Seeking Safety
Seeking Safety is a present-focused coping skills model for clients with a history of trauma and/or 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 psychoeducation and coping skills 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
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Areas of Interest
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Mental health treatment
Substance use disorder treatment
Co-occurring disorders
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Outcomes
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1: Drug use
2: Symptom severity of psychological distress
3: Employment
4: Posttraumatic stress symptoms
5: Perceived social support
1: Substance use
2: Trauma-related symptoms
3: Psychopathology
4: Treatment retention
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Outcome Categories
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Alcohol
Drugs
Employment
Mental health
Social functioning
Trauma/injuries
Treatment/recovery
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Ages
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13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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Genders
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Male
Female
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Races/Ethnicities
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American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
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Settings
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Inpatient
Residential
Outpatient
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Geographic Locations
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Urban
Suburban
Rural and/or frontier
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Implementation History
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Seeking Safety has been implemented in more than 15,000 clinical settings and as part of numerous state- and county-wide initiatives. It has been implemented in programs for substance abuse, mental health, domestic violence, homelessness, women and children, military 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, the United Kingdom, and Sweden. It has been implemented by peers, paraprofessionals, case managers, domestic violence advocates, as well as all types of professionals. No specific degree or experience level is required.
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NIH Funding/CER Studies
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Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
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Adaptations
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Seeking Safety has been tested with co-occurring disorders samples of 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). Seeking Safety materials have been translated into English, Spanish, French, German, Dutch, Polish, Chinese, Swedish, Vietnamese, Italian, and Portuguese; and Japanese and Greek are set for release.
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Adverse Effects
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No adverse effects, concerns, or unintended consequences were identified by the developer.
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IOM Prevention Categories
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IOM prevention categories are not applicable.
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Quality of Research
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 1Boden, M. T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., et al. Seeking Safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction, 107(3), 578-586. Study 2Desai, R. A., Harpaz-Rotem, I., Najavits, L. M., & Rosenheck, R. A. Impact of the Seeking Safety program on clinical outcomes among homeless female veterans with psychiatric disorders. Psychiatric Services, 59(9), 996-1003.
Desai, R. A., Harpaz-Rotem, I., Najavits, L. M., & Rosenheck, R. A. Seeking Safety therapy: Clarification of results [Letter to the editor]. Psychiatric Services, 60(1), 125.
Supplementary Materials Hwang, S. W., Kirst, M. J., Chiu, S., Tolomiczenko, G., Kiss, A., Cowan, L., et al. Multidimensional social support and the health of homeless individuals. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 86(5), 791-803.
McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al. The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9(3), 199-213.
Miele, G., Ball, S., Cohen, L., Hatch-Maillette, M., Hodgkins, C., Jiang, H., et al. Counselor and supervisor training and fidelity in a multi-site psychotherapy study for women with trauma and addictions. Unpublished manuscript.
Najavits, L. M., & Hien, D. Helping vulnerable populations: A comprehensive review of the treatment outcome literature on substance use disorder and PTSD. Journal of Clinical Psychology, 69(5), 433-479.
Seeking Safety Adherence Scale (Version 3), Adherence Scale Score Sheet (Version 3), and Format Worksheet
Outcomes
| Outcome 1: Drug use |
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Description of Measures
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Drug use was assessed using two measures:
- The Drug Use domain composite score from the Addiction Severity Index (ASI). The ASI is a clinician-administered, semistructured interview that measures types and severity of problems in seven domains: Drug Use, Alcohol Use, Medical, Employment and Financial Support, Legal Status, Family/Social Relations, and Psychiatric. A composite score ranging from 0 to 1 was generated for the Drug Use domain, with higher scores reflecting greater problem severity of drug use.
- The total days of drug use in the past 30 days. The total was calculated from the Drug Use domain of the ASI by summing the number of days in the past 30-day period that the respondent reported using any of the following drugs: heroin, methadone, or other opiates/analgesics; barbiturates, sedatives, hypnotics, or tranquilizers; cocaine; amphetamines; cannabis; hallucinogens; and inhalants.
