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Seeking Safety (Adult version)

Topic Areas
Scientific Rating
Child Welfare Relevance
Substance Abuse Treatment (Adult)
2  — Supported by Research Evidence
Medium
Trauma Treatment (Adult)
2  — Supported by Research Evidence
Medium

About This Program

Target Population: Adults who have a history of trauma and/or substance abuse

Program Overview

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; with 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 as many sessions as time allows, and in any order. 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. Seeking Safety is also rated on the CEBC in the Substance Abuse Treatment (Child & Adolescent) and Trauma Treatment - Client-Level Interventions (Child & Adolescent) topic areas, click here to go to this entry.

Program Goals

The primary goals of Seeking Safety are:

  • Reduce trauma and/or substance abuse symptoms
  • Increase safe coping in relationships
  • Increase safe coping in thinking
  • Increase safe coping in behavior
  • Increase safe coping in emotions

Logic Model

The program representative did not provide information about a Logic Model for Seeking Safety (Adult version).

Essential Components

The essential components of Seeking Safety include:

  • Individual or group intervention (if group, between 2 and 50 participants per group)
  • Five key principles:
    • Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions)
    • Integrated treatment (working on both trauma and substance abuse at the same time, if clients have both)
    • A focus on ideals to counteract the loss of ideals in both trauma and substance abuse
    • Four content areas: cognitive, behavioral, interpersonal, and case management
    • Attention to clinician processes (helping clinicians work on their emotional responses, self-care, and other issues)
  • 25 treatment topics, each with a clinician guide and client handouts:
    • Seven interpersonal topics:
      • Asking for Help
      • Honesty
      • Setting Boundaries in Relationships
      • Healthy Relationships
      • Community Resources
      • Healing from Anger
      • Getting Others to Support Your Recovery
    • Seven behavioral topics:
      • Detaching from Emotional Pain: Grounding
      • Taking Good Care of Yourself
      • Red and Green Flags
      • Commitment
      • Coping with Triggers
      • Respecting Your Time
      • Self-Nurturing
    • Seven cognitive topics:
      • PTSD: Taking Back Your Power
      • Compassion
      • When Substances Control You
      • Recovery Thinking
      • Integrating the Split Self
      • Creating Meaning
      • Discovery
    • Four combination topics:
      • Introduction to Treatment/Case Management
      • Safety
      • The Life Choices Game (Review)
      • Termination

Program Delivery

Adult Services

Seeking Safety (Adult version) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Trauma and/or substance abuse and coping skills

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. It has ranged from 20 minutes to two hours. The goal is to provide whatever is feasible in the setting and based on the modality (group or individual).

Recommended Duration:

The model was designed for a high level of flexibility for different settings, clients, and clinicians. The model can be conducted for as long or short as time allows. For example, if the goal is to do all 25 topics and it's conducted twice per week, it will take three months. But if the goal is to do 12 topics and it is conducted once per week, that would take three months as well. In general, the more sessions that can be done, the better, but research shows that positive outcomes have been found with as few as 6 sessions. If there is very limited time, such as on a detoxification unit, conducting even 1-3 sessions has value.

Delivery Settings

This program is typically conducted in a(n):

  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

Seeking Safety (Adult version) includes a homework component:

Clients are encouraged to make a "commitment" of one thing they'll do for their recovery prior to the next session (essentially homework); however, this is optional.

Languages

Seeking Safety (Adult version) has materials available in languages other than English:

Arabic, Chinese, Dutch, French, German, Greek, Italian, Japanese, Korean, Polish, Portuguese, Spanish, Swedish, Vietnamese

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

There are no space/room/audiovisual requirements. The only thing needed is a copy of the program materials, which can be photocopied from the Seeking Safety book by the clinician for use with their clients; there is also an electronic version for telehealth. Additional implementation materials are available, but are optional (see the Implementation Information section below).

Manuals and Training

Prerequisite/Minimum Provider Qualifications

No specific degree, license, training, 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, peers and peer support workers, and substance abuse counselors.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual information:

  • Najavits, L. M. (2002). Seeking Safety: A treatment manual for ptsd and substance abuse. The Guilford Press.

