This document was printed from the website of the California Evidence-Based Clearinghouse for Child Welfare (CEBC), which you can access at http://www.cebc4cw.org/
This document was printed from the website of the California Evidence-Based Clearinghouse for Child Welfare (CEBC), which you can access at http://www.cebc4cw.org/
Child Welfare Outcomes: Child/family well-being
Type of Maltreatment: Emotional abuse, Exposure to domestic violence, Physical abuse, Physical neglect, and Sexual abuse
Target Population: Adults who have a history of trauma and/or substance abuse.
Brief Description:(The information in this program outline is provided by the program representative and edited by the CEBC staff.)
Seeking Safety has been rated by the CEBC in the area of Substance Abuse Treatment (Adult). Seeking Safety is a present-focused, coping skills therapy to help people attain safety from trauma and/or substance abuse. The treatment is available as a book, providing both client handouts and clinician guidelines. The treatment may be conducted in group or individual format; females and males; and in various settings (e.g., outpatient, inpatient, residential, home care, schools). Seeking Safety consists of 25 topics that can be conducted in any order and number. Examples of topics are Safety, Asking for Help, Setting Boundaries in Relationships, Healthy Relationships, Community Resources, Compassion, Creating Meaning, Discovery, Recovery Thinking, Taking Good Care of Yourself, Commitment, Coping with Triggers, Self-Nurturing, Red and Green Flags, and Life Choices. Since Seeking Safety is highly rated on the Scientific Rating Scale, information on available pre-implementation assessments, implementation tools, and fidelity measures was requested from the program representative. Please see the program's separate Implementation Information page for details.
The key principles of Seeking Safety are:
Seeking Safety offers 25 treatment topics, each with a clinician guide and client handouts. The seven interpersonal topics are:
The seven behavioral topics are:
The seven cognitive topics are:
In addition, four combination topics are:
Seeking Safety was designed to be conducted in a group.
Seeking Safety has been tested for use in a group setting.
Testing references:
Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O’Keefe, M., Rose, T., et al. (2007). Effectiveness of an integrated, trauma-informed approach to treating women with co-occurring disorders and histories of trauma: the Los Angeles site experience. Journal of Community Psychology, 35, 863-878.
Hien, D. A., et al. (in press). Effectiveness of behavior therapy groups for co-occurring PTSD and substance use disorders: Primary outcomes from the NIDA Clinical Trials Network “Women and Trauma” multi-site randomized control trial. Journal of Consulting and Clinical Psychology
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.
The recommended group size is: Seeking Safety groups can be any size from 2 to 50 people
Recommended intensity: The length and pacing of sessions are flexible: some programs conduct 1 hour once per week, others 1.5 hours twice a week, etc. The goal is to provide whatever is feasible in the setting.
Recommended duration: The model was designed for a high level of flexibility for different settings, clients, and clinicians. The model can be conducted as long or short as there is time for. For example, if one conducts it twice per week it will take about three months if one does all of the topics; if once per week it would take about six months; however, one does not have to do all the topics—any number can be done, based on time available.
Seeking Safety includes a homework component.
Description: Clients are asked to make a “commitment” of one thing they’ll do for their recovery prior to the next session (essentially homework); however, it is optional.
Seeking Safety is typically conducted in a(n): Community Agency, Hospital, Outpatient Clinic, Residential Care Facility, and School.
Seeking Safety was designed with a Parent Component.
Seeking Safety addresses the following presenting problems and symptoms: Trauma and/or substance abuse and has been used extensively with adults.
Seeking Safety was not designed with a Child Component.
Seeking Safety was not developed for children with developmental delays.
Seeking Safety has not been tested for children with developmental delays.
Seeking Safety has materials available in a language other than English.
Language(s) available:
French, German, Spanish, and Swedish. For information on which materials are available in these languages, please check on the program's website or contact the program representative (all contact information is listed at the bottom of this page).
There is a manual that describes how to implement this program.
There is training available for Seeking Safety.
