Session Structure

Sobriety Success

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The session structure includes a check-in, a quotation (to emotionally engage clients), handouts, and a check-out (see Table 10.2). The structure is designed to model good use of time, appropriate containment, and achievement of goals. For clients with SUD and PTSD, who are often impulsive and

Specialized Populations and Delivery TABLE 10.1. Seeking Safety Topics

1. Introduction to treatment/Case Management

This topic covers (a) introduction to the treatment, (b) getting to know the client, and (c) assessment of case management needs.

2. Safety (combination)

Safety is described as the first stage of healing from both PTSD and substance abuse, and the key focus of the treatment. A list of over 80 Safe Coping Skills is provided and clients explore what safety means to them.

3. PTSD: Taking Back Your Power (cognitive)

Four handouts are offered: (a) What is PTSD?; (b) The Link between PTSD and Substance Abuse; (c) Using Compassion to Take Back Your Power; and (d) Long-Term PTSD Problems. The goal is to provide information as well as a compassionate understanding of the disorder.

4. Detaching from Emotional Pain: Grounding (behavioral)

A powerful strategy, "grounding," is offered to help clients detach from emotional pain. Three types of grounding are presented (mental, physical, and soothing), with an experiential exercise to demonstrate the techniques. The goal is to shift attention toward the external world, away from negative feelings.

5. When Substances Control You (cognitive)

Eight handouts are provided, which can be combined or used separately: (a) Do You Have a Substance Abuse Problem? (b) How Substance Abuse Prevents Healing from PTSD; (c) Choose a Way to Give Up Substances; (d) Climbing Mount Recovery, an imaginative exercise to prepare for giving up substances; (e) Mixed Feelings; (f) Self-Understanding of Substance Use; (g) Self-Help Groups; and (h) Substance Abuse and PTSD: Common Questions.

6. Asking for Help (interpersonal)

Both PTSD and substance abuse lead to problems in asking for help. This topic encourages clients to become aware of their need for help and provides guidance on how to obtain it.

7. Taking Good Care of Yourself (behavioral)

Clients explore how well they take care of themselves using a questionnaire that lists specific behaviors (e.g., "Do you get regular medical checkups?"). They are asked to take immediate action to improve at least one self-care problem.

8. Compassion (cognitive)

This topic encourages the use of compassion when trying to overcome problems. Compassion is the opposite of "beating oneself up," a common tendency for people with PTSD and substance abuse. Clients are taught that only a loving stance toward the self produces lasting change.

Note. Each topic represents a safe coping skill relevant to both SUD and trauma/PTSD, and can be conducted over one or more sessions. After the first topic, the rest can be conducted in any order based on clinician and client preference. Domains are listed in parentheses (cognitive, behavioral, interpersonal, or a combination).

Adapted from (Najavits, 2002c). Copyright 2002 by the American Psychological Association Press. Reprinted by permission.

9. Red and Green Flags (behavioral)

Clients explore the up-and-down nature of recovery in both PTSD and substance abuse through discussion of "red and green flags" (signs of danger and safety). A Safety Plan is developed to identify what to do in situations of mild, moderate, and severe relapse danger.

10. Honesty (interpersonal)

Clients discuss the role of honesty in recovery and role-play specific situations. Related issues include: What is the cost of dishonesty? When is it safe to be honest? What if the other person does not accept honesty?

11. Recovery Thinking (cognitive)

Thoughts associated with PTSD and substance abuse are contrasted with healthier recovery thinking. Clients are guided to change their thinking using rethinking tools such as List Your Options, Create a New Story, Make a Decision, and Imagine. The power of rethinking is demonstrated through think-aloud exercises.

12. Integrating the Split Self (cognitive)

Splitting is identified as a major psychic defense in both PTSD and substance abuse. Clients are guided to notice splits (e.g., different sides of the self, ambivalence, denial) and to strive for integration as a means to overcome these.

13. Commitment (behavioral)

The concept of keeping promises, both to self and others, is explored. Clients are offered creative strategies for keeping commitments, as well as the opportunity to identify feelings that can get in the way.

14. Creating Meaning (cognitive)

Meaning systems are discussed with a focus on assumptions specific to PTSD and substance abuse, such as Deprivation Reasoning, Actions Speak Louder Than Words, and Time Warp. Meanings that are harmful versus healing in recovery are contrasted.