The manual is available as paperback or ebook online; see https://www.treatment-innovations.org/books.html.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Note: For clinical implementation, training is not required, but can be very helpful to teach staff how to conduct the model. However, for research studies on Seeking Safety, training and fidelity assessment are always required by a certified trainer who is listed on the Seeking Safety website.

The following training resources are available on the Seeking Safety website (www.seekingsafety.org) in the Order section:

  • Monthly 1-day training webinars that anyone can register for and attend
  • Training Videos: The Seeking Safety training videos were designed to provide an overview of the model, an example of a session conducted with real clients, and related implementation material. The series has 4 videos. They total 4.5 hours and were developed with a grant from the National Institute on Drug Abuse. The training videos can also be used in combination with the Teaching Guide described in the next bullet point.
  • Teaching Guide: The teaching guide allows a provider to introduce Seeking Safety to others in the agency. It is used with the training videos (above).
  • Training Online: The training videos (above) and/or Seeking Safety book can be combined with online learning, which can be done with continuing education credits or without.
  • Phone consultation: Phone consultation is available either on its own or with some other training type (such as after an onsite training ). Calls provide an opportunity to discuss Seeking Safety implementation and allow for open discussion as well as themes that we provide to help guide discussion (how to get started with Seeking Safety, challenging clinical scenarios, etc.)
  • Fidelity rater training and/or certification: Agency staff can be trained via telephone on how to conduct fidelity ratings and, within a few sessions, can obtain certification so they can rate other agency staff.
  • Supervisor training and/or certification: Agency staff can be trained via telephone on how to supervise on Seeking Safety and, within a few sessions, can obtain certification so they can rate other agency staff.
  • Conducting Seeking Safety certification: Agency staff can be certified in their conduct of Seeking Safety. This is required for research outcome studies and involves audio-recording actual sessions or role-played sessions, with feedback delivered via phone.
  • Additional materials: Optional client-engagement materials are available and include a card deck, magnet, key chain, and poster of the Safe Coping Skills from Seeking Safety. These materials are also available in Spanish and some are available in French..
Number of days/hours:

Flexible; a typical training is either 1 day, 1.5 days, or 2 days, but any length is possible.

Implementation Information

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Seeking Safety (Adult version).

Formal Support for Implementation

There is formal support available for implementation of Seeking Safety (Adult version) as listed below:

Formal support is optional for clinical implementation, but is required for research that will have published or publicly available outcomes. Formal support is provided via phone/zoom and can also be onsite or via email or any combination of these. Formal support is available for training, fidelity monitoring and certification of fidelity raters, certification of supervisors, as well as research consultation and program effectiveness evaluation.

Fidelity Measures

There are fidelity measures for Seeking Safety (Adult version) as listed below:

The following are fidelity measures:

Fidelity Measure Requirements:

Fidelity measures are required for outcome research that will be published or publicly available. They are not required for regular clinical implementation.

Established Psychometrics:

Psychometrics of the SS Adherence Scale are reported in:

  • Hien, D. A., Wells, E. A., Jiang, H., Suarez-Morales, L., Campbell, A. N. C., Cohen, L. R., Miele, G. M., Killeen, T., Brigham, G. S., Zhang, Y., Hansen, C., Hodgkins, C., Hatch-Maillette, M., Brown, C., Kulaga, A., Kristman-Valente, A., Chu, M., Sage, R., Robinson, J. A., . . . Nunes, E. V. (2009). Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. Journal of Consulting and Clinical Psychology, 77(4), 607–619. https://doi.org/10.1037/a0016227

Implementation Guides or Manuals

There are implementation guides or manuals for Seeking Safety (Adult version) as listed below:

These and several other articles on implementation of Seeking Safety are available at http://www.treatment-innovations.org/articles-ss-implementation.html:

Implementation Cost

There have been studies of the costs of implementing Seeking Safety (Adult version) which are listed below:

Washington State Institute for Public Policy. (2019). Benefit-Cost results: Substance use disorders—Seeking Safety. https://www.wsipp.wa.gov/BenefitCost/Program/307

Research on How to Implement the Program

Research has been conducted on how to implement Seeking Safety (Adult version) as listed below:

Anderson, M. L., & Craig, K. S. W., (2018). Developing therapy approaches for deaf clients impacted by language deprivation. In Language deprivation and deaf mental health (pp. 83-100). Routledge.