Training contact: Note that training is not actually required to conduct Seeking Safety, but can be very helpful to introduce staff to the model, etc. Website: www.seekingsafety.org – Training section, Email: contactinfo@seekingsafety.org, Phone: 617-731-1501, Training Videos: www.seekingsafety.org – Order section.
Number of days/hours: Flexible; a typical training is either 1 day, 1.5 days, or 2 days, but any length is possible
Training is obtained: (a) Onsite training is common; and there is no limit on the number of attendees, so some programs set up a training and invite others from the region to attend. Training associates are available throughout the country. (b) Training videos are also an option, and (c) Phone consultation is also possible.
There currently are not additional qualified resources for training.
The typical resources for implementing Seeking Safety are: There are no space/room/AV requirements. The only things needed are copies of the program materials, which can be photocopied from the book by the clinician for use with his/her clients.
No specific degree or experience is required. The program has been led by social workers, psychologists, nurses, case managers, emergency workers, domestic violence advocates, paraprofessionals, mental health counselors, substance abuse counselors, and even has been done in peer-led version.
Seeking Safety is rated a "2 - Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one rigorous randomized controlled trial with a sustained effect of at least 6 months. For more information on the rating of a "2 - Supported by Research Evidence," please see the Scientific Rating Scale.
Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. (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.
Type of Study: Uncontrolled trial
Number of participants: 27
Population:
Location/Institution: Boston area
Summary: (To include comparison groups, outcomes, measures, notable limitations) In this study, outcome results were reported for 17 women outpatients who completed group modality Seeking Safety treatment, with 25 sessions over 3 months. Completion of the treatment was defined as six or more sessions (met by 63% of the 27 who enrolled). All the women met criteria for current substance dependence and PTSD. All had five or more lifetime traumas, with an average age of 7 at first trauma. Sixty-five percent of the sample had one or more co-occurring personality disorders. Forty-one percent had drug dependence, 41% alcohol dependence, and 18% both. Assessments were conducted at pre-treatment, post-treatment, and 3-month follow-up. Results showed significant improvements in substance use (both alcohol and drug), trauma-related symptoms, suicide risk, suicidal thoughts, social adjustment, family functioning, problem solving, depression, cognitions about substance use, and didactic knowledge related to the treatment. The only negative finding was a worsening of somatic symptoms (which may have been a function of substance withdrawal). Patients’ treatment attendance (67% of available sessions), alliance, and satisfaction were also very strong. Treatment completers were more impaired than dropouts, yet more engaged in the treatment. Results are limited however, due to the lack of a control group, external treatments the patients may have engaged in, multiple comparisons, and the lack of assessment on dropouts.
Length of post-intervention follow-up: 3 months.
Zlotnick C., Najavits L. M., & Rohsenow, D. J. (2003) A cognitive-behavioral treatment for incarcerated women with substance use disorder and posttraumatic stress disorder: Findings from a pilot study. Journal of Substance Abuse Treatment, 25, 99-105.
Type of Study: Uncontrolled trial
Number of participants: 17
Population:
Location/Institution: Rhode Island
Summary: (To include comparison groups, outcomes, measures, notable limitations) This was a study of 17 women in a minimum-security correctional setting, using group modality Seeking Safety treatment, with 25 sessions over 3 months. All participants met criteria for current PTSD and substance dependence, and all had histories of repeated physical abuse, sexual abuse, or both (with an average age of 8 at first trauma). The most common drug of choice was cocaine. All of the women who were offered treatment began treatment. The attendance rate was 83% of sessions, and measures of client satisfaction and alliance were high. Results showed that, of the 17 women, nine (53%) no longer met criteria for PTSD at the end of the three-month treatment; and at a follow-up three months later, 46% still no longer met criteria for PTSD. PTSD symptoms decreased significantly from pre-treatment to post-treatment, and this was maintained at the 3-month follow-up. During incarceration, random urinalysis showed none of the women using a substance. A follow-up six weeks after release from prison indicated that 29% were using an illegal substance, and at three months after release the rate was 35%. A significant decrease in drug and alcohol use, and legal problems was found from pre-treatment to both 6-weeks after release and 3-months after release. Recidivism rate (return to prison) was 33% at three month follow-up, a rate typical of this population.