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Key Findings
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A randomized clinical trial was conducted with male veterans who had co-occurring substance use disorder and full or partial PTSD according to DSM-IV criteria. Participants were stratified by partnered status (i.e., married, single, living with a significant other), Operation Enduring Freedom/Operation Iraqi Freedom participation, and use of illicit drugs. They were then randomly assigned by blocks within each stratification group to receive Seeking Safety groups twice weekly plus treatment as usual for 3 months or recovery groups twice weekly plus treatment as usual for 3 months . Treatment as usual consisted of at least three group therapy sessions, which were led by bachelor's- or master's-level therapists and social workers, with a focus on motivational enhancement and treatment engagement; in addition, each participant received a full intake assessment and treatment planning with individualized case management services and individual therapy sessions when indicated. The Seeking Safety groups were open (rolling admission) and each session covered one Seeking Safety topic, led by a trained Ph.D.-level psychologist. Participants in the recovery groups received group sessions that focused on building abstinence and maintaining abstinence. In addition to twice-weekly recovery group sessions over 3 months, participants in the recovery groups could attend groups on smoking cessation, sobriety support, cocaine recovery, alcohol recovery, dual diagnosis recovery, family therapy, anger management, cognitive behavioral therapy, fitness, relaxation, health education, hepatitis education, and developing outside activities. Participants in both study conditions also had individual case management sessions.
Participants were assessed at baseline (corresponding to the first day of treatment), at 3 months after baseline (corresponding to the end of the trial period), and at 6 months after baseline (corresponding to 3 months after the trial period). Findings included the following:
- From baseline to both 3 months and 6-months, participants who received Seeking Safety had lower ASI Drug Use domain composite scores than participants in the recovery groups (p < .05).
- Also from baseline to the 6-month follow-up, participants who received Seeking Safety had a greater reduction in total days of drug use in the past 30 days relative to participants in the recovery groups, who had an increase (5.1 to 3.1 days vs. 6.2 to 6.7 days; p < .05).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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3.3
(0.0-4.0 scale)
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| Outcome 2: Symptom severity of psychological distress |
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Description of Measures
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Symptom severity of psychological distress was assessed using two measures:
- The Global Severity Index (GSI) of the 30-item Symptom Checklist-Revised (SCL-30-R). The SCL-30-R is a self-report instrument that assesses the severity level of psychological distress across nine primary symptom dimensions: Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. Using a 5-point scale ranging from 1 (not at all) to 5 (extremely), respondents rate each item for past-month distress. The GSI score, which ranges from 1 to 5, was calculated as the average rating given across all 30 items, with higher scores indicating greater symptom severity of psychological distress.
- The Psychiatric domain composite score from the Addiction Severity Index (ASI). The ASI is a clinician-administered, semistructured interview that measures types and severity of problems in seven domains: Drug Use, Alcohol Use, Medical, Employment and Financial Support, Legal Status, Family/Social Relations, and Psychiatric. A composite score ranging from 0 to 1 was generated for the Psychiatric domain, with higher scores reflecting greater symptom severity of psychological distress.
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Key Findings
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A quasi-experimental study was conducted with female veterans who were homeless or at high risk of becoming homeless, had comorbid substance abuse and trauma histories, had psychiatric or addiction problems but were medically and psychiatrically stable, presented to programs for homeless women veterans at 11 Department of Veterans Affairs (VA) medical centers, and had not been receiving VA health services for more than 6 weeks at the time of study entry. The study included two successive treatment phases (conditions) of 6 months each. In the first phase (comparison condition), participants received transitional residential treatment with case management of variable length and level of services that were based on the needs of the participant (as determined from assessment and treatment referral) and the program offered at the VA site. Many of the VA sites also provided substance abuse counseling through program clinicians. In the second study phase (intervention condition), the same case managers who served in phase 1 of the study at the 11 VA sites were now trained and certified in Seeking Safety, and a cohort of participants enrolled in the programs for homeless women veterans, in which they received up to 25 sessions of Seeking Safety. The case managers had little or no prior training in conducting psychotherapy.