Crisanti, A. S., Murray-Krezan, C., Karlin, L. S., Sutherland-Bruaw, K., & Najavits, L. M. (2016). Evaluation of an evidence-based practice training for peer support workers in behavioral health care, Cogent Psychology, 3, Article 1212453. https://doi.org/10.1080/23311908.2016.1212453

Hien, D., Kropp, F., Wells, E. A., Campbell, A., Hatch-Maillette, M., Hodgkins, C., Killeen, T., Lopez-Castro, T., Morgan-Lopezi, A., Ruglass, L. M., Saavedra, L., & Nunes, E. V. (2020). The "Women and Trauma" study and its national impact on advancing trauma specific approaches in community substance use treatment and research. Journal of Substance Abuse Treatment, 112(Suppl.), 12–17. https://doi.org/10.1016/j.jsat.2020.02.003

Marsh, T. N., Coholic, D., Cote-Meek, S., & Najavits, L. M. (2015). Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduction Journal, 12(1), 14–25. https://doi.org/10.1186/s12954-015-0046-1

Marsh, T. N., Cote-Meek, S., Toulouse, P., Najavits, L. M., & Young, N. L. (2015). The application of two-eyed seeing decolonizing methodology in qualitative and quantitative research for the treatment of intergenerational trauma and substance use disorders. International Journal of Qualitative Methods, 14(5). https://doi.org/10.1177/1609406915618046

Marsh, T. N., Cote-Meek, S., Young, N. L., Najavits, L. M., & Toulouse, P. (2016). Indigenous healing and seeking safety: A blended implementation project for intergenerational trauma and substance use disorders. The International Indigenous Policy Journal, 7, Article 3. https://doi.org/10.18584/iipj.2016.7.2.3

Marsh, T. N., Marsh, D. C., & Najavits, L. M. (2020). The impact of training indigenous facilitators for a two-eyed seeing research treatment intervention for intergenerational trauma and addiction. International Indigenous Policy Journal, 11(4). https://doi.org/10.18584/iipj.2020.11.4.8623

Rodriguez, A., Lau, A. S., Wright, B., Regan, J., & Brookman-Frazee, L. (2018). Mixed-method analysis of program leader perspectives on the sustainment of multiple child evidence-based practices in a system-driven implementation. Implementation Science, 13(1), Article 44. https://doi.org/10.1186/s13012-018-0737-6

Full texts of the implementation research articles above can be found at http://www.treatment-innovations.org/articles-ss-implementation.html

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

A meta-analysis, see citation following, has also been conducted on Seeking Safety though this article is not used for rating and therefore is not summarized:

  • Lenz, A. S., Henesy, R., & Callender, K. (2016). Effectiveness of Seeking Safety for co–occurring posttraumatic stress disorder and substance use. Journal of Counseling & Development, 94(1), 51–61. https://doi.org/10.1002/jcad.12061

When more than 10 research articles have been published in peer-reviewed journals, the CEBC reviews all of the articles as part of the rating process and identifies the most relevant articles, with a focus on randomized controlled trials (RCTs) and controlled studies that have an impact on the rating. The articles chosen for Seeking Safety [Substance Abuse Treatment (Adult) and Trauma Treatment (Adult)] are summarized below:

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(8), 1426–1432. https://doi.org/10.1176/appi.ajp.161.8.1426

Type of Study: Randomized controlled trial
Number of Participants: 107

Population:

  • Age — 18 years or older
  • Race/Ethnicity — Seeking Safety: 49% African American, 24% Caucasian, 24% Hispanic, and 2% Other and/or Multiiracial; Relapse Prevention: 50% Caucasian, 35% African American, and 15% Hispanic; Community Care: 41% African American, 41% Caucasian, and 19% Hispanic
  • Gender — 100% Female
  • Status — Participants were low-income urban women with current PTSD and substance use disorder who were receiving outpatient services.

