and substance use disorder. In P. Ouimette & P. Brown (Eds.), Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders (pp. 147-170). Washington, DC: American Psychological Association Press.

Najavits, L. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press.

Najavits, L. (2004). Implementing Seeking Safety therapy for PTSD and substance abuse: Clinical guidelines. Alcoholism Treatment Quarterly, 22(1), 43-62.

Najavits, L. (2005). A client's story: Teaching grounding to a client [VHS].

Najavits, L. (2005). Example of a group session: Asking for help [VHS].

Najavits, L. (2005). Seeking Safety: Therapy for trauma/PTSD and substance abuse [VHS].

Najavits, L. (2005). Session for Adherence Scale rating: Healthy Relationships [VHS].

Najavits, L. (2006). Seeking Safety. In V. Follette & J. Ruzek (Eds.), Cognitive-Behavioral Therapies for Trauma (2nd ed.) (pp. 228-257). New York: Guilford Press.

Seeking Safety Web site, http://www.seekingsafety.org

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
4.0	4.0	3.9	4.0

Dissemination Strengths

Implementation materials are intended to be used by clinicians, though the written materials, Web site information, video tapes, and classes could also be useful for trainees. The program Web site provides detailed information on available trainings and discusses available on-site and telephone consultation. An adherence scale is provided to support quality assurance. Intervention adherence is reviewed as part of the offered consultation.

Dissemination Weaknesses

Little information on organizational implementation guidance was provided for review. Links are provided on the Web site to direct users to possible ways of measuring outcomes; however, no specific guidance is provided on some universal measures, nor on how to measure outcomes related to the model.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Manual	$46 each	Yes
Poster of safe coping skills	$16 each	No
Card deck of safe coping skills	$16 each	No
Training videos	$250 per set	No
1- , 1.5- , or 2-day, on-site training	About $1,600 per day depending on site needs and trainer selected, plus travel expenses	No
Telephone consultation	About $115 per hour depending on site needs	No
Adherence scale	Free	No

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

* Hien, D. A., Cohen, L. R., Miele, G. M., Litt, L. C., & Capstick, C. (2004). Promising treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry, 161, 1426-1432.

* Holdcraft, L. C., & Comtois, K. A. (2002). Description of and preliminary data from a women's dual diagnosis community mental health program. Canadian Journal of Community Mental Health, 21, 91-109.

* Morrissey, J. P., Jackson, E. W., Ellis, A. R., Amaro, H., Brown, V. B., & Najavits, L. M. (2005). Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services, 56, 1213-1222.

* Najavits, L. M., Gallop, R. J., & Weiss, R. D. (2006). Seeking Safety therapy for adolescent girls with PTSD and substance use disorder: A randomized controlled trial. Journal of Behavioral Health Services & Research, 33, 453-463.

* Najavits, L. M., Schmitz, M., Gotthardt, S., & Weiss, R. D. (2005). Seeking Safety plus exposure therapy: An outcome study on dual diagnosis men. Journal of Psychoactive Drugs, 37, 425-435.

* Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. R. (1998). "Seeking Safety": Outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. Journal of Traumatic Stress, 11, 437-456.

* Weller, L. A. (2005). Group therapy to treat substance use and traumatic symptoms in female veterans. Federal Practitioner, 27-38.

* Zlotnick, C., Najavits, L. M., Rohsenow, D. J., & Johnson, D. M. (2003). A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: Findings from a pilot study. Journal of Substance Abuse Treatment, 25, 99-105

Contact Information

To learn more about implementation or research, contact:
Lisa M. Najavits, Ph.D.
(617) 731-1501
Lnajavits@hms.harvard.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):

http://www.seekingsafety.org