15. Community Resources (interpersonal)

A lengthy list of national nonprofit resources is offered to aid clients' recovery (including advocacy organizations, self-help, and newsletters). Also, guidelines are offered to help clients take a consumer approach in evaluating treatments.

16. Setting Boundaries in Relationships (interpersonal)

Boundary problems are described either in terms of too much closeness (difficulty saying no in relationships) or too much distance (difficulty saying yes in relationships). Ways to set healthy boundaries are explored, and domestic violence information is provided.

17. Discovery (cognitive)

Discovery is offered as a tool to reduce the cognitive rigidity common to PTSD and substance abuse (called "staying stuck"). Discovery is a way to stay open to experience and new knowledge, using strategies such as Ask Others, Try It and See, Predict, and Act As If. Suggestions for coping with negative feedback are provided.

cont.

Specialized Populations and Delivery TABLE 10.1. cont.

18. Getting Others to Support Your Recovery (interpersonal)

Clients are encouraged to identify which people in their lives are supportive, neutral, or destructive toward their recovery. Suggestions for eliciting support are provided, as is a letter that they can give to others to promote understanding of PTSD and substance abuse. A safe family member or friend can be invited to attend the session.

19. Coping with Triggers (behavioral)

Clients are encouraged to actively fight triggers of PTSD and substance abuse. A simple three-step model is offered: change who you are with, what you are doing, and where you are (similar to AA's "change people, places, and things").

20. Respecting Your Time (behavioral)

Time is explored as a major resource in recovery. Clients may have lost years to their disorders, but they can still make the future better than the past. They are asked to fill in schedule blanks to explore issues, such as the following: Do they use their time well? Is recovery their highest priority? Also addressed is how to balance structure versus spontaneity; work versus play; and time alone versus time in relationships.

21. Healthy Relationships (interpersonal)

Healthy and unhealthy relationship beliefs are contrasted. For example, the unhealthy belief, "Bad relationships are all I can get," is contrasted with the healthy belief, "Creating good relationships is a skill I can learn." Clients are guided to notice how PTSD and substance abuse can lead to unhealthy relationships.

22. Self-Nurturing (behavioral)

Safe self-nurturing is distinguished from unsafe self-nurturing (e.g., substances and other "cheap thrills"). Clients are asked to create a gift to the self by increasing safe self-nurturing and decreasing unsafe self-nurturing. Pleasure is explored as a complex issue in PTSD/substance abuse.

23. Healing from Anger (interpersonal)

Anger is explored as a valid feeling that is inevitable in recovery from PTSD and substance abuse. Anger can be used constructively (as a source of knowledge and healing) or destructively (when acted out against self or others). Guidelines for working with both types of anger are offered.

24. The Life Choices Game (combination)

As part of termination, clients are invited to play a game as a way to review the material covered in the treatment. Clients pull from a box slips of paper that list challenging life events (e.g., "You find out your partner is having an affair"). They respond with how they would cope, using game rules that focus on constructive coping.

25. Termination

Clients express their feelings about the ending of treatment, discuss what they liked and disliked about it, and finalize aftercare plans. An optional termination letter can be read aloud to clients to validate the work they have done.

overwhelmed, the predictable session structure helps them know what to expect. It offers, in its process, a mirror of the focus and careful planning that are needed for recovery from the disorders. Most of the session is devoted to the topic selected for the session (per Table 10.1), relating it to current and specific problems in clients' lives. Priority is on any unsafe behavior the client reported during the check-in. The tone of the treatment, when conducted well, feels like deep therapy rather than just psychoeduca-tion or school. There is strong emphasis on rehearsal of the skills during sessions, using any of a number of methods (e.g., role play, experiential exercises, think-alouds, discussion, question-answer, replaying a scene of poor coping, and processing obstacles). There are no particular coping skills or topics clients must master; rather, they are offered a wide variety from which to choose. The goal is to "go where the action is"—to use the materials in a way that adapts to the client, the clinician, and the program.

TABLE 10.2. Session Format

1. Check-In

The goal of the check-in is to find out how clients are doing (up to 5 minutes per patient). Clients report on five questions: Since the last session (a) How are you feeling? (b) What good coping have you done? (c) Describe your substance use and any other unsafe behavior; (d) Did you complete your Commitment? and (e) Community Resource update.

2. Quotation

The quotation is a brief device to help emotionally engage clients in the session (up to 2 minutes). A client reads the quotation out loud. The clinician asks What is the main idea in the quotation? and links it to the topic of the session.