Location/Institution: New York City

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare the efficacy of a manualized cognitive behavior therapy, Seeking Safety that addresses both posttraumatic stress disorder (PTSD) and substance abuse 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. Participants were randomly assigned to one of two active treatment conditions: Seeking Safety or relapse prevention. Measures utilized include the Substance Use Inventory, the Clinical Global Impression (CGI), the Structured Clinical Interview for DSM-IV (SCID)—SAC, the Clinician-Administered PTSD Scale Version, and the Global Assessment Scale. Results indicate that 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 experienced greater improvement in substance use and PTSD symptoms at 6-month and 9-month follow-ups than subjects in the community care group. Limitations include the use of a nonmanualized community care comparison group, length of follow-up, and small sample size.

Length of controlled postintervention follow-up: 6 months and 9 months.

Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O'Keefe, M., Rose, T., & Bjelajac, P. (2007). Effectiveness of an integrated trauma-informed approach to treating women with co-occurring disorders and histories of trauma. Journal of Community Psychology, 35(7), 863–878. https://doi.org/10.1002/jcop.20186

Type of Study: Pretest-posttest study with a nonequivalent control group (Quasi-experimental)
Number of Participants: 313

Population:

  • Age — 18 years or older
  • Race/Ethnicity — Seeking Safety: 39% Caucasian, 27% Hispanic, 21% African American, 11% Native American, 2% Biracial, and .53% Asian; Control: 35% Caucasian, 26% Hispanic, 24% African American, 13% Native American, 1% Asian, and 1% Biracial
  • Gender — 100% Female
  • Status — Participants were women in community treatment with substance use disorder, history of trauma, and one or more psychiatric disorders.

Location/Institution: Los Angeles

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effectiveness of an integrated trauma-informed approach, Seeking Safety in treating women with co-occurring disorders and histories of trauma. Participants were assigned to either Seeking Safety or a comparison group. Baseline and 12-month assessments were completed by 136 intervention and 177 comparison group women. Measures utilized include the Addiction Severity Index (ASI), the Brief Symptom Inventory, the Global Severity Index—(GSI), the PTSD Symptom Scale (PSS), and the Life Stressor Checklist–Revised (LSC-R). Results indicate that there were no differences in the improvement experienced by women in the Seeking Safety and comparison groups on substance abuse problems or symptoms of psychological distress. Seeking Safety 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. Limitations include lack of randomization, differences between groups at baseline on substance use variables, and differences in attrition rates between the intervention and comparison groups.

Length of controlled postintervention follow-up: Varied. None for the Seeking Safety group, 2–6 months for the comparison group, depending on the agency.

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(9), 996–1003. https://doi.org/10.1176/ps.2008.59.9.996 & Desai, R. A., Harpaz-Rotem, I., Najavits, L. M., & Rosenheck, R. A. (2009). Seeking Safety therapy: Clarification of results. Psychiatric Services, 60(1), 125. https://doi.org/10.1176/ps.2009.60.1.125

Type of Study: Pretest-posttest study with a nonequivalent control group (Quasi-experimental)
Number of Participants: 450

Population:

  • Age — 18 years or older
  • Race/Ethnicity — Seeking Safety: 46% African American, 42% Caucasian, 3% Hispanic, and 9% Other and/or Multiracial; Control: 53% African American, 33% Caucasian, 8% Hispanic, and 6% Other and/or Multiracial
  • Gender — 100% Female
  • Status — Participants were homeless women veterans with psychiatric and/or substance abuse problems.

Location/Institution: Eleven homeless women veterans programs

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the effectiveness of Seeking Safety, a manualized cognitive–behavioral therapy intervention, with homeless women veterans with psychiatric or substance abuse problems. Participants were a cohort of homeless women veterans recruited before Seeking Safety was implemented. After clinicians were trained and certified in Seeking Safety, a postimplementation cohort was recruited and offered Seeking Safety treatment. Measures utilized include the Addiction Severity Index (ASI), the 30-item Symptom Checklist Revised (SCL-30-R), the PTSD Checklist, and the 12-Item Short-Form Survey (SF-12). Results indicate that the Seeking Safety cohort had significantly better outcomes over one year in employment, social support, general symptoms of psychiatric distress, and symptoms of PTSD, particularly avoidance and arousal clusters. However, the Seeking Safety cohort was significantly more likely to have used drugs in the past 30 days. The correction to this article provides end-of-treatment outcomes (at six months) and major loss during follow-up. Limitations include lack of randomization, the nonequivalent comparison groups, reliance on self-report of substance use, and low follow-up rates.