Participants were assessed at 3-month intervals that started at baseline (study entry) and continued to 12 months after baseline for each phase, and data were analyzed from baseline to 6 months (i.e., the end of each treatment phase) and from baseline to 12 months (i.e., 6 months after the end of each treatment phase). Findings included the following:
- From baseline to 6 months, the change in symptom severity of psychological distress (as reflected by the GSI score from the SCL-30-R and the ASI Psychiatric domain composite score) did not differ significantly between participants who received Seeking Safety and those in the comparison condition.
- From baseline to 12 months, relative to participants in the comparison condition, those who received Seeking Safety had lower GSI scores from the SCL-30-R (p = .034) and lower ASI Psychiatric domain composite scores (p = .026), after adjustment for baseline GSI scores from the SCL-30-R and ASI Psychiatric domain composite scores, number of days spent in residential treatment in the past 3 months, usual employment pattern in the past 3 years, 3 months, usual employment pattern in the past 3 years, age, and study dropout rate.
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Studies Measuring Outcome
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Study 2
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.8
(0.0-4.0 scale)
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| Outcome 3: Employment |
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Description of Measures
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Employment was assessed using the Employment domain from the Addiction Severity Index (ASI). The ASI is a clinician-administered, semistructured interview that measures types and severity of problems in seven domains: Drug Use, Alcohol Use, Medical, Employment and Financial Support, Legal Status, Family/Social Relations, and Psychiatric. Through the Employment domain, respondents indicated the number of days worked in the past 30 days.
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Key Findings
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A quasi-experimental study was conducted with female veterans who were homeless or at high risk of becoming homeless, had comorbid substance abuse and trauma histories, had psychiatric or addiction problems but were medically and psychiatrically stable, presented to programs for homeless women veterans at 11 Department of Veterans Affairs (VA) medical centers, and had not been receiving VA health services for more than 6 weeks at the time of study entry. The study included two successive treatment phases (conditions) of 6 months each. In the first phase (comparison condition), participants received transitional residential treatment with case management of variable length and level of services that were based on the needs of the participant (as determined from assessment and treatment referral) and the program offered at the VA site. Many of the VA sites also provided substance abuse counseling through program clinicians. In the second study phase (intervention condition), the same case managers who served in phase 1 of the study at the 11 VA sites were now trained and certified in Seeking Safety, and a cohort of participants enrolled in the programs for homeless women veterans, in which they received up to 25 sessions of Seeking Safety. The case managers had little or no prior training in conducting psychotherapy.
Participants were assessed at 3-month intervals that started at baseline (study entry) and continued to 12 months after baseline for each phase, and data were analyzed from baseline to 6 months (i.e., the end of each treatment phase) and from baseline to 12 months (i.e., 6 months after the end of each treatment phase).
Findings included the following:
- From baseline to 6 months, the change in number of days worked in the past 30 days did not differ significantly between participants who received Seeking Safety and those in the comparison condition.
- From baseline to 12 months, relative to participants in the comparison condition, those who received Seeking Safety had a greater number of days worked in the past 30 days (p = .002), after adjustment for baseline number of days worked in the past 30 days, baseline Global Severity Index scores from the 30-item Symptom Checklist-Revised, number of days spent in residential treatment in the past 3 months, usual employment pattern in the past 3 years, age, and study dropout rate.
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Studies Measuring Outcome
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Study 2
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.8
(0.0-4.0 scale)
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| Outcome 4: Posttraumatic stress symptoms |
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Description of Measures
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Posttraumatic stress symptoms were assessed using the military version of the Posttraumatic Stress Disorder Checklist (PCL-M), a 17-item self-report checklist of PTSD symptoms based on DSM-IV criteria that are referenced to a "stressful military experience." The PCL-M includes three subscales that measure the three symptom clusters of PTSD according to DSM-IV criteria: Avoidant/Numbing Behavior (7 items), Intrusive/Re-Experiencing Thoughts (5 items), and Hypervigilance/Hyper-Arousal (5 items). Respondents rate each item on a 5-point scale ranging from 1 (not at all) to 5 (extremely) to indicate the degree to which they have been bothered by the particular symptom over the past month. Examples of items include the following: "avoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it"; "repeated, disturbing memories, thoughts, or images of a stressful military experience"; "repeated, disturbing dreams of a stressful military experience"; and "having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience."
