Day Four

About Seeking Safety

Given that the literature suggests that treatments for Aboriginal people are most effective when cultural components are incorporated, the Seeking Safety model was examined for its cultural underpinnings. Its roots are from mainstream American samples (Najavits et al., 1998; Najavits, 2002; Najavits & Hien, 2013) and it has subsequently been applied in many diverse groups within the United States. While it incorporates spirituality in the model, it does not include spiritual practices that are part of the Aboriginal traditions of Canada. Thus, the idea to blend the two approaches, Indigenous Healing and Seeking Safety, was considered as an option for this model.

Agenda - Day Four

9:00 – 10:00

Introductions, Expectations & Experiential Exercise

 Check-in

10:00 – 11:00

About Seeking Safety

11:00 – 11:15

Break

11:15 – 12:15 PM

More about Seeking Safety

Experiential Exercise

12:15 – 1:00

Lunch

1:00 – 3:00

Meditation/Breathing/Grounding/ focussing

Implementing Seeking Safety

Experiential Seeking Safety group

3:00 – 3:15

Break

3:15 – 4:00

Individual check-in

Feedback and a Brief Evaluation of the Day

About Seeking Safety

Seeking Safety is a manualized psycho-educational counseling program that targets the unique problems resulting from struggling with SUD or trauma. The program aims to increase the coping skills of participants with the goal of reducing the chance of relapse by emphasizing values such as respect, care, integration, and healing of self (Najavits, 2007). In this program, participants work to reduce suicidal and self-harming thoughts and behaviours, including the urge to use substances and engage in other unsafe behaviours. They also work to remove themselves from unhealthful relationships to gain a sense of control and healing (Najavits, 2002a). Participants develop skills such as grounding, joining the present, and changing what can be changed to reduce the severity of their urge to self-harm (Najavits, 2009). Seeking Safety is considered a first-stage therapy: the primary goals of treatment are abstinence from substances and acquiring coping skills to obtain personal safety (Najavits, 2002a).

Seeking Safety has been used successfully among many minority populations, including African-Americans, Hispanics, and Asian Americans, as well as challenging populations (e.g., the homeless, prisoners, adolescents, public-sector clients, and veterans). The model has also been translated into numerous languages with international implementation (Najavits 2002a, 2007, 2009; Najavits & Hein, 2013).

The Seeking Safety model includes spiritual discussions through the offering of a philosophical quote at the beginning of the group sessions (Najavits, 2007; Najavits & Hein, 2013), as well as discussions about safety, cultural continuity, gentle language, and teachings about the genesis of intergenerational trauma and SUD (Najavits, 2002a; Najavits & Hein, 2013). Seeking Safety incorporates the inclusion of the mind, body, spirit, and self-awareness during treatment, as well as connection to community through emphasis on the utilization of community resources. Specifically, this model was chosen because it offered an individually empowering approach to the treatment of trauma and SUD (Najavits, 2002).

Effectiveness of Seeking Safety

Research shows that all forms of this model have been effective when delivered in a group or with individuals, with individuals from marginalized populations, or via inpatient or outpatient services (Hien, Jiang, Campbell, Miele, G. Cohen, Nunes, 2010; Hien, Levin,  Ruglass, López-Castro, Papini, Hu, Cohen, & Herron, 2015). The International Society for Traumatic Stress Studies (ISTSS) Practice Guidelines (2009) recognized Seeking Safety as the only effective treatment model currently available for PTSD and Substance Use Disorders. This recommendation was based on 12 studies ranked as Level A to C in the ISTSS expert review process (International Society for Traumatic Stress Studies Practice Guidelines, 2009). These studies included a range of participant groups from community treatment, adolescents, homeless, veterans, prisoners and others (Cook, Walser, Kane, Ruzek, & Woody, 2006; Hien, Cohen, Litt, Miele, & Capstick, 2004; Hien et al., 2009; Hein et al., 2015; Najavits, Schmitz, Gotthardt, & Weiss, 2005; Najavits, Weiss, Shaw & Muenz, 1998; Rosenheck, & Craig, 2006; Weller, 2005; Zlotnick, Johnson, Najavits, 2009). For example, a recent study of Seeking Safety compared to Treatment as Usual in 30 Australian prisoners (23% of whom were Aboriginal), found a reduction in trauma symptoms, as measured by the Clinician Administered PTSD Scale severity total score, from 56.1 (SD 20.31) at baseline to 36.4 (SD 20.69) post-treatment for Seeking Safety, compared to a reduction from 58.9 (SD 22.56) at baseline to 44.1 (SD 27.27) post-treatment for the control group (Barrett et al., 2015). The reduction in trauma symptom severity was maintained at 6months post-intervention (Barrett et al., 2015).