Length of controlled postintervention follow-up: 3 months and 6 months.

Zlotnick, C., Johnson, J., & Najavits, L. M. (2009). Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD. Behavioral Therapy, 40(4), 325–336. https://doi.org/10.1016/j.beth.2008.09.004

Type of Study: Randomized controlled trial
Number of Participants: 49

Population:

  • Age — Mean=34.6 years
  • Race/Ethnicity — 47% Caucasian, 33% African American, 14% Hispanic, and 6% Other
  • Gender — 100% Female
  • Status — Participants were women in a residential substance abuse treatment program in a minimum security prison.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effectiveness of Seeking Safety in a sample of incarcerated women with substance use disorder (SUD). Participants were randomly assigned to a Seeking Safety (treatment group) or to a treatment as usual (TAU) comparison group. Measures utilized include the Clinician-Administered Posttraumatic Stress Disorder Scale-I (CAPS-I), Structured Clinical Interview for DSM-IV Patient Version (SCID), Addiction Severity Index (ASI), Time Line Follow Back (TLFB), Brief Symptom Inventory (BSI), Treatment Services Review (TSR), Client Satisfaction Questionnaire (CSQ), End-of-Treatment Questionnaire, Evaluation of Treatment Interview, and the Seeking Safety Adherence Scale. Results indicate that there were no significant differences between conditions on all key domains (PTSD, SUD, psychopathology, and legal problems); but both conditions showed significant improvements from intake to later time points on all of these outcomes across time. Limitations include lack of assessment of Seeking Safety outcomes at end of group treatment; lack of blind assessment; omission of the Seeking Safety case management component; and possible contamination between the two conditions.

Length of controlled postintervention follow-up: 6 months.

Boden, M. T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., Walser, R., & Trafton, J. A. (2012). Seeking Safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction, 107(3), 578–586. https://doi.org/10.1111/j.1360-0443.2011.03658.x

Type of Study: Randomized controlled trial
Number of Participants: 98

Population:

  • Age — Intervention: Mean=55.1 years; Control: Mean=52.9 years
  • Race/Ethnicity — Intervention: 65% African American, 14% Caucasian, 8% Hispanic, 4% Native American, and 4% Other; Control: 55% African American, 25% Caucasian, 6% Hispanic, and 6% Other
  • Gender — Male
  • Status — Participants were male veterans who met criteria for current PTSD.

Location/Institution: Oakland, California - VA outpatient substance use disorder treatment clinic

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine whether substituting Seeking Safety for part of treatment as usual (TAU) improved substance use outcomes among male military veterans with a substance use disorder and co-occurring PTSD symptomatology. Participants were randomly assigned to Seeking Safety or TAU. Measures utilized include the Addiction Severity Index (ASI), the Impact of Events Scale-Revised, the Client Satisfaction Questionnaire, and the Coping Responses Inventory. Results indicate that Seeking Safety compared to TAU was associated with better drug use outcomes, but alcohol use and PTSD severity decreased equally under both treatments. Seeking Safety versus TAU was associated with increased treatment attendance, client satisfaction, and active coping. Limitations included differences in education levels between the Seeking Safety and TAU providers, lack of generalizability to women and nonveterans, and smaller group sizes in the Seeking Safety condition.

Length of controlled postintervention follow-up: 3 months.

Lynch, S. M., Heath, N. M., Mathews, K. C., & Cepeda, G. J. (2012). Seeking Safety: An intervention for trauma exposed incarcerated women? Journal of Trauma and Dissociation, 13(1), 88–101. https://doi.org/10.1080/15299732.2011.608780

Type of Study: Pretest-posttest study with a nonequivalent control group (Quasi-experimental)
Number of Participants: 114

Population:

  • Age — 19–60 years
  • Race/Ethnicity — 84% Caucasian, 15% Native American, 12% Hispanic, 3% African American, and 3% Asian American/Pacific Islander
  • Gender — 100% Female
  • Status — Participants were incarcerated women with a reported history of trauma, history of substance use disorder, and moderate to severe PTSD symptoms.

Location/Institution: A Northwestern women's state prison

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the effectiveness of Seeking Safety in a group format with incarcerated women who were receiving typical prison programming (e.g., educational services, substance abuse relapse prevention, work related skills, and some specialized classes) compared to a waitlisted group of offenders. Participants were assigned to Seeking Safety or to a waitlist group. Measures utilized include the Trauma History Questionnaire, PTSD Checklist – Civilian Version, Alcohol and Drug Use History Questionnaire, Center for Epidemiological Studies – Depression Scale, the Brief COPE, and the Inventory of Interpersonal Problems. Results indicate that participants in Seeking Safety demonstrated greater symptom improvement in PTSD and depression as well as improved interpersonal functioning and coping as compared to waitlisted offenders. Limitations include the lack of randomization, the possibility that the results may be due to participation in a structured group rather than to the specific Seeking Safety treatment, lack of follow-up, and a lack of assessment of substance use.

Length of controlled postintervention follow-up: None.

Wolff, N., Hueninga, J., Shi, J., Frueh, B. C., Hoover D. R., & McHugo, G. (2015). Implementation and effectiveness of integrated trauma and addiction treatment for incarcerated men. Journal of Anxiety Disorders, 30, 66–80. https://doi.org/10.1016/j.janxdis.2014.10.009

Type of Study: Randomized controlled trial
Number of Participants: 230

Population:

  • Age — 18 years or older
  • Race/Ethnicity — 48% Black/African American, 35% Caucasian, 17% Other, and 10% Latino/Hispanic
  • Gender — 100% Male
  • Status — Participants were maximum security male inmates with comorbid posttraumatic stress disorder and substance use disorder.

Location/Institution: Pennsylvania

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine implementation and effectiveness of integrated group therapy for comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) on PTSD and mental health symptoms for 230 incarcerated men. Participants were assigned randomly or by preference to receive Seeking Safety or Male-Trauma Recovery Empowerment Model (M-TREM), with a waitlist group. Measures utilized include the PTSD Checklist for Civilians (PCL-C), the Clinician-Administered PTSD Scale (CAPS), the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI), the Rosenberg Self-Esteem Scale (SES), the Proactive Coping Inventory (PCI), and the Generalized Perceived Self-Efficacy (GPEF). Results indicate that in terms of absolute effectiveness (waitlist comparison), participants receiving integrated treatment (Seeking Safety or M-TREM) showed statistically and clinically significant improvement in PTSD symptom severity over time, although the difference in improvements was not statistically significant compared to the waitlist group (controlling for baseline differences) and the effect size was small. When treatment was disaggregated by intervention type, the effect of M-TREM on PTSD severity was double that found for Seeking Safety and significantly different from the waitlist group. Seeking Safety was found to outperform no treatment on three outcomes: mental health symptoms, self-esteem, and proactive coping. In terms of relative effectiveness (head-to-head comparison between Seeking Safety and M-TREM), based on intent-to-treat and completer analyses, no statistical differences were found between the performance of Seeking Safety and M-TREM on primary or second outcomes; both were associated with significant improvements in primary and secondary outcomes over time, but neither was superior to the other intervention on these measures. Results also indicate significant improvements in PTSD symptom severity over time and in mental health symptom severity, as well as self-esteem, proactive coping, and self-efficacy for both Seeking Safety and M-TREM, compared to no treatment. Limitations include violation of ecological validity, not generalizable to a non-English speaking population, substance abuse outcomes not measured, and length of follow up.

Length of controlled postintervention follow-up: 3 and 6 months.

Najavits , L. M., Krinsley, K., Waring, M. E., Gallagher, M. W., & Skidmore, C. (2018). A randomized controlled trial for veterans with PTSD and substance use disorder: Creating Change versus Seeking Safety. Substance Use & Misuse, 53(11), 1788–1800. https://doi.org/10.1080/10826084.2018.1432653

Type of Study: Randomized controlled trial
Number of Participants: 52

Population:

  • Age — Not specified
  • Race/Ethnicity — Not specified
  • Gender — 73% Male
  • Status — Participants were male or female veterans with current posttraumatic stress disorder and substance use disorder.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare Seeking Safety to Creating Change (CC) on symptoms of both posttraumatic stress disorder (PTSD) and substance use disorder (SUD). Participants were randomly assigned to either Seeking Safety or CC. Measures utilized include the Addiction Severity Index; the Mini Neuropsychiatric Interview PTSD Module; Beliefs about Substance Use; Nicotine Screen; the Brief Biosocial Gambling Screen; Trauma History Questionnaire; the PTSD Checklist; the Trauma-Related Guilt Inventory; the World Assumptions Scale; the Coping Self-Efficacy Scale; the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form; the General Self-Efficacy Scale; the Global Severity Index of the Brief Symptom Inventory; the Clinical Global Impressions Scale-Patient version; the Structured Clinical Interview for DSM-IV Personality Disorders; the Suicidal Behaviors Questionnaire; the Client Satisfaction Questionnaire; the Helping Alliance Scale; the Creating Change Feedback Questionnaire; the Creating Change Fidelity Scale, and the Seeking Safety Adherence Scale. Results indicate that both conditions improved over time, with no difference between conditions, on PTSD, alcohol use, and drug use as well as mental health symptoms, quality of life, self-efficacy, and SUD cognitions. Limitations include small sample size, no treatment-as-usual or no-treatment control, and length of follow-up.

Length of controlled postintervention follow-up: 3 months.

Crisanti, A. S, Murray-Krezan, C., Reno J., & Killough, C. (2019). Effectiveness of peer-delivered trauma treatment in a rural community: A randomized non-inferiority trial. Community Mental Health Journal, 55(7), 1125–1134. https://doi.org/10.1007/s10597-019-00443-3

Type of Study: Randomized controlled trial
Number of Participants: 291

Population:

  • Age — 18 years or older
  • Race/Ethnicity — Ethnicity: 83% Hispanic; Race: 62% Caucasian, 26% Multiracial, 11% Native American, 1% African American, and 0% Asian
  • Gender — 56% Male and 44% Female
  • Status — Participants were from a recovery center or a residential treatment program.

Location/Institution: A rural county in a Southwestern state

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to explore the effectiveness of Seeking Safety delivered by peer providers compared to its delivery by licensed behavioral health clinicians. Participants were randomized to peer-led Seeking Safety (PL-Seeking Safety) or clinician-led Seeking Safety (CL-Seeking Safety). Measures utilized include the Post-Traumatic Stress Disorder Checklist Civilian version (PCL-C), the Coping Scale, and the Seeking Safety Adherence Scale. Results indicate that at 6 months PTSD symptoms decreased by 5.1 points and by 4.9 points and coping skills increased by 5.5 points and by 5.6 points, in the peer- and clinician-led groups, respectively. Limitations include high attrition rate (24%) and no true baseline data (interviews were conducted after first Seeking Safety session).

Length of controlled postintervention follow-up: 3 and 6 months.

Tripodi, S. J., Mennicke, A. M., McCarter, S. A., & Ropes, K. (2019). Evaluating seeking safety for women in prison: A randomized controlled trial. Research on Social Work Practice, 29(3), 281–290. https://doi.org/10.1177/1049731517706550

Type of Study: Randomized controlled trial
Number of Participants: 40

Population:

  • Age — Control: Mean=37.3; Treatment: Mean=43.1
  • Race/Ethnicity — Control: 66% White, 17% Black, and 17% Other; Treatment: 74% White, 13% Black, and 13% Other
  • Gender — 100% Female
  • Status — Participants were incarcerated women.

Location/Institution: Medium/maximum-level security prison in North Carolina.

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to explore the utility of Seeking Safety for incarcerated women by comparing Seeking Safety participants to a treatment-as-usual control group on depression and posttraumatic stress disorder (PTSD) at posttest and again at 4-month follow-up. Participants were randomly assigned to Seeking Safety or TAU. Measures include the Center for Epidemiology Studies–Depression Scale (CES-D), and the 17-item PTSD Checklist-Civilian version PCL-C. Results indicate that both groups decreased their scores on the CES-D and the PTSD Checklist, although improvement was greater for treatment group participants except for depression at 4-month follow-up. Limitations include small sample size, attrition (11 participants had dropped out by follow up), fidelity to the intervention, and the potential of control group contamination.