Each PCL-M subscale can be summed separately, with scores ranging from 7 to 35 for the Avoidant/Numbing Behavior subscale and 5 to 25 for both the Intrusive/Re-Experiencing Thoughts and Hypervigilance/Hyper-Arousal subscales. Higher scores indicate a more severe level of subscale symptoms. Total PCL-M scores range from 17 to 85, with higher scores indicating posttraumatic stress symptoms of greater severity; scores of 50 or higher suggest a probable diagnosis of combat-related PTSD by DSM-IV criteria.
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Key Findings
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A quasi-experimental study was conducted with female veterans who were homeless or at high risk of becoming homeless, had comorbid substance abuse and trauma histories, had psychiatric or addiction problems but were medically and psychiatrically stable, presented to programs for homeless women veterans at 11 Department of Veterans Affairs (VA) medical centers, and had not been receiving VA health services for more than 6 weeks at the time of study entry. The study included two successive treatment phases (conditions) of 6 months each. In the first phase (comparison condition), participants received transitional residential treatment with case management of variable length and level of services that were based on the needs of the participant (as determined from assessment and treatment referral) and the program offered at the VA site. Many of the VA sites also provided substance abuse counseling through program clinicians. In the second study phase (intervention condition), the same case managers who served in phase 1 of the study at the 11 VA sites were now trained and certified in Seeking Safety, and a cohort of participants enrolled in the programs for homeless women veterans, in which they received up to 25 sessions of Seeking Safety. The case managers had little or no prior training in conducting psychotherapy.
Participants were assessed at 3-month intervals that started at baseline (study entry) and continued to 12 months after baseline for each phase, and data were analyzed from baseline to 6 months (i.e., the end of each treatment phase) and from baseline to 12 months (i.e., 6 months after the end of each treatment phase).
Findings included the following:
- From baseline to 6 months, relative to participants in the comparison condition, those who received Seeking Safety had lower Avoidant/Numbing Behavior subscale scores (p = .0213), after adjustment for baseline Avoidant/Numbing Behavior subscale scores, baseline Global Severity Index (GSI) scores from the 30-item Symptom Checklist-Revised (SCL-30-R), number of days spent in residential treatment in the past 3 months, usual employment pattern in the past 3 years, age, and study dropout rate.
- From baseline to 12 months, relative to participants in the comparison condition, those who received Seeking Safety had lower total PCL-M scores (p = .027), lower Avoidant/Numbing Behavior subscale scores (p = .007), and lower Hypervigilance/Hyper-Arousal subscale scores (p = .039), after adjustment for baseline total PCL-M scores and Avoidant/Numbing Behavior and Hypervigilance/Hyper-Arousal subscale scores, baseline GSI scores from the SCL-30-R, number of days spent in residential treatment in the past 3 months, usual employment pattern in the past 3 years, age, and study dropout rate.
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Studies Measuring Outcome
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Study 2
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.9
(0.0-4.0 scale)
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| Outcome 5: Perceived social support |
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Description of Measures
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Perceived social support was assessed using three interview questions that measured perceived access to financial, instrumental, and emotional support through friends, family, neighbors, service providers, and clergy:
- "Suppose you needed a short-term loan of $100. Who, in the past 6 months, could you have counted on to give you the money (regardless of whether you would have accepted the loan)?"
- "Suppose you had an appointment but couldn't get there on your own and you didn't have a car. Who, in the last 6 months, could you have counted on to give you a ride (regardless of whether you would have accepted the ride)?"
- "Now, considering a more serious problem, suppose you were depressed or frustrated and felt like committing suicide. Who, in the last 6 months, could you have counted on to help you with those feelings?"
