Additional Features of the Treatment Program

Use of educational research strategies.

Several strategies are derived from educational research to maximize learning (Najavits & Garber, 1989), including contrast-set teaching (comparing extremes such as safe vs. unsafe coping, supportive vs. destructive people); role preparation (e.g., explicitly telling patients how to make the most of the treatment); teaching for generalization (e.g., asking patients to teach a new skill to a partner who can cue them to use it); structured treatment (e.g., each session follows a consistent format); affectively engaging themes and materials (e.g., the quotation for each topic), and memory enhancement devices (e.g., a list of Core Concepts of Treatment).

A focus on potential rather than pathology.

To increase patients’ (and therapists’!) hopefulness, the treatment emphasizes the present and future more than the past, and stresses patients’ strengths more than their pathology. It is necessary to be aware of patients’ deficits; however, in an early-stage treatment in which the goal is to help patients attain safe functioning, focusing on the past or pathology appears to demoralize patients. Thus the stance is to keep an optimistic frame, aim high (believing that patients truly can get better), and use praise rather than negative reinforcement to promote change. Specific techniques include having patients report good coping at each session’s check-in, teaching compassion rather than self-blame, allowing patients to return to treatment no matter what (except in the case of physical danger), and delaying exploration of past trauma and interpretive psychodynamic work until later stages of treatment (see “What Is Not Part of This Treatment,” below).

Attention to language.

The treatment is designed to use simple, everyday words; to avoid jargon; to use humanistic rather than scientific terms; and, when possible, to convey patients’ experience with quotations in their own words. For example, “rethinking” is used rather than “cognitive restructuring”; “commitment” rather than “homework”; “honesty” rather than “assertiveness”; and “emotional pain” rather than “psychiatric symptom.” To focus on strengths rather than pathology, virtually every term that began as a negative was reframed after it became clear that negative language made patients feel worse about themselves. Thus the standard CBT phrase “cognitive distortions” was reworked as “creating meaning.” Also, therapists are encouraged to allow patients to decide what language fits them. For example, some patients with PTSD prefer the term “healing” to “recovery” because they believe that no matter how well they become, trauma has changed them forever; thus PTSD is an existential issue rather than a “medical illness” that one “recovers” from. Finally, language is genderneutral whenever possible, so that both women and men can relate to the material. Patient examples from both genders and from a variety of types of trauma are provided throughout.

Emphasis on practical solutions.

The treatment attempts to provide materials that are highly practical in nature: lists of national resources; extensive handouts for each topic; the broad list of Safe Coping Skills; specific in-session exercises to try (e.g., an actual script to rehearse grounding). The goal is that patients will never need to believe “There is nothing I can do.” If one tool doesn’t work, the idea is to use another.

Relating the material to patients’ lives.

With so much written material, it is a challenge to keep the treatment therapeutic rather than didactic or intellectual. Ways to do so include relating the material to current and specific problems in patients’ lives; and, whenever possible, directly rehearsing skills both in and outside of the session so that patients, in the words of the famous educator John Dewey, “learn by doing” (Dewey, 1983).

Clinical realism.

Although the material conveys how sessions will ideally go, there is also a great deal of attention to the realities of front-line clinical work. Thus “Clinical Warnings” are given for material that may be upsetting to some patients; “Suggestions” for each topic address issues that may emerge when using the treatment; “Tough Cases” are provided for each topic to present some challenging comments patients tend to make; a section on “What Didn’t Work” when developing this treatment is provided at the end of Chapter 2. Moreover, there is emphasis throughout on understanding the limits of patients’ lives and, when implementing strategies, avoiding simplistic solutions (such as “positive thinking” in the cognitive topics).

An urgent approach to time.

The conjoint influences of managed care, the typically short retention in treatment of many patients with substance abuse (Crits-Christoph & Siqueland, 1996), and the severity of patients with this dual diagnosis lead to a sense of urgency in trying to help them quickly. Indeed, Seeking Safety was initially tested as a short-term (3-month) group treatment with a single therapist, to evaluate whether gains could be achieved within these limits (Najavits et al., 1998e). It can and, it is hoped, will be conducted over a longer time frame if the setting allows it, but for most patients, there is too little time and a great deal to accomplish. Thus sessions are highly focused to make the best use of time available, and time outside of sessions is utilized whenever possible to promote recovery (e.g., making case management calls during the session, completing commitments between sessions). One of the key skills the therapist needs to master is “redirection” to help keep the sessions goaldirected.

Making the treatment interesting to patients.

Considerable attention has been devoted to making the treatment accessible and engaging with devices such as the Life Choices Game; recording therapeutic audiotapes in the session; providing self-exploration questions on patient handouts; the use of metaphors; and a quotation to start each topic. Such efforts may be particularly important for patients with PTSD and substance abuse, who represent a more impaired, treatment-resistant group than those with substance abuse alone (Brady et al., 1994; Najavits et al., 1996b, 1998c). Their clinical presentation, especially early in treatment, may be marked by poor concentration, dissociation, and impulsiveness, which can limit the impact of traditional verbal therapy. Several writers have commented on the need to “hook” these patients into treatment (Abueg & Fairbank, 1991; Jelinek & Williams, 1984; Kofoed et al., 1993). The high dropout rate from substance abuse treatment in general (Craig, 1985) warrants strong efforts to make treatment stick. CBT is sometimes perceived as mechanistic, superficial, and inattentive to feelings (Clark, 1995; Gluhoski, 1994), so it appears especially important to make treatment as creative as possible. Moreover, this utilizes a primary defense in PTSD—the use of fantasy—as a tool for recovery (Herman, 1992).

Substance abuse as a priority.

Substance abuse treatment and mental health treatment have, for most of the 20th century, been two different cultures. Each has derived its own strategies from clinical experience with many patients over time. For therapists who are new to substance abuse treatment, there is often a steep learning curve. Some of the approaches to substance abuse in this treatment include making it a priority at each session; conveying that while the goal is to understand substance use incidents, there is never an excuse for using (i.e., it is always possible to cope in a better way); using urinalysis and breathalyzer testing; validating mixed feelings about giving up substances; recognizing that giving up substances will not feel good; understanding how substances “solve” particular PTSD and other problems in the short term (although they do not work in the long term); understanding the biological basis of addiction; recognizing denial and other defenses typical of substance abuse; setting abstinence as the goal, but harm reduction as a means to that end if needed; and strongly encouraging twelve-step self-help groups while never forcing patients to attend them.

What Is Not Part of This Treatment

There are two main areas that this treatment explicitly omits: exploration of past trauma and interpretive psychodynamic work. Exploration of past trauma is, in and of itself, a major intervention for PTSD in a variety of treatments, including mourning (Herman, 1992), exposure therapy (Foa & Rothbaum, 1998), eye movement desensitization reprocessing (Shapiro, 1995), the counting method (Ochberg, 1996), the rewind method (Muss, 1991), and thought field therapy (Figley, Bride, & Mazza, 1997). By directly processing trauma memories, they no longer hold such emotional power over the patient. For example, in exposure therapy (Foa & Rothbaum, 1998), the patient describes the trauma in detail (“imaginal exposure”), perhaps audiotaping the trauma narrative and listening to it outside of sessions, as well as confronting feared reminders of trauma (“in vivo exposure,” such as driving over a bridge where an assault occurred). As patients face these trauma triggers, they are flooded by overwhelming emotion—typically anxiety, sadness, or anger—that gradually dissipates with repeated exposure to them. It follows a classic behavioral model of exposure to feared stimuli. It is highly effective for PTSD (Foa & Rothbaum, 1998; Marks et al., 1998) in as few as nine sessions or in prolonged versions for more complex cases. The “mourning” phase described by Herman (1992) is similar, but draws on psychodynamic influences, emphasizing a review of the patient’s life before the trauma, creation of meaning to understand what happened, emphasis on how trauma affected relationships, and trauma imagery.

There are several reasons why exploration of trauma memories is not part of Seeking Safety. Primarily, it is not yet known whether it is safe and effective for patients who are actively abusing substances. Numerous experts have recommended that for substance abusers, such work not begin until they have achieved a period of stable abstinence and functionality (Chu, 1988; Keane, 1995; Ruzek et al., 1998; Solomon, Gerrity, & Muff, 1992). The concern is that if patients are overwhelmed by painful memories from the past, their substance use could worsen in a misguided attempt to cope. Moreover, Seeking Safety was initially tested in a time-limited group format, which did not appear to be an appropriate context in which to conduct exposure methods for victims of repeated early trauma, who represent a large number of patients with this dual diagnosis (Najavits et al., 1997). Even small mention of trauma experiences has been found to trigger other patients, and in a short-term group treatment there may be insufficient time to fully process the material.

It can be noted, however, that when Seeking Safety has been conducted as an individual therapy over a longer time frame, it has been combined with exposure therapy and, at least thus far, appears to be a highly compatible mix of treatments. A pilot study using this combination in a sample of men is described in “Empirical Results” later in this chapter (Najavits, Schmitz, Gotthardt, & Weiss, 2001), and initial guidelines for combining the treatments are described in the section “Treatment Guidelines” in Chapter 2. However, until further research explores the use of exposure techniques with a broad range of this dual-diagnosis population, it is not included as part of Seeking Safety.

Interpretive psychodynamic work is also specifically avoided in Seeking Safety. There is little, if any, processing of the patient’s relationship with the therapist or, in group treatment, of members’ relationships with each other. There is also no exploration of intrapsychic motives or dynamic insights. Although these powerful interventions are likely to be helpful in later stages of treatment, they are believed too advanced and potentially upsetting for patients at this stage. See the topic Safety for more on this issue.