Overview

The title of the treatment, Seeking Safety, expresses a central idea: 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: safety from substances, safety from dangerous relationships (including domestic violence and drug-using friends), and safety from extreme symptoms, such as dissociation and self-harm. Many of these self-destructive behaviors reenact trauma—having been harmed through trauma, clients now harm themselves. "Seeking safety" refers to helping clients free themselves from such negative behaviors and, in so doing, to move toward freeing themselves from trauma at a deep emotional level.

Seeking Safety is an integrated treatment for SUD and trauma/PTSD that can be used from early recovery onward. It was designed to help explore the link between them, but without delving into details about the past that may destabilize clients during early recovery. Its goal is a present-focused, empathic approach that helps clients "own" and name the trauma experience, validates the connection to substance use, provides psychoeducation, and offers specific "safe coping skills" to manage the often overwhelming impulses and emotions of this dual diagnosis. The model focuses equally on both disorders, at the same time, from the start of treatment, but in a way that is designed to be as safe, supportive, and containing as possible.

The treatment provides 25 topics to help clients attain safety. Topics are evenly divided among cognitive, behavioral, and interpersonal domains, with a clinician guide and extensive client handouts. Each topic addresses both trauma/PTSD and SUD. The seven interpersonal topics are:

• Setting boundaries in relationships

• Healthy relationships

• Community resources

• Healing from anger, and

• Getting others to support your recovery

The seven behavioral topics are:

• Detaching from emotional pain: Grounding

• Taking good care of yourself

• Commitment

• Coping with triggers

• Respecting your time, and

• Self-nurturing

The seven cognitive topics are:

• PTSD: Taking back your power

• Compassion

• When substances control you

• Recovery thinking

• Integrating the split self

• Creating meaning

In addition, the four combination topics are:

• Introduction to treatment/case management

• Termination

See Table 10.1 for a brief description of all topics. The treatment manual provides a summary for each topic, a therapist orientation with background and clinical strategies for conducting the session, a quotation to read aloud at the start of each session to engage clients emotionally, client handouts, and examples of "tough cases" that the therapist can rehearse to prepare for the topic. Background chapters on the dual diagnosis and how to conduct the treatment are also provided.

The topics are written in simple language and designed to be emotionally compelling, with a respectful tone that honors clients' courage in fighting the disorders. The topics address new ways of coping and convey the idea that no matter what happens, clients can learn to cope in safe ways—without substances and other destructive behavior. Special emphasis is placed on the clinician's role, such as countertransference and self-care, given the often difficult nature of working with this dual-diagnosis population.

The treatment was developed to be broadly applicable in a wide variety of settings. It has been used for clients with formal diagnoses of both PTSD and SUD, those with one disorder but not the other, and those who do not meet diagnostic criteria (e.g., a trauma history but no PTSD, and/or a SUD history that is not current). For simplicity, the terms PTSD and SUD are used below, although clients do not have to meet formal criteria for these disorders. Topics can be conducted in any order, with the order selected by clients, clinicians, or both. Extensive handouts are available from which clients and clinicians can select those that are most relevant. Each topic is independent of the others and can be conducted as a single session or over multiple sessions, depending on the client's length of stay. Suggestions for how to select the order of topics are provided in the manual.

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