For each question, respondents answered "yes" or "no" to each of nine relationship categories: (1) spouse or significant other, (2) adult child, (3) parent, (4) brother or sister, (5) other family member, (6) friend or neighbor, (7) service provider, (8) clergy, and (9) other. The numbers of "yes" responses were summed across the three questions for a Total Social Support score, with higher scores indicating more perceived social support.
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Key Findings
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A quasi-experimental study was conducted with female veterans who were homeless or at high risk of becoming homeless, had comorbid substance abuse and trauma histories, had psychiatric or addiction problems but were medically and psychiatrically stable, presented to programs for homeless women veterans at 11 Department of Veterans Affairs (VA) medical centers, and had not been receiving VA health services for more than 6 weeks at the time of study entry. The study included two successive treatment phases (conditions) of 6 months each. In the first phase (comparison condition), participants received transitional residential treatment with case management of variable length and level of services that were based on the needs of the participant (as determined from assessment and treatment referral) and the program offered at the VA site. Many of the VA sites also provided substance abuse counseling through program clinicians. In the second study phase (intervention condition), the same case managers who served in phase 1 of the study at the 11 VA sites were now trained and certified in Seeking Safety, and a cohort of participants enrolled in the programs for homeless women veterans, in which they received up to 25 sessions of Seeking Safety. The case managers had little or no prior training in conducting psychotherapy.
Participants were assessed at 3-month intervals that started at baseline (study entry) and continued to 12 months after baseline for each phase, and data were analyzed from baseline to 6 months (i.e., the end of each treatment phase) and from baseline to 12 months (i.e., 6 months after the end of each treatment phase).
Findings included the following:
- From baseline to 6 months, relative to participants in the comparison condition, those who received Seeking Safety had a greater increase in Total Social Support scores (p < .0001), after adjustment for baseline Total Social Support scores, baseline Global Severity Index (GSI) scores from the 30-item Symptom Checklist-Revised (SCL-30-R), number of days spent in residential treatment in the past 3 months, usual employment pattern in the past 3 years, age, and study dropout rate.
- From baseline to 12 months, relative to participants in the comparison condition, those who received Seeking Safety had higher Total Social Support scores (p = .028), after adjustment for baseline Total Social Support scores, baseline GSI scores from the SCL-30-R, number of days spent in residential treatment in the past 3 months, usual employment pattern in the past 3 years, age, and study dropout rate.
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Studies Measuring Outcome
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Study 2
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Study Designs
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Quasi-experimental
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Quality of Research Rating
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2.7
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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26-55 (Adult)
55+ (Older adult)
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100% Male
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60.2% Black or African American
19.4% White
11.2% Race/ethnicity unspecified
7.1% Hispanic or Latino
2% American Indian or Alaska Native
0% Asian
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Study 2
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26-55 (Adult)
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100% Female
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51.8% Black or African American
35.1% White
6.9% Hispanic or Latino
6.2% Race/ethnicity unspecified
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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:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Drug use
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3.5
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3.4
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3.4
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3.0
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3.1
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3.7
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3.3
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2: Symptom severity of psychological distress
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3.8
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3.5
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3.2
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1.5
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2.0
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3.1
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2.8
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3: Employment
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3.6
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3.4
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3.2
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1.5
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2.0
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3.1
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2.8
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4: Posttraumatic stress symptoms
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3.8
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3.5
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3.2
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1.9
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2.1
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3.1
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2.9
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5: Perceived social support
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3.0