3. Relate the Topic to Clients' Lives

The clinician and/or client select any of the 25 treatment topics (see Table 1) that feels most relevant. This is the heart of the session, with the goal of meaningfully connecting the topic to clients' experience (30-40 minutes). Clients look through the handout for a few minutes, which may be accompanied by the clinician summarizing key points (especially for clients who are cognitively impaired). Clients are asked what they most relate to in the material, and the rest of the time is devoted to addressing the topic in relation to specific and current examples from clients' lives. As each topic represents a safe coping skill, intensive rehearsal of the skill is strongly emphasized.

4. Check-Out

The goal is to reinforce clients' progress and give the clinician feedback (a few minutes per client). Clients answer two questions: (a) Name one thing you got out of today's session (and any problems with it) and (b) What is your new commitment?

Note. From Najavits (2002d). Copyright 2002 by The Guilford Press. Reprinted by permission.

At the end of each session clients are asked to select a commitment to try before the next session. Commitments are very much like cognitive-behavioral therapy (CBT) homework, but the language is changed to emphasize that clients are making a promise—to themselves, to the therapist, and, in group treatment, to the group—to promote their recovery by taking at least one action step forward. Commitments do not have to be written, because clinical experience with this population suggests that some clients do not like written assignments. Examples of commitments include "Ask your partner not to offer you any more cocaine," "Read a book on parenting," and "Write a supportive letter to the young side of you that feels scared." Ideas for commitments are offered at the end of each handout, but therapists are encouraged to customize them to best fit each client (see also Najavits, in press).

The treatment is thus both highly structured yet also extremely flexible— characteristics that may be particularly important when working with severe populations. The multiple needs, impulsivity, and intense affect of such populations can lead to derailed sessions if the clinician does not impose clear structure. Yet the treatment is also highly flexible to allow clients' most important concerns to be kept primary, to allow adaptation to a variety of settings, to respect clinicians' clinical judgment, and to encourage clinicians to remain inspired and interested in the work. These considerations are believed to be paramount when working with a population such as this, where the risks of client dropout and clinician burnout are high (Najavits, 2001). Moreover, the model was designed to adapt to the managed care era, in which many clients have limited access to treatment. Thus the treatment can be extremely short-term (e.g., one or a few sessions, such as on a brief inpatient stay), or can be extended to long-term treatment. The therapy is also designed to be integrated with other treatments. Although it can be conducted as a stand-alone intervention, the severity of clients' needs usually suggests that they be in several treatments at the same time (e.g., 12-step groups, pharmacotherapy, individual therapy, group therapy). Thus, not only was the treatment designed to be used in conjunction with other treatments, but it also includes an intensive case management component to help engage clients in other treatments.

Seeking Safety has been conducted in a variety of formats, including group and individual; open and closed groups; sessions of varying lengths (50 minutes, 1 hour, 90 minutes, and 2 hours); sessions of varying pacing (weekly, twice weekly, and daily); singly and co-led; outpatient, inpatient, and residential; integrated with other treatments or as a stand-alone therapy; and single gender or mixed gender. Some programs have covered all 25 topics, others created two blocks of 12 sessions each, and others allowed clients to cycle through the entire treatment multiple times. In some programs particular topics were added to ongoing treatments (e.g., Healing from Anger was added to an existing anger management group), or only selected topics were covered. in general, however, it is recommended to first try conducting the treatment as planned, in terms of both the topics and the session format, before adapting it. Empirical studies of the treatment thus far, however, were conducted under constrained conditions to evaluate gains within the typical limits of managed care treatment. The treatments were time-limited (typically twice per week for 3 months), with one session per topic. A recent article (Brown et al., 2005) describes adaptations of Seeking Safety in three community programs, with a summary of satisfaction and feedback from both clients and clinicians.

The treatment was first described in an early paper (Najavits et al., 1996), although the treatment evolved considerably after that: from a focus on women to both genders, from group modality to individual as well, and from outpatient to diverse settings. The therapy was developed over 10 years, beginning in the early 1990s, under grants from the National Institute on Drug Abuse. An iterative process was used, such that clinical experience with this dual-diagnosis population led to various versions of the manual over time, with the final version published in 2002. The treatment also drew on educational innovation and research (i.e., how to convey concepts in a way clients can understand). In the rest of this chapter, the treatment is described in more detail, and implementation and assessment considerations are offered.

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