1. S EEKING S AFETY : T REATMENT FOR PTSD AND S UBSTANCE ABUSE Presented by: Caryn Brakenridge

2. L ITERATURE R EVIEW A large number of clients in substance abuse treatment have current posttraumatic stress disorder, estimated to range from 33%-59% in women to 12%-34% in men. The majority of SUD clients have a history of trauma (often multiple traumas), such as child abuse, rape, criminal assault, serious accidents, natural disasters, and combat. Traditional SUD treatment however has neglected these issues.

3. L ITERATURE R EVIEW Most clients in substance abuse treatment programs do not receive assessment or treatment for their PTSD symptoms. Many programs (e.g. Alcoholics Anonymous) suggest holding off on PTSD treatment altogether until clients have been abstinent for several months. Research has shown however that this is often counterproductive for individuals with co-occurring PTSD and SUD. PTSD symptoms may actually worsen during abstinence, especially during the initial phases

4. L ITERATURE R EVIEW Reports on rates of PTSD among women receiving treatment for substance abuse range from 20% to as much as 59%. Current research shows that 48% to 90% of women with co- occurring mental health and substance abuse disorders also have histories of interpersonal violence. According to Brown et al. (2007), fewer than half of women in SUD treatment will receive treatment that addresses their PTSD symptoms along with co-occurring SUD

5. S EEKING S AFETY M ETHOD As a result of the lack of empirically based treatments for women with PTSD and substance abuse, a new, manualized cognitive behavioral group psychotherapy was developed in 1992 under the National Institute on Drug Abuse Behavioral Therapies Development grant. In 1996, Dr. Lisa M. Najavits (Ph.D.) introduced “Seeking Safety”, an integrated intervention for substance abuse and trauma (PTSD)

6. S EEKING S AFETY METHOD What is Seeking Safety? Seeking Safety is a present-focused therapy to help people attain safety from trauma/PTSD and substance abuse. The treatment was designed for flexible use. It has been conducted in group and individual format; for women, men, and mixed-gender; using all topics or fewer topics; in a variety of settings (outpatient, inpatient, residential); and for both substance abuse and dependence. It has also been used with people who have a trauma history, but do not meet criteria for PTSD.

7. S EEKING S AFETY METHOD Introduction/Case Management Safety PTSD: Taking Back Your Power Detaching from Emotional Pain (Grounding) When Substances Control You Honesty Asking for Help Setting Boundaries in Relationships Getting Others to Support Your Recovery Healthy Relationships Community Resources Compassion Creating Meaning Discovery Integrating the Split Self Recovery Thinking Taking Good Care of Yourself Commitment Respecting Your Time Coping with Triggers Self-Nurturing Red and Green Flags Healing from Anger Life Choices Termination Seeking Safety consists of 25 topics that can be conducted in any order:

8. S EEKING S AFETY METHOD The key principles of Seeking Safety are : 1. Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions). 2. Integrated treatment (working on both PTSD and substance abuse at the same time) 3. A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse 4. Four content areas : cognitive, behavioral, interpersonal, case management 5. Attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues)

9. P ROPOSED G ROUP O BJECTIVES This group will be developed as an integrated treatment for PTSD and SUD and will begin during early recovery from both disorders. The group will follow the key principles of Seeking Safety: 1. Emphasize safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions). 2. Follow an integrated treatment (working on both PTSD and substance abuse at the same time) 3. Focus on ideals to counteract the loss of ideals in both PTSD and substance abuse 4. Focus on the four content areas : cognitive, behavioral, interpersonal, case management 5. Pay attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues)

10. C OMPOSITION OF THE G ROUP The “Seeking Safety Group” will consist of 5-7 adult women of mixed race/ethnicity Have reported : Active substance abuse or dependence Have been physically or sexually abused Have been previously diagnosed with PTSD or meet many of the DSM- IV-TR criteria for PTSD. Facilitators = 2 female counselors Group Membership will be open but limited The group will be titled “Seeking Safety Group” to reduce potential fear for clients who may have a negative association with words such as “trauma” or “PTSD”

11. R ECRUITMENT Information about the Seeking Safety Group will be distributed to AODA and mental health facilities and agencies throughout Milwaukee and the surrounding areas. Information will also be posted on the Seeking Safety website which provides information about the Seeking Safety Group, the treatment method used, group membership fees, and registration options (http://www.seekingsafety.org)http://www.seekingsafety.org

12. C LINICIAN S ELECTION / L EADERSHIP The most essential characteristics for selecting clinicians to conduct Seeking Safety are their wish to work with this client population and their willingness to use a manual- based treatment Clinician who do not have any prior background in PTSD, substance abuse, or CBT, some training and/or supervision on should be sought as needed

13. S CREENING AND S ELECTION P ROCESS Interested individuals will participate in a short (30 minute) interview Potential participants will be given an opportunity to discuss their expectations of such a group, including any issues or concerns that they may have has a group member Individuals who have not previously been diagnosed with PTSD will be also be assessed using the Structured Clinical Interview for DSM-IV, to assess symptomatology Counselors will assemble a group composed of members whose needs are compatible with the group and whose well-being will not be jeopardized by the group experience Chosen members will be asked to consent to join the group

14. FREQUENCY / DURATION OF GROUP & GROUP CONTENT The proposed group will also follow the bi-weekly, 90 minute, 25 session program The group will cover each of the 25 treatment topics, Each has a clinical guide and client handouts Topics can be conducted in any order It is recommended that the Introduction to Treatment/Case Management topic be covered first to provide a foundation Each session will contain a sequence of four steps: 1) check-in, 2) the quotation, 3) relating the material to patient’s lives, and 4) check-out

15. T ERMINATION Termination will be the last topic for the last group session It is meant to encourage patients to express their feelings about the ending of treatment, discuss what they liked and disliked about it, and finalize their after care plans A termination letter will be given to the group members to thank them for their efforts in treatment and to wish them the best in their future prospects Group members will be given the Seeking Safety Feedback Questionnaire to rate what they specifically liked and disliked about the treatment.

16. E VALUATION During Treatment: End-of-Session Questionnaires Urinalysis will be completed once a week during treatment Session End: The Seeking Safety Feedback Questionnaire Protocol Implementation Questionnaire (as cite in Brown et al., 2007) will be administered at the conclusion of the Seeking Safety Group

17. L EGAL / E THICAL C ONCERNS Confidentiality in a group setting is one of the most important issue that should be addressed at the beginning of any group. Facilitators should make group members aware of their rights to confidentiality as well as the limitations to confidential in the group setting Group setting can not provide same confidentiality as in individual therapy Group facilitator should still encourage group members to keep group communication within the group

18. S EEKING S AFETY W EBSITE www.seekingsafety.org