Length of controlled postintervention follow-up: 4 months.

Ledgerwood, D. L., Najavits, L. M., & Afifi, T. O. (2021). A randomized controlled trial for gambling disorder and PTSD: Seeking Safety and CBT, Manitoba Problem Gambling Research Program.

Type of Study: Randomized controlled trial
Number of Participants: 65

Population:

  • Age — Not specified
  • Race/Ethnicity — 69% White, 31% Minority, 13% Indigenous, 9% Asian, 6% Black, and 3% Hispanic
  • Gender — 58% Female, 40% Male, and 2% Nonbinary
  • Status — Participants were recruited via using online listservs, Craigslist, and Canadian gambling and mental health programs

Location/Institution: Manitoba and Ontario Canada.

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare Seeking Safety an integrated treatment for posttraumatic stress disorder (PTSD) and addiction to Cognitive-Behavioral Therapy for Pathological Gambling (CBT-PG), which addresses gambling alone. Participants with current comorbid gambling disorder and PTSD were randomly assigned to receive Seeking Safety or CBT-PG. Measures utilized include assessment of net gambling losses and number of times gambling (Timeline follow-back), Clinician-Administered Posttraumatic Stress Disorder Scale (CAP-5), the Posttraumatic Stress Disorder Checklist, the Gamblers’ Beliefs Questionnaire, the Gambling Self-Efficacy Questionnaire, the PTSD World Assumptions Scale; the Basis-32, the Coping Self-Efficacy Scale, the Helping Alliance Questionnaire (HAQ), the Treatment Services Review, the Client Satisfaction Questionnaire (CSQ), and the Telepresence in Videoconference Scale (TVS). Results indicate that participants improved across time on almost all study measures, including gambling, trauma/ PTSD, other psychiatric symptoms, functioning, and coping. Improvements were similar across CBT-PG and Seeking Safety treatments. Participants receiving Seeking Safety demonstrated significantly stronger session attendance. Strong therapeutic alliance and treatment satisfaction were found, and the telehealth format was rated as highly acceptable. Participants improved across time on almost all study measures, and the strong effect sizes on both gambling disorder and PTSD measures show that both treatments led to substantial symptom improvements. Limitations include small sample size, reliance on self-reported measures, and lack of a nontreatment control or waitlist condition.

Length of controlled postintervention follow-up: 1 year.

The following studies were not included in rating Seeking Safety (Adult version) on the Scientific Rating Scale...

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(10), 1213–1222. https://doi.org/10.1176/appi.ps.56.10.1213

Note: Since this study did not present the results specific to the four Seeking Safety sites separately, results cannot be attributed directly to Seeking Safety, and therefore this study was not used in the rating/review process: The purpose of the study was to develop and test the effectiveness of new service approaches specifically designed for women with co-occurring mental health and substance use disorders. Participants were assigned to Seeking Safety or a control group. Four of nine sites used the Seeking Safety model and five sites used other treatments. Measures utilized include the Addiction Severity Index (ASI), the Global Severity Index (GSI) of the Brief Symptom Inventory, and the Posttraumatic Symptom Scale (PSS) of the Posttraumatic Diagnostic Scale. Results indicate that for substance use outcomes, no effect was found. There was small but statistically significant overall improvement in women’s trauma and mental health symptoms in the Seeking Safety group relative to the usual-care comparison condition. Limitations include results specific to the four Seeking Safety sites are not presented separately, so the results above cannot be attributed to directly to Seeking Safety; and randomization was not used.

Additional References

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

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). Elsevier Press.

Najavits, L. M., & Hien, D. A. (2013). Helping vulnerable populations: A comprehensive review of the treatment outcome literature on substance use disorder and PTSD. Journal of Clinical Psychology, 69(5), 433–480. https://doi.org/10.1002/jclp.21980

Contact Information

Jamie Miller
Title: Training Coordinator
Agency/Affiliation: Treatment Innovations
Website: www.seekingsafety.org
Email:
Phone: (617) 299-1610

Date Research Evidence Last Reviewed by CEBC: February 2023

Date Program Content Last Reviewed by Program Staff: August 2022

Date Program Originally Loaded onto CEBC: January 2009