Seeking Safety has been researched in various studies including a multisite controlled trial with homeless women veterans (Desai, Harpaz-Rotem, Najavits, & Rosenheck, 2008); randomized control trials with low-income urban women and adolescent girls (Hien, Cohen, Miele, Litt & Capstick, 2004; Najavits, Gallop, & Weiss, 2006); combining Seeking Safety with Sertraline for PTSD and alcohol use disorders: a randomized controlled trial (Hien, Levin, Ruglass, López-Castro, Papini, Hu, Cohen, & Herron, (2015); a multi-site randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders (Hien, D. Wells, Jiang, Suarez-Morales, Campbell, Cohen, Miele, Killeen, Brighman, Zhang, Hansen, Hodgkins, Hatch-Maillette, Brown, Kulaga, Kristman-Valente, Chu, Sage, Robinson, Liu, & Nunes, (2009); a controlled trial (Gatz et al., 2007); and uncontrolled pilot studies (e.g., Najavits, Weiss, Shaw, Muenz, 1998; Zlotnick, Najavits, & Rohsenow, 2003; Cook, Walser, Kane, Ruzek, & Woody, 2006; Patitz, Anderson, & Najavits, 2015).

Overall, results show numerous positive outcomes across the domains of PTSD, SUD, and other variables, including psychopathology, cognitions, and coping (Najavits & Hien, 2013). The perspective of Seeking Safety is convergent with Aboriginal traditional methods. Because of the content and delivery method of Seeking Safety, the program complements traditional teachings such as holism, relational connection, spirituality, cultural presence, honesty, and respect (Gone, 2008; Lavallée, 2009; Menzies, 2014). Specifically, this model was chosen because it offered an individually empowering approach to the treatment of trauma and SUDs (Najavits, 2002). In a larger national multisite community study, Seeking Safety was compared to a women’s health education (WHE) control group (Hien et al., 2009).  353 Women receiving standard community treatment as usual were randomized to 12 twice-weekly sessions of Seeking Safety or WHE. Both interventions were delivered in a group format to more closely resemble how treatment is delivered in community programs; the Seeking Safety and WHE groups experienced significantly reduced PTSD symptoms. However, neither of the therapy groups had a significant impact upon abstinence rates over time. Interestingly, among women who had the largest reduction in PTSD symptom severity at the 12-month follow-up, those who had received Seeking Safety were more than twice as likely to be abstinent from substances than those who had received WHE (43% versus 19%, respectively).

Patitz, et al. (2015) in a pilot study investigated the impact of Seeking Safety (Najavits, 2002), on trauma symptoms among 23 rural women with comorbid substance use and trauma. To assess the trauma symptoms, the Trauma Symptom Inventory (TSI; Briere, 1995) was utilized pre- and post-intervention. The Seeking Safety groups occurred over 12 weeks and 24 sessions were offered. There were no dropouts. The mean scores on all TSI subscales decreased significantly from pre -to post-intervention. Participants also showed changes across all trauma symptoms, including highly impairing symptoms, such as hyper-arousal, depression, flashbacks, dissociation and avoidance (Patitz, et al., 2015).

Given that the literature suggests that treatments for Aboriginal people are most effective when cultural components are incorporated, the Seeking Safety model was examined for its cultural underpinnings. Its roots are from mainstream American samples (Najavits et al., 1998; Najavits, 2002; Najavits & Hien, 2013) and it has subsequently been applied in many diverse groups within the United States. While it incorporates spirituality in the model, it does not include spiritual practices that are part of the Aboriginal traditions of Canada. Thus, the idea to blend the two approaches, Indigenous Healing and Seeking Safety, was considered as an option for this thesis.

From: Najavits LM (2004). Implementing Seeking Safety therapy for PTSD and substance abuse: Clinical guidelines.  Alcoholism Treatment Quarterly, 2004; 22:43-62.  Core principles 

The Five Central Ideas the Treatment is Based On

(1) Safety as the priority of treatment.  The title “Seeking Safety” expresses its basic philosophy: when a person has both substance abuse and PTSD, the most urgent clinical need is to establish safety.  Safety is a broad term that includes discontinuing substance use, reducing suicidality and self-harm behavior, ending dangerous relationships (such as domestic abuse and drug using friends), and gaining control over symptoms of both disorders.  In Seeking Safety, safety is taught through Safe Coping Skills, a Safe Coping Sheet, a Safety Plan, and a report of safe and unsafe behaviors at each session, for example.

(2) Integrated treatment.  Seeking Safety is designed to treat PTSD and substance abuse at the same time.  An integrated model is recommended as more likely to succeed, more sensitive to client needs, and more cost-effective than sequential treatment of one disorder then the other (Abueg & Fairbank, 1991; Evans & Sullivan, 1995).  In Seeking Safety, integrated treatment includes helping clients understand the two disorders and why they so frequently co-occur; teaching safe coping skills that apply to both; exploring the relationship between the two disorders in the present (e.g., using drugs to cope with trauma flashbacks); and teaching that healing from each disorder requires attention to both disorders. 

(3) A focus on ideals. Both PTSD and substance abuse individually, and especially in combination, lead to demoralization and loss of ideals. Thus, Seeking Safety evokes humanistic themes to restore clients' feeling of potential for a better future.  The title of each session is framed as a positive ideal, one that is the opposite of some pathological characteristic of PTSD and substance abuse.  For example, the topic Honesty combats denial, lying, and the “false self”.  Commitment is the opposite of irresponsibility and impulsivity.  The language throughout emphasizes values such as “respect”, “care”, “integration”, and “healing”.  By aiming for what can be, the hope is to instill motivation for the hard work of recovery from both disorders.

(4) Four content areas: cognitive, behavioral, interpersonal, and case management.  While originally designed as a cognitive-behavioral intervention (a theoretical orientation that appears well-suited for early recovery stabilization), the treatment was expanded to include interpersonal and case management domains. The interpersonal domain is an area of special need because PTSD most commonly arises from traumas inflicted by others, both for women and men (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).  Interpersonal issues include how to trust others, confusion over what can be expected in relationships, and the need to avoid reenactments of abusive power.  Similarly, addiction is often perpetuated in relationships.  The case management component offers help obtaining referrals for problems such as housing, job counseling, HIV testing, domestic violence, and childcare.

(5) Attention to clinician processes.  It can be a challenge to provide effective therapy to clients with this dual diagnosis, who are often considered “difficult.”  Clinician processes emphasized in Seeking Safety include compassion for clients’ experience; using coping skills in one’s own life; giving the client control whenever possible (to counteract the loss of control inherent in both trauma and addiction); meeting the client more than halfway (e.g., doing anything possible within professional bounds to help the client get better); and obtaining feedback about how clients view the treatment.  A balance of praise and accountability are also suggested.   The opposite of such positive therapist processes are negative processes such as harsh confrontation, sadism, difficulty holding clients accountable due to misguided sympathy, becoming “victim” to the client’s abusiveness, and power struggles.

FIVE NATURAL EMOTIONS GIVEN TO US TO NEGOTIATE LIFE 

  1. GRIEF         repressed             Sadness and Depression

  2. FEAR          repressed             Panic and Anxiety

  3. ENVY          repressed             Jealousy

  4. ANGER       repressed             Rage and/or Violence

  5. LOVE          repressed             Possessiveness