Length of post-intervention follow-up: 3 months on PTSD and 6 weeks or 3 months after release for substance use.
Hien, D. A., Cohen L. R., Litt, L. C., Miele, G. M., & Capstick, C. (2004). Promising empirically supported treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry, 161, 1426-1432.
Type of Study: Randomized controlled trial
Number of participants: 107
Population:
Location/Institution: New York City
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study compared the efficacy of a manualized cognitive behavior therapy that addresses both posttraumatic stress disorder (PTSD) and substance abuse (Seeking Safety) with a manualized cognitive behavior therapy that addresses only substance abuse (Relapse Prevention) and with standard community care for the treatment of comorbid posttraumatic stress disorder (PTSD) and substance use disorder. One hundred and seven women from an urban, low-income population who had comorbid PTSD and substance use disorder were randomly assigned to receive one of the two kinds of cognitive behavior therapy or standard community treatment. Participants were recruited from both community and clinical populations and evaluated with structured clinical instruments. Forty-one women received Seeking Safety therapy, 34 received Relapse Prevention therapy, and 32 received standard community care. At the end of 3 months of treatment, participants in both Seeking Safety and Relapse Prevention had significant reductions in substance use, PTSD, and psychiatric symptoms, but community care participants worsened over time. Participants in both Seeking Safety and Relapse Prevention sustained experienced greater improvement in substance use and PTSD symptoms at 6-month and 9-month follow-ups than subjects in the community care group. Seeking Safety and Relapse Prevention are efficacious short-term treatments for low-income urban women with PTSD, substance use disorder, and other psychiatric symptoms.
Length of post-intervention follow-up: 6 months and 9 months.
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.
Type of Study: Controlled trial
Number of participants: 2,026 total across all sites (Seeking Safety at four of the nine study sites)
Population:
Location/Institution: National, multi-site
Summary: (To include comparison groups, outcomes, measures, notable limitations) Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the usual-care group. For substance use outcomes, no effect was found. The meta-analysis demonstrated small but statistically significant overall improvement in women's trauma and mental health symptoms in the intervention relative to the usual-care comparison condition. Analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement, whereas the delivery of numerous core services yielded less improvement relative to the comparison group. A few person-level characteristics were associated with increases or decreases in the intervention effect. These neither moderated nor supplanted the effects of integrated counseling. Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment.
Length of post-intervention follow-up: 12 months.
Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O'Keefe, M., Rose, T., et al. (2007). Effectiveness of an integrated trauma-informed approach to treating women with co-occurring disorders and histories of trauma. Journal of Community Psychology, 35, 863-878.
Type of Study: Controlled trial
Number of participants: 313
Population:
Location/Institution: Los Angeles
Summary: (To include comparison groups, outcomes, measures, notable limitations) Effectiveness of an integrated trauma-informed approach to treating women with co-occurring disorders and histories of trauma was evaluated. Baseline and 12-month assessments were completed by 136 intervention and 177 comparison group women. The intervention group received Seeking Safety, a trauma-specific group treatment focusing on safety and coping skills, in the context of integrated substance abuse and mental health services. The comparison group received similar services but not trauma-specific group treatment. Intervention women showed significantly better treatment retention over three months and greater improvement on posttraumatic stress symptoms and coping skills. Those who completed treatment improved more than those who discontinued on most outcomes. Improvements on symptoms of distress and drug problem severity were partially mediated by gains in coping skills.
Length of post-intervention follow-up: None.
Brown, V. B., Najavits, L. M., Cadiz, S., Finkelstein, N., Heckman, J. P., & Rechberger, E. (2007). Implementing an evidence-based practice: Seeking Safety group. Journal of Psychoactive Drugs, 39, 231-240.
Type of Study: Secondary analysis from controlled trial
Number of participants: 157 client, 32 clinicians
Population:
Location/Institution: Multisite (Los Angeles, Boston, New York City)
Summary: (To include comparison groups, outcomes, measures, notable limitations) Note: This study uses the same sample from Morrisey et al., above. This paper presents findings from a multi-site study on adopting and implementing Seeking Safety, for women with co-occurring disorders and experiences of physical and sexual abuse. It focused upon what implementation decisions different sites made to optimize the compatibility of Seeking Safety with the site’s needs and experiences and on issues posed by Rogers in the Diffusion of Innovations (1995) as relevant to successful diffusion of an innovative practice. A total of 157 clients and 32 clinicians reported on satisfaction with various aspects of the model. It also examined cross-site differences. Results show that Seeking Safety appears to be an intervention that clinicians perceive as highly relevant to their practice, and one that adds value. Clients perceive the treatment as uniquely touching on their needs in a way that previous treatments had not.
Length of post-intervention follow-up: Not applicable.
Desai, R.A., Harpaz-Rotem, I, Najavits, L.M., & Rosenheck, R.A. (2008).Treatment for homeless female veterans with psychiatric and substance abuse disorders: Impact of "Seeking Safety" on one-year clinical outcomes. Psychiatric Services, 59, 996-1003. & Desai, R. A. et al. (2009). Seeking Safety therapy: Clarification of results.Psychiatric Services, 60, 125.
Type of Study: Controlled trial
Number of participants: 450
Population:
Location/Institution: National, multisite
Summary: (To include comparison groups, outcomes, measures, notable limitations) Seeking Safety is a manualized cognitive-behavioral therapy designed to treat clients with comorbid substance abuse and trauma histories. In this study, it was applied to homeless women veterans with psychiatric and/or substance abuse problems at eleven Homeless Women Veterans Programs. The intervention consists of 25 sessions that cover topics to help build safety in clients’ lives and is present-focused, offering psycho-education and coping skills. A cohort of homeless women veterans (phase I, n=359) was recruited before Seeking Safety was implemented. After clinicians were trained and certified in Seeking Safety a post-implementation cohort (phase II, n=91) was recruited and offered Seeking Safety treatment. All participants were interviewed every three months for one year and received intensive case management and other services during the study. Mixed models were used to compare one-year clinical outcomes across phases. At baseline, there were few differences between groups. All women entering the program showed significant improvement on most clinical outcome measures. The Seeking Safety cohort reported significantly better outcomes over one year in employment, social support, general symptoms of psychiatric distress, and symptoms of PTSD, particularly avoidance and arousal clusters. Seeking Safety appears to have had a moderately beneficial impact on several clinical outcomes. While the non-equivalent comparison groups and low follow-up rates limit the internal validity [glossary] of these results, availability of Seeking Safety may be of benefit for homeless female veterans. It is noteworthy that it could be delivered and implemented by case managers with little or no prior counseling experience. The correction to this article provides end-of-treatment outcomes (at six months) and major loss during follow-up. In sum, at the end of treatment, participants in both Seeking Safety and the comparison condition evidenced consistent and positive outcomes on substance use and related areas. On 2 of 12 outcomes, differences between conditions favored the Seeking Safety intervention. Later time points (nine and 12 months) were a follow-up period for Seeking Safety, and sample attrition [glossary] was substantial (the majority of the Seeking Safety sample was not assessed.
Length of post-intervention follow-up: 3 months and 6 months.
Najavits, L. M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford.
Najavits, L. M. (2007). Seeking Safety: An evidence-based model for substance abuse and trauma/PTSD. In K. A. Witkiewitz & G. A. Marlatt (Eds.), Therapist's guide to evidence-based relapse prevention: Practical resources for the mental health professional (pp. 141-167). San Diego: Elsevier Press.
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. The Journal of Behavioral Health Services & Research, 33, 453-463.
Contact name: Lisa M. Najavits, PhD
Affiliation/Agency: Treatment Innovations
Email: info@seekingsafety.org
Phone: 617-731-1501
Fax: 617- 701-1295
Website: http://www.seekingsafety.org