Safety as the Goal of this First-Stage Treatment

The title of the book and program, Seeking Safety, expresses the basic philosophy of the treatment. That is, when a person has both active substance abuse and PTSD, the most urgent clinical need is to establish safety. “Safety” is an umbrella term that signifies various elements: discontinuing substance use, reducing suicidality, minimizing exposure to HIV risk, letting go of dangerous relationships (such as domestic abuse and drug-using “friends”), gaining control over extreme symptoms (such as dissociation), and stopping self-harm behaviors (such as cutting). Many of these are self-destructive behaviors that reenact trauma, particularly for victims of childhood abuse, who represent a large segment of people with this dual diagnosis (Najavits et al., 1997). Even though the trauma may have occurred long ago, patients treat themselves in ways that repeat it, ignoring their needs and perpetuating pain (albeit sometimes in the guise of trying to satisfy short-term impulses). These patients have typically been abused and are now abusing themselves; this is not coincidence, but rather represents a meaningful connection between their disorders. “Seeking safety” refers to helping patients free themselves from such negative behaviors and, in so doing, to move toward freeing themselves from trauma at a deep emotional level.

Just as violations of safety are life-destroying, the means of establishing safety are life-enhancing: learning to ask for help from safe people, utilizing community resources, exploring “recovery thinking,” taking good care of one’s body, rehearsing honesty and compassion, increasing self-nurturing activities, and so on. It is these skills that this treatment attempts to teach.

The treatment thus fits what has been described as first-stage therapy for each of the disorders. Experts within the PTSD and substance abuse fields have independently described an extremely similar first stage of treatment. For example, within the PTSD domain, Herman’s (1992) model of a first-stage recovery group is defined by a focus on safety and selfcare as the primary therapeutic tasks, a present-time orientation, homogeneous membership (all patients have the same primary diagnoses), low tolerance for conflict within the group, an open-ended format, didactic intent, and a moderate level of cohesion among members. Likewise, for substance abuse, Kaufman and Reoux (Kaufman, 1989; Kaufman & Reoux, 1988) depicts the first stage of treatment as “achieving abstinence,” including assessing the extent and impact of substance use, developing a plan for abstinence, reviewing the patient’s recent drug use and craving at each session, and diagnosing and treating coexisting psychiatric illness.

These suggestions are echoed by other writers as well (Brown, 1985; Carroll, Rounsaville, & Keller, 1991; Evans & Sullivan, 1995; Marlatt & Gordon, 1985; Sullivan & Evans, 1996). In the topic Safety, a more extensive description of the stages of healing from both PTSD and substance abuse is provided. To summarize here briefly, the three stages are as follows (using Herman’s terms):
Stage 1: Safety
Stage 2: Mourning
Stage 3: Reconnection

This treatment addresses only Stage 1. The first stage, safety, is in and of itself an enormous therapeutic task for some patients. Thus, if patients remember nothing else from the treatment, the hope is that they will “take home” the idea of safety above all. It is addressed over and over in numerous ways, including the Safe Coping Sheet (see Chapter 2), the list of Safe Coping Skills (in the topic Safety), the Safety Plan (in the topic Red and Green Flags), the Safety Contract (in the topic Healing from Anger), and the report of unsafe behaviors at each session’s check-in, for example.

The concepts of safety and first-stage treatment are designed to protect therapists as well as patients. By helping their patients move toward safety, therapists are protecting themselves from the sequelae of treatment that could move too fast without a solid foundation: worry over the patients’ well-being, vicarious traumatization, medico-legal liability, and dangerous transference and countertransference dilemmas that may be evoked by inappropriate treatment (Chu, 1988; Pearlman & Saakvitne, 1995). Thus “seeking safety” is, it is hoped, both patients’ and therapists’ goal.