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2.8
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3.2
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2.0
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2.2
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3.1
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2.7
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Study Strengths The ASI is a well-known, clinician-administered interview instrument that has been used extensively for substance abuse treatment planning and outcome evaluation; it has established internal consistency and split-half and test-retest reliability, in addition to demonstrated content, criterion and construct validity. The SCL-30-R had excellent internal consistency in the study sample, and the PCL-M has been shown to have high internal consistency and test-retest reliability in veteran population samples. The PCL-M has construct validity for three factors--avoidant/numbing behavior, intrusive/re-experiencing thoughts, and hypervigilance/hyper-arousal--and correspond to DSM-IV symptom clusters for a PTSD diagnosis; it also has high convergent validity with other established and psychometrically strong, self-report PTSD symptom scales (e.g., Mississippi Scale for Combat-Related PTSD, Keane PTSD Scale of the Minnesota Multiphasic Personality Inventory-2, Impact of Event Scale-Revised, Clinician-Administered PTSD Scale for DSM-IV). Internal consistency was good for the social support measurement items in the study sample, and the social support items have face validity. The intervention is manual driven and was delivered by a Ph.D.-level psychologist in one study. In both studies, therapists were trained to mastery of the treatment manual, and sessions were audiotaped for subsequent review and fidelity scoring. In one study, 20% of taped treatment sessions were randomly selected and rated for fidelity using the previously validated Adherence Scale, and ongoing corrective feedback was provided. In the other study, the program developer provided on-site training to clinical case management therapists at the 11 sites implementing the intervention, and the therapists had to be certified by achieving a certain level of fidelity to the treatment manual before being permitted to deliver the intervention. A national clinical supervisor rated session audiotapes from each therapist at least once monthly, using the Adherence Scale, and provided corrective feedback to maintain fidelity and prevent therapist drift. In one study, participants were randomly assigned to conditions, which controlled for many potential confounding factors. One study carried out a prospective power analysis and included analyses of potential outcome mediators. The statistical modeling of the datasets in both studies was appropriate.
Study Weaknesses No biomarkers or collateral interview data were collected to validate the drug use outcome in one study. In the other study, there was no independent verification of the social support reports, despite participants and case managers knowing study condition assignment and case managers also assessing outcomes. In one study, attrition at the 6-month follow-up was moderate at 20% for the intervention condition and 29% for the comparison condition. In the other study, attrition was very large and differed significantly between study groups at the 9-month follow-up (60% for the intervention condition and 44% for the comparison condition) and 12-month follow-up (73% for the intervention condition and 47% for the comparison condition). One study had a quasi-experimental design with a pre-to-post nonequivalent comparison group, introducing potential order effects such as overall improvement of participants over time (treatment dose effects) and improved quality of treatment delivery (better overall counseling skills over time), which could account for some of the outcome differences between groups. It is not known what other community services may have been received by participants in the intervention and comparison conditions. Also in this study, case managers delivered services to participants in both conditions and collected the outcome data; therefore, therapist/assessor (experimenter) bias cannot be ruled out, nor can participant social desirability bias in self-reports be ruled out. In one study, most of the intervention sample was lost to follow-up at 12 months; because participants who have the most severe comorbid substance use disorder/PTSD symptomatology tend to drop out over time, the effect of a sample bias on the outcome findings cannot be ruled out.
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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 1Hien, D. A., Cohen, L. R., Miele, G. M., Litt, L. C., & Capstick, C.. Promising treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry, 161, 1426-1432. Study 2Holdcraft, L. C., & Comtois, K. A. 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 3Morrissey, J. P., Jackson, E. W., Ellis, A. R., Amaro, H., Brown, V. B., & Najavits, L. M. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services, 56, 1213-1222. Study 4Najavits, L. M., Gallop, R. J., & Weiss, R. D. Seeking Safety therapy for adolescent girls with PTSD and substance use disorder: A randomized controlled trial. Journal of Behavioral Health Services and Research, 33, 453-463. Study 5Najavits, L. M., Schmitz, M., Gotthardt, S., & Weiss, R. D. Seeking Safety plus exposure therapy: An outcome study on dual diagnosis men. Journal of Psychoactive Drugs, 37, 425-435. Study 6Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. R. "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. Study 7Weller, L. A. Group therapy to treat substance use and traumatic symptoms in female veterans. Federal Practitioner, 27-38. Study 8Zlotnick, C., Najavits, L. M., Rohsenow, D. J., & Johnson, D. M. 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. 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. 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 |
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Description of Measures
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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.
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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:
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
|
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.
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
|
4.0
|
4.0
|
Dissemination Strengths Implementation materials are clearly written and easy to use, and they include all that is needed to deliver the highly structured sessions in this intervention. The program manual is detailed in all aspects of implementation and includes all needed checklists and scripts for clinicians. The program Web site serves as a comprehensive and current resource for information on training events and support. Training opportunities are plentiful and can be tailored for individual site needs. The developer offers coaching and consultation beyond training in multiple formats. Consultation and training regarding fidelity and adherence guidelines are available for program supervisors. The developer offers resources and support for a range of outcome monitoring options.
Dissemination Weaknesses No weaknesses were identified by reviewers.
|
|
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.
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
|
|
Seeking Safety: A Treatment Manual for PTSD and Substance Abuse
|
$60 each
|
Yes
|
|
Safe Coping Skills card deck
|
$18 each
|
No
|
|
Grounding Skills keychain
|
$5 each
|
No
|
|
Safe Coping Skills poster (24 by 36 inches)
|
$18 each
|
No
|
|
Safe Coping Skills magnet
|
$4 each
|
No
|
|
Safe Coping Skills reminder list for clients (8.5 x 11 inches)
|
$1.50
|
No
|
|
Seeking Safety Training Series: 1--Seeking Safety (DVD)
|
$120 or $60 to rent each
|
No
|
|
Seeking Safety Training Series: 2--Example of a Group Session: Asking for Help (DVD)
|
$120 or $60 to rent each
|
No
|
|
Seeking Safety Training Series: 3--A Client's Story/Teaching Grounding (DVD)
|
$65 or $33 to rent each
|
No
|
|
Seeking Safety Training Series: 4--Adherence Rating Session: Healthy Relationships (DVD)
|
$65 or $33 to rent each
|
No
|
|
Seeking Safety Training DVDs (4-DVD set)
|
$330 per set or $110 to rent
|
No
|
|
Treatment/Innovations Facilitator Guide for Seeking Safety DVDs
|
$50 each
|
No
|
|
1-, 1.5-, or 2-day, on-site initial Seeking Safety Training
|
$2,200 per day (prorated for half day) for unlimited number of participants, plus travel expenses
|
No*
|
|
1-, 1.5-, or 2-day, Webinar-based initial Seeking Safety Training
|
$1,650 per day (prorated for half day) for unlimited number of participants
|
No
|
|
1-, 1.5-, or 2-day, off-site initial Seeking Safety Training
|
Varies depending on hosting agency
|
No
|
|
1-, 1.5-, or 2-day, on-site follow-up Seeking Safety Training, Supervisor Training, or Fidelity Rater Training
|
$2,200 per day (prorated for half day) for unlimited number of participants, plus travel expenses. Also, the Fidelity and/or Supervisor Training can be done by phone instead of onsite, using an hourly rate of $140/hour
|
No
|
|
Telephone-based implementation or evaluation consultation
|
$140 per hour for unlimited number of participants
|
No
|
|
1-hour, open theme-based consultation calls
|
Free for staff of Department of Veterans Affairs or Department of Defense
|
No
|
|
Session video or audio review and Adherence Scale completion by developer
|
$140 per hour for review, scoring, and follow-up phone conversation
|
No*
|
|
Online learning for Seeking Safety (6 total; 2 are for use with the Seeking Safety book; 4 are for use with the Seeking Safety Training DVDs)
|
available with ($170) or without CEUs ($120) for all 6
|
No
|
|
Quality assurance documents: Adherence Scale, Adherence Score Sheet, Brief Adherence Form, and Session Format Checklist
|
Free
|
No*
|
|
Articles on implementation and description of Seeking Safety (downloads from website)
|
Free
|
No
|
|
Teaching Guide to Introduce Seeking Safety to Your Agency
(online resource for use with the Seeking Safety Training DVDs
|
$70
|
No
|
|
Seeking Safety HIV Guide
|
$35
|
No
|
Additional Information
Asterisked materials in the Costs table are required for
formal research outcome studies only. VHS
copies of the Seeking Safety Training series are available at a 50% discount.
The developer and trainers are available to deliver plenary talks and half-day
workshops on a variety of Seeking Safety topics. Agencies that host training
can choose to have a closed training or an open training that is co-hosted with
Treatment Innovations. Certification in the program is available but is not
required except for research studies.
|