Agenda:

Background on Trauma and Substance Abuse

and Overview of Seeking Safety

9:00am – 10:30am
Background Rates of trauma and substance abuse
• Clinical presentations
• Treatment challenges
• Assessment and community resources
10:30am-10:45am
Break
10:45am – 12:00pm
Treatment
• Stages of treatment
• Overview of Seeking Safety
12:00pm-12:30pm
Lunch
12:30pm – 1:00pm
Video on trauma and substance abuse
1:00pm-2:15pm
More on Seeking Safety
• Evidence base
• Specific interventions
• Frequently asked questions
2:15pm-2:30pm
Break
2:30pm-3:30pm
Clinical demonstration
• Video demonstration of Seeking Safety topic, “Asking for Help” with real clients
• Break into small groups and practice session, Asking for Help
• “Tough cases”: discussion of clinical scenarios that may arise

© Najavits, 1996 (updated 2017), Treatment Innovations, Newton Centre, MA. Downloaded
from www.treatment-innovations.org / Training
 Seeking Safety

Title: Seeking Safety: An evidence-based model for trauma and/or substance abuse

Trainer: certified to provide this training by Lisa Najavits, the developer of Seeking Safety. To
see or verify our list of certified trainers, please see www.treatment-innovations.org / About us /
Team. Lisa supervises each trainer on each training, including preparation and materials.
Slides, videos, and content are identical to those Lisa uses the trainer audiotapes all trainings
(including the one at your site, if you allow it) so they can be reviewed for quality.

Martha Schmitz, Ph.D.is a senior trainer and consultant with Treatment Innovations. For over a
decade, she has offered continuing education workshops and supervision in the treatment of
PTSD and substance abuse to clinicians throughout the United States and abroad. She began
working with Lisa Najavits in 2000 in a postdoctoral fellowship on Seeking Safety research at
McLean Hospital. Dr. Schmitz is currently a staff psychologist at San Francisco VA Medical
Center and an Assistant Clinical Professor at the University of California at San Francisco
School of Medicine. She received her doctorate in counseling psychology from the University of
Missouri at Columbia after earning her master’s and bachelor’s degrees from the University of
California at Davis. She has collaborated on several research projects in both the United States
and France. Her clinical and research interests include posttraumatic stress disorder, substance
abuse, and resiliency in survivors of trauma. She is based in San Francisco, CA. For details,
see her complete resume.

Summary: The goal of this presentation is to describe Seeking Safety, an evidence-based

model for trauma and/or substance abuse (clients do not have to have both issues). By the end
of the training day, participants can implement Seeking Safety in their setting if they choose
to.Seeking Safety teaches present-focused coping skills to help clients attain safety in their
lives. It is highly flexible and can be conducted in any setting by a wide range of clinicians and
also peers. There are 25 treatment topics, each representing a safe coping skill relevant to both
trauma and/or substance abuse, such as “Asking for Help”, “Creating Meaning”, “Compassion”,
and “Healing from Anger”. Topics can be done in any order and the treatment can be done in
few or many sessions as time allows. Seeking Safety strives to increase hope through emphasis
on ideals; it offers exercises, emotionally-evocative language, and quotations to engage
patients; attends to clinician processes; and provide concrete strategies to build recovery skills.
In this training we cover (a) background on trauma and substance abuse (rates, presentation,
models and stages of treatment, clinical challenges); and (b) overview of Seeking Safety
including evidence-base; and (c) clinical implementation such as use of the model with specific
populations. Assessment tools and national resources are also described. Learning methods
include PowerPoint, video, exercises, role-play, and discussion. For more information on
Seeking Safety see www.seekingsafety.org.

Objectives:
1) To review current understanding of evidence-based treatment of trauma and substance
abuse
2) To increase empathy and understanding of trauma and substance abuse
3) To describe Seeking Safety, an evidence-based model for trauma and/or substance abuse
4) To provide assessment and treatment resources
5) To identify how to apply Seeking Safety for specific populations, such as homeless,
adolescents, criminal justice, HIV, military/veteran, etc.
References:

Najavits, L.M. (2017). Recovery from trauma, addiction or both: Finding your best self. New
York: Guilford.

Lenz, A. S., Henesy, R., & Callender, K. (2016). Effectiveness of Seeking Safety for co
occurring posttraumatic stress disorder and substance use. Journal of Counseling &
Development, 94(1), 51-61. doi:10.1002/jcad.12061

Najavits, L. M. (2015). Trauma and substance abuse: A clinician's guide to treatment. In M.

Cloitre & U. Schynder (Eds.), Evidence-based treatments for trauma-related disorders:
Springer-Verlag.

Substance Abuse Mental Health Services Administration (SAMHSA) (2014). TIP: Trauma
Informed Care in Behavioral Health Services Treatment Improvement Protocol (TIP) Series.
Washington, DC: Substance Abuse Mental Health Services Administration (SAMHSA),
Department of Health and Human Services.

Ouimette, P., & Read, J. P. (Eds.). (2014). Handbook of Trauma, PTSD and Substance Use
Disorder Comorbidity. Washington, DC: American Psychological Association Press.

Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books.

Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse.
New York: Guilford Press.

Najavits, L. M. (2007). Seeking Safety: An evidence-based model for substance abuse and
trauma/PTSD In K. A. Witkiewitz & G. A. Marlatt (Eds.), Therapist's Guide to Evidence Based
Relapse Prevention: Practical resources for the mental health professional (pp. 141-167). San
Diego: Elsevier Press.

Najavits, L. M., & Hien, D. A. (2013). Helping vulnerable populations: A comprehensive review
of the treatment outcome literature on substance use disorder and PTSD Journal of Clinical
Psychology, 69, 433-480.
Provided by Treatment Innovations (www.treatment-innovations.org / www.seekingsafety.org) for
8/13/2017
your personal use. For information on adapting / training others please contact us at
info@treatment-innovations.org or info@seekingsafety.org. Thanks!

Seeking Safety
 Training or treatment
 Highly flexible
Seeking Safety:  No training nor certification required (public-health
An evidence-based model for trauma oriented); can be done by any clinical staff & peers
and/or addiction  The lowest-cost PTSD model available
 Easy; safe
 Used for over 20 years
Lisa M. Najavits, PhD  For any type of trauma, any substance type and can
Boston University School of Medicine also be applied to other addictions.
Veterans Affairs Boston  Can be used with people who have just trauma
issues or just addiction (don’t have to have both)
and also for general stabilization

Implementation Seeking Safety evidence

▪ Strong research support for PTSD with SUD-- Division 12
 For complex, vulnerable populations (Psychotherapy) of the American Psychological Association
(APA)
▪ Strong research support for adults and modest research
 Non-English speaking (translated into support for adolescents for SUD -- Society of Addiction
numerous languages); diverse clients Psychology (Division 50) of the APA
▪ Highest level of evidence (level A) -- International Society
for Traumatic Stress Studies treatment guidelines
▪ Supported by research evidence for adults and promising
research evidence for adolescents-- California Evidence-
Based Clearinghouse
▪ National Registry of Evidence-Based Practices and
Programs of the Substance Abuse and Mental Health
Services Administration

DSM-5
Trauma
Posttraumatic Stress Disorder
 DSM-5 (narrower definition): experience, 1. Trauma (experience, threat, or witnessing of death,
threat, or witnessing of death, serious serious injury or sexual violence)
injury or sexual violence 2. Intrusion

 SAMHSA (broader definition): events 3. Avoidance

experienced as physically or emotionally 4. Negative thoughts and mood
harmful or life-threatening with lasting 5. Arousal and reactivity
adverse effects on the individual's 6. More than one month
functioning and mental, physical, social, 7. Functional problems
emotional, or spiritual well-being. 8. Not due to substance use, etc.

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DSM-5 Substance use disorder Clinical Importance

11 symptoms to ask about…  Comorbid PTSD/SUD associated with

– worse treatment outcome
MILD = 2-3 – greater psychiatric, medical, legal, and
MODERATE = 4-5 social problems
SEVERE = six or more – lower functioning
– worse coping
– more positive views of substances

Explore substance use How is PTSD addressed?

in the context of PTSD
 Why are they using?  Present-focused

 Past-focused

Recovery phases Seeking Safety

 Safety plan
Safety
 Safety contract
 Check-in on safe behaviors
Mourning
 Safe coping skills
 Present-focused
Reconnection
(Herman, Trauma and Recovery, 1992)

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Format Session
 Up to 25 topics
 Group or individual
 Open / closed  Check-in
 Women, men, or mixed  Quote
 Adult / adolescent  Content (discussion and rehearsal)
 Check-out

Check-In Topics
 Introduction / Case Management
1. How are you feeling?
 Safety
2. What good coping have you done?
 PTSD: Taking Back Your Power
3. Any substance use or other unsafe behavior?  Substance Abuse
4. Did you complete your commitment?  Asking for Help
 Detaching from Emotional Pain
5. Case management update
(Grounding)
 Taking Good Care of Yourself
 Setting Boundaries in Relationships

Topics Topics
 Discovery
 Community Resources
 Self-Nurturing
 Recovery Thinking
 Getting Others to Support Your Recovery
 Compassion  Respecting Your Time
 Creating Meaning  Healthy Relationships
 Commitment  Integrating the Split Self
 Honesty  Red and Green Flags
 Coping with Triggers  The Life Choices Game (Review)
 Healing from Anger  Termination

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Check-Out End-of-Session Questionnaire

1. Name one thing you got out of the  How helpful was today’s session? Topic?
Handout? Therapist?
session (and any problems with it)
 How much did the session help your PTSD?
2. What is your new Commitment? Your substance abuse?
 How can the treatment be more helpful?
All rated 0 - 4

Safe Coping Skills

 Grounding  Inspire yourself
 Ask for help  Leave a bad scene
 Persistence  Move toward your
 Cry opposite
 Honesty  Compassion
 When in doubt, do  Try an experiment
what’s hardest  Find meaning
 Avoid avoidable  Take responsibility
suffering  Say what you really
 Ask others think

The Treatment Philosophy For More Information

 Safety
 Integrated treatment
 Ideals
 Cognitive, behavioral, interpersonal, case www.seekingsafety.org
management
 Structure / flexibility www.treatment-innovations.org
 Simple language
 Clinician processes

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Also, a new book...

Seeking Safety Book
– Includes some elements of SS
– Self-help and/or clinician-led
– 35 short chapters
– Exercises
– Recovery voices (personal
recovery stories, each chapter)
– Reflection questions
– Culturally sensitive
– Many new topics, e.g., Social pain; The culture
of silence; How do people change? ; Wish vs.
reality; Body and biology; Dark feelings

Trauma-Informed Treatment Culture / diversity

 Routine assessment for trauma and PTSD  Respect cultures

– Healing traditions
 Trauma-informed services vs. trauma-specific – Language and examples
services  Do not assume the treatment needs to be
adapted
 Diversity training for staff
–

Seeking Safety Outcomes

Examples of Studies  Over 20 pilot studies including:
Veteran / military
Criminal justice
Female samples
Male samples
Peer-led
Problem gambling
Inpatient, outpatient, residential
 Over 10 controlled and/or randomized controlled trials
– Veterans
– Low-income urban women
– Adolescent girls
– Women in community treatment
– Women in prison
– Men and women outpatients
 3 multisite trials
– Homeless women veterans
– Women with co-occurring disorders/violence
– Women in community treatment
www.treatment-innovations.org has a summary of each study

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Men and Women with PTSD and alcohol use Peer- versus Clinician-Led Seeking Safety
disorder (AUD) (Hien et al., 2015) (Crisanti et al., under review)
Randomized controlled trial, outpatient, 12 Randomized ontrolled trial; outpatient, weekly
sessions (partial dose study); individual format group SS in context of TAU in rural New
(Seeking Safety plus sertraline versus Seeking Mexico (primarily Hispanic); peer- versus
Safety plus medication placebo); n=69, primarily
clinician-led; n=291. Baseline, 3 and 6 month
African-American. Both conditions showed
significant improvement in both PTSD and AUD followups. Significant improvements over time
at end of treatment, with gains sustained on with no difference between clinician vs. peer-led
both sustained at 6- and 12-month followups. SS: ASI drug use, PTSD Checklist, mental health
The SS/sertraline condition had greater functioning, coping skills. No improvement on
reduction than SS/placebo on PTSD but not physical health functioning.
AUD.

Seeking Safety vs. Creating Change Low-Income Urban Women

(Najavits et al., under review) (Hien et al., 2004)
Randomized ontrolled trial; outpatient men and Randomized controlled trial, outpatient, 3
women veterans; 17 weekly individual SS vs. CC in months, individual format (Seeking Safety,
context of TAU; n=52. Baseline, end of treatment, 3 Relapse Prevention; and TAU non-randomized
month followup. Significant improvements from control); n=107. At end of treatment, SS and
baseline through end of treatment, with gains RP improved in PTSD, substance use, and
sustained at followup, and no difference between psychiatric symptoms, while TAU worsened. At
6- and 9-month follow-up, both SS and RP
treatments: ASI alcohol, drug use, PTSD Checklist,
sustained greater improvement than TAU in
PTSD diagnosis; mental health; quality of life, self-
PTSD and substance use symptoms.
efficacy, SUD cognitions (all medium to large effect
sizes). No change on 3 secondary measures. High
satisfaction and safety profile.

Adolescent Girls Homeless Women Veterans

(Najavits et al., 2006) (Desai et al., 2008, 2009)
Randomized controlled trial, outpatient, 11 VA sites. Controlled study: 359 women
individual format (Seeking Safety vs. TAU); in TAU versus 91 women in SS (2 phase
n=33 (18 vs. 15). Significantly better outcomes study). Group treatment, 26 sessions. pre-
for SS than TAU, including substance use and treatment versus 6 months later. At end of
associated problems, some trauma-related treatment (6 months), SS outperformed
symptoms, cognitions related to PTSD and SUD, TAU in PTSD symptoms, avoidant behavior,
and several other areas of pathology (e.g., social support and days worked; both
anorexia, somatization). Effect sizes were conditions improved in substance use, self-
generally in the moderate to high range. Some esteem, general psychiatric symptoms,
gains were sustained at 3-month follow-up. medical symptoms, hypervigilance, and
days homeless.

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Men Veterans
Implementation
(Boden et al., 2012)
Randomized controlled trial, VA; outpatient,
twice-weekly SS in context of TAU versus TAU-
alone (dosage identical); group format; n=96.
SS significantly outperformed TAU in drug use
over time (31% greater reduction), as well as
greater treatment attendance, client
satisfaction, and increase in active coping. Both
conditions improved over time in alcohol use,
with no difference between them.

Implementation Rehearsal

Discussion vs rehearsal  Interpersonal topics: e.g, role-plays

 Cognitive topics: e.g., think-aloud
Balance
 Behavioral topics: e.g., walk-
“How did you cope?” through

Implementation Process
 Format first  Session safe
 Covering material  Problem solving / support
 Both trauma and substance abuse  Feedback constructive
 Your own style  Trauma bond
 Cross-training  80/20 guideline
 Avoid overcontrolling

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Tips Tips
Check-In:
 Clients do not comment Quote
 All 5 questions each – As written
 Don’t read questions – Respond positively
 Take notes – Don’t “teach”
 Volunteer
Handouts:
– Scan
 Don’t intervene
– “Reactions?”
 “No good coping”: Safe Coping List – Try different ways
 Brief support / concern Check-Out
 Redirect – 1-2 minutes
 Questions 1 & 2 separate – Same as check-in
– Listen; no wrong answers
 Update, news
– Ideas for Commitment, but offer help
 Commitment Sheet

Implementation (continued) Articles

 Link trauma / addiction  Implementing Seeking Safety
 Trainingclinicians in Seeking Safety
 Current, specific client problems  Overviews of Seeking Safety (book
chapters)
 Not “school”  Outcome studies (various)

All at www.seekingsafety.org, Library

How to Start on Seeking Safety For any use

 Chapters 1, 2 & one topic  Grounding
 Try roleplay or with clients  Safety
 “Tough cases”
 PTSD: Taking back your power
 Observe a session
 Asking for help
 Visit www.seekingsafety.org
 Healing from anger
 Coping with triggers

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Frequently Asked Questions

“Adaptation”
(FAQs)
 Within vs outside the model

FAQ FAQ
 “How long should the session and the  “Do clients have to have a formal
treatment be?” diagnosis of PTSD and substance use
--Whatever fits the agency, but in general disorder”
the more the better. Sessions have ranged --No. It’s very common for clients to have a
from 45 minutes to 2 hours, and from just trauma or substance abuse history (or just
a few sessions to six months of treatment. one of these).

FAQ FAQ
 “Can the skills be applied to other  “Any suggestion for naming the group?”
addictive behavior (e.g., bingeing, --Avoid names such as “Trauma Group” or
cutting, gambling)?” “PTSD Group”-- rather, try “Seeking Safety
 --Yes. That is how it’s been implemented Group”, “Safety Group”, or “Coping Skills
in practice and seems to go well. Group”
However, you also would want to refer out
to other focused treatments (e.g., eating
disorder treatment).

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FAQ FAQ
“What background does the clinician need?”  ”Should groups be open or closed?”
--Open groups are the easiest in many
 No specific degree required (has been run with settings; however, it’s been tried in both
various counselors, case managers, etc.)
formats.
 More subtle characteristics do matter:
– Want to work with this population (e.g., some
clinicians may not be a good match for trauma/PTSD
or SUD)
– Willingness to use a manual and follow format
 But more research needed on this topic

FAQ FAQ
 “With all the handouts, how do I select  “Should a client join Seeking Safety only
what to focus on?” after an initial stabilization period?”
--Prioritize any unsafe behavior a client --It was designed for use from the very start
reported at check-in of treatment, and for all types of
--Go where the client goes: Have clients treatments (e.g., inpatient, residential).
scan handouts and ask “What strikes you?
What would you like to focus on?”

FAQ FAQ
 “What if a client brings up trauma  “How do I select clients for the
details during the session?” treatment?”
--Redirect kindly and supportively --Be inclusive: allow all clients unless a
--Explain that group needs to stay safe for problem occurs
all clients and trauma details can be --Select clients who want to be in the
triggering treatment
--Describe readiness for trauma processing
(for individual treatment): ability to stop
using, cutting; ability to ask for help, etc.

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FAQ FAQ
 “Arethere particular issues for group  “How can I adapt the treatment for short
time frames?”
treatment?”
--Try breaking it into smaller chunks (e.g., 2
--Plan the number of clients based based on 12-session phases)
session length (remembering check-in is 5
--Try running it more times per week
minutes each)
--Allow clients to just do what topics they
--Limit the number of clients who over- can
dominate (e.g., manic) --Select key topics (e.g., Safety, PTSD,
Grounding, Asking for Help)

FAQ FAQ
 ”How should absences or dropouts be  “What if clients try to use the style
handled?” accepted in other groups-- lots of
--Open door: Welcome clients back, no confrontation and feedback?”
matter how many sessions they miss --Explain that because this group focuses on
--Consumer approach: Allow clients to drop trauma, the style needs to be different:
out without feelings of shame or failure giving each person space to talk, focusing
on own recovery not others’, providing
support rather than confrontation.

FAQ FAQ
 “Do clients get dismissed from the  “What if a client can’t read the material?”
treatment for not showing up, or not --Summarize it briefly
doing commitments?” --Ask other clients to read small sections out
--No. Only dismiss a client who is directly a loud
threat to group (e.g., threat of physical
harm to other members, selling drugs)

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FAQ FAQ
 “What if I plan to do the topic ‘Grounding’  “Can you do mixed-gender groups?”
and the client says she was evicted from --It’s been done that way, but only when the
her home that week?” clients are willing, and when none have a
--Change to a different topic that is relevant history of being perpetrators.
(e.g., Community Resources)

FAQ FAQ
 “How do I limit the check-in to 5 minutes  “Are there liability issues in having
per client?” substance abuse counselors treat PTSD?”
--Two steps: validate and contain (e.g., “You’re
bringing up very important material, but in the --Focus on psychoeducation, coping skills
interest of time, I’d like to ask you the next (not trauma “processing”)
check-in question) --Have mental health backup and refer out
--Make a plan to return to it later in the session when needed
--Ask the client’s permission (e.g., “Would you be
okay if I interrupt you there, so others get a --Provide supervision and peer support
chance to check in too?”)

FAQ
 How can a client best be added to an on-
going (open) Seeking Safety group?
– Do topic 1-A Introduction individually or in
small subgroup (to orient new clients)
– Consider also doing PTSD: Taking Back Your
Power (to help client learn about trauma and
PTSD)

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2017 / Lisa Najavits, PhD / Treatment Innovations / Short version of basic handouts

To download long version of these handouts (including educational resources and assessments):
www.seekingsafety.org (section Training / Materials / Handouts)

PTSD
DSM-V definition: After a trauma (the experience, threat, or witnessing of physical harm, e.g., rape, hurricane), the
person has each of the following key symptoms for over a month, and they result in decreased ability to function (e.g.,
work, social life): intrusion (e.g., flashbacks, nightmares); avoidance (not wanting to talk about it or remember);
negative thoughts and mood; and arousal (e.g., insomnia, anger).
Simple PTSD results from a single event in adulthood (DSM-V symptoms); Complex PTSD is not a DSM term but
may result from multiple traumas, typically in childhood (broad symptoms, including personality problems)
Rates: 10% for women, 5% for men (lifetime, U.S.). Up to 1/3 of people exposed to trauma develop PTSD.
Treatment: if untreated, PTSD can last for decades; if treated, people can recover. Evidence-based treatments
include cognitive-behavioral-- coping skills training and exposure, i.e., processing the trauma story.

Substance Abuse
“The compulsion to use despite negative consequences” (e.g., legal, physical, social, psychological). Note that
neither amount of use nor physical dependence define substance abuse.
DSM-V term is “substance-related and addictive disorder”, which can be mild, moderate, or severe.
Rates: 35% for men; 18% for women (lifetime, U.S.)
It is treatable disorder and a “no-fault” disorder (i.e., not a moral weakness)
Two ways to give it up: “cold turkey” (give up all substances forever; abstinence model) or “warm turkey” (harm
reduction, in which any reduction in use is a positive step); moderation management, some people can use in a
controlled fashion-- but only those not dependent on substances, and without co-occurring disorders).

The Link Between PTSD and Substance Abuse

About PTSD and substance abuse
Rates: Of clients in substance abuse treatment, 12%-34% have current PTSD. For women, rates are 33%-59%.
Gender: For women, typically a history of sexual or physical childhood trauma; for men, combat or crime
Drug choice: No one drug of choice, but PTSD is associated with severe drugs (cocaine, opioids); in 2/3 of cases
the PTSD occurs first, then substance abuse.

Recommended treatment strategies

Treat both disorders at the same time. Research supports this and clients prefer this.
Decide how to treat PTSD in context of active substance abuse. Options: (1) Focus on present only (coping skills,
psychoeducation, educate about symptoms) [safest approach, widely recommended]. (2) Focus on past only (tell the
trauma story) [high risk; works for some clients] (3) Focus on both present and past
Know that treatments helpful for either disorder alone may be problematic if someone has both disorders (e.g.,
emotionally intense exposure therapies, benzodiazepines), and should be evaluated carefully prior to use.

Diversity Issues
In the US, rates of PTSD do not differ by race (Kessler et al., 1995). Substance abuse: Hispanics and African-
Americans have lower rates than Caucasians; Native Americans have higher rates than Caucasians (Kessler et al.,
1995, 2005). Rates of abuse increase with acculturation. Some cultures have protective factors (religion, kinship).
It is important to respect cultural differences and tailor treatment to be sensitive to historical prejudice. Also, terms
such as “trauma,” “PTSD,” and “substance abuse” may be interpreted differently based on culture.

Seeking Safety
About Seeking Safety
 A present-focused model to help clients (male and female) attain safety from PTSD and substance abuse.
 Up to 25 topics that can be conducted in any order, doing as many as time allows:
• Interpersonal topics: Honesty, Asking for Help, Setting Boundaries in Relationships, Getting Others to
Support Your Recovery, Healthy Relationships, Community Resources
• Cognitive topics: PTSD: Taking Back Your Power, Compassion, When Substances Control You, Creating
Meaning, Discovery, Integrating the Split Self, Recovery Thinking
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• Behavioral topics: Taking Good Care of Yourself, Commitment, Respecting Your Time, Coping with
Triggers, Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding)
• Other topics: Introduction/Case Management, Safety, Life Choices, Termination
 Designed for flexible use: can be conducted in group or individual format; for women, men, or mixed-gender;
using all topics or fewer topics; in a variety of settings; and with a variety of providers (and peers).

Key principles of Seeking Safety

 Safety as the goal for first-stage treatment (later stages are mourning and reconnection)
 Integrated treatment (treat both disorders at the same time)
 A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse
 Four content areas: cognitive, behavioral, interpersonal, case management
 Attention to clinician processes: balance praise and accountability; notice your own emotional responses (fear,
wish to control, joy in the work, disappointment); all-out effort; self-care

Additional features
 “Headlines, not details” in relation to trauma.
 Identify meanings of substance use in context of PTSD (to remember, to forget, to numb, to feel, etc.)
 Optimistic: focus on strengths and future
 Help clients obtain more treatment and attend to daily life problems (housing, AIDS, jobs)
 Harm reduction model or abstinence
 12-step groups encouraged, not required
 Empower clients whenever possible
 Make the treatment engaging: quotations, everyday language
 Emphasize core concepts (e.g., “You can get better”)

Evidence Base
Seeking Safety is an evidence-based model, with over 40 published peer-reviewed study articles and consistently
positive results. See www.seekingsafety.org, section Evidence. Studies include pilots, randomized controlled trials,
multi-site trials.

Resources on Seeking Safety. All below are available from www.seekingsafety.org.

 Implementation / research articles / Fidelity Scale can be freely downloaded.
 Training: training calendar and information on setting up a training (section Training).
 Consultation: on clinical implementation, research studies, evaluation projects.
 Book: Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. Has the clinician guide and all
client handouts. Also available in over 10 languages including Spanish, French, German, Chinese.
 DVD training series
 Online learning
 Teaching Guide to Introduce Seeking Safety to your agency
 Poster: poster of over 80 safe coping skills, full-color, scenic background; large format (24 x 30”) or 1-page format
(in English or Spanish).
 Card deck: all of the safe coping skills and quotations on cards, with ideas for games. English or Spanish.
 Magnets, key chain to remind clients of the skills.

Contact Information
Contact: Treatment Innovations, 28 Westbourne Road, Newton Centre, MA 02478; 617-299-1610 [phone];
info@treatment-innovations.org [email]; www.seekingsafety.org or www. www.treatment-innovations.org [web]

Would you like to be added to the Seeking Safety website to list that you conduct Seeking Safety? If so, please
email info@seekingsafety.org your basic information OR fill out the online entry on the website. Example: Boston, MA:
Karen Smith, LICSW; group and individual Seeking Safety; private practice with sliding scale. 617-300-1234.
Karensmith@netzero.com.
 3

With appreciation to the Allies Program (Sacramento, CA) for formatting this Safe Coping List.
© Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <info@seekingsafety.org> or <permissions@guilford.com>
 4

© Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <permissions@guilford.com>
 5
Lisa Najavits, PhD
Detaching From Emotional Pain (Grounding)
WHAT IS GROUNDING?
Grounding is a set of simple strategies to detach from emotional pain (for example, drug cravings, self-harm
impulses, anger, sadness). Distraction works by focusing outward on the external world-- rather than
inward toward the self. You can also think of it as “distraction,” “centering,” “a safe place,” “looking outward,”
or “healthy detachment.”
WHY DO GROUNDING?
When you are overwhelmed with emotional pain, you need a way to detach so that you can gain control
over your feelings and stay safe. As long as you are grounding, you cannot possibly use substances or hurt
yourself! Grounding “anchors” you to the present and to reality.
Many people with PTSD and substance abuse struggle with either feeling too much (overwhelming
emotions and memories) or too little (numbing and dissociation). In grounding, you attain balance between the
two-- conscious of reality and able to tolerate it.
Guidelines
 Grounding can be done any time, any place, anywhere and no one has to know.
 Use grounding when you are: faced with a trigger, having a flashback, dissociating, having a substance
craving, or when your emotional pain goes above 6 (on a 0-10 scale). Grounding puts healthy distance
between you and these negative feelings.
 Keep your eyes open, scan the room, and turn the light on to stay in touch with the present.
 Rate your mood before and after to test whether it worked. Before grounding, rate your level of emotional
pain (0-10, where means “extreme pain”). Then re-rate it afterwards. Has it gone down?
 No talking about negative feelings or journal writing. You want to distract away from negative feelings, not
get in touch with them.
 Stay neutral-- no judgments of “good” and “bad”. For example, “The walls are blue; I dislike blue because it
reminds me of depression.” Simply say “The walls are blue” and move on.
 Focus on the present, not the past or future.
 Note that grounding is not the same as relaxation training. Grounding is much more active, focuses on
distraction strategies, and is intended to help extreme negative feelings. It is believed to be more effective for
PTSD than relaxation training.
WAYS TO GROUND
Mental Grounding
 Describe your environment in detail using all your senses. For example, “The walls are white, there are
five pink chairs, there is a wooden bookshelf against the wall...” Describe objects, sounds, textures, colors,
smells, shapes, numbers, and temperature. You can do this anywhere. For example, on the subway: “I’m on
the subway. I’ll see the river soon. Those are the windows. This is the bench. The metal bar is silver. The
subway map has four colors...”
 Play a “categories” game with yourself. Try to think of “types of dogs”, “jazz musicians”, “states that begin
with ‘A’”, “cars”, “TV shows”, “writers”, “sports”, “songs”, “European cities.”
 Do an age progression. If you have regressed to a younger age (e.g., 8 years old), you can slowly work
your way back up (e.g., “I’m now 9”; “I’m now 10”; “I’m now 11”…) until you are back to your current age.
 Describe an everyday activity in great detail. For example, describe a meal that you cook (e.g., “First I peel
the potatoes and cut them into quarters, then I boil the water, I make an herb marinade of oregano, basil,
garlic, and olive oil…”).
 Imagine. Use an image: Glide along on skates away from your pain; change the TV channel to get to a
better show; think of a wall as a buffer between you and your pain.
 Say a safety statement. “My name is ____; I am safe right now. I am in the present, not the past. I am
located in _____; the date is _____.”
 Read something, saying each word to yourself. Or read each letter backwards so that you focus on the
letters and not on the meaning of words.
 Use humor. Think of something funny to jolt yourself out of your mood.
 Count to 10 or say the alphabet, very s..l..o..w..l..y.
 Repeat a favorite saying to yourself over and over (e.g., the Serenity Prayer).
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Physical Grounding
• Run cool or warm water over your hands.
• Grab tightly onto your chair as hard as you can.
• Touch various objects around you: a pen, keys, your clothing, the table, the walls. Notice textures, colors,
materials, weight, temperature. Compare objects you touch: Is one colder? Lighter?
• Dig your heels into the floor-- literally “grounding” them! Notice the tension centered in your heels as you
do this. Remind yourself that you are connected to the ground.
• Carry a grounding object in your pocket-- a small object (a small rock, clay, ring, piece of cloth or yarn) that
you can touch whenever you feel triggered.
• Jump up and down.
• Notice your body: The weight of your body in the chair; wiggling your toes in your socks; the feel of your
back against the chair. You are connected to the world.
• Stretch. Extend your fingers, arms or legs as far as you can; roll your head around.
• Walk slowly, noticing each footstep, saying “left”,”right” with each step.
• Eat something, describing the flavors in detail to yourself.
• Focus on your breathing, noticing each inhale and exhale. Repeat a pleasant word to yourself on each
inhale (for example, a favorite color or a soothing word such as “safe,” or “easy”).
Soothing Grounding
❖ Say kind statements, as if you were talking to a small child. E.g., “You are a good person going through a
hard time. You’ll get through this.”
❖ Think of favorites. Think of your favorite color, animal, season, food, time of day, TV show.
❖ Picture people you care about (e.g., your children; and look at photographs of them).
❖ Remember the words to an inspiring song, quotation, or poem that makes you feel better (e.g., the Serenity
Prayer).
❖ Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or
a favorite room); focus on everything about that place-- the sounds, colors, shapes, objects, textures.
❖ Say a coping statement. “I can handle this”, “This feeling will pass.”
❖ Plan out a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath.
❖ Think of things you are looking forward to in the next week, perhaps time with a friend or going to a movie.
WHAT IF GROUNDING DOES NOT WORK?
• Practice as often as possible, even when you don’t “need” it, so that you’ll know it by heart.
• Practice faster. Speeding up the pace gets you focused on the outside world quickly.
• Try grounding for a looooooonnnnngggg time (20-30 minutes). And, repeat, repeat, repeat.
• Try to notice whether you do better with “physical” or “mental” grounding.
• Create your own methods of grounding. Any method you make up may be worth much more than those
you read here because it is yours.
• Start grounding early in a negative mood cycle. Start when the substance craving just starts or when
you have just started having a flashback.
© Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <permissions@guilford.com>
 7
Lisa Najavits, PhD

Taking Good Care of Yourself

Answer each question below “yes” or “no.”; if a question does not apply, leave it blank.

DO YOU…

Associate only with safe people who do not abuse or hurt you? YES___ NO___
Have annual medical check-ups with a:
•Doctor? YES___ NO ___ •Dentist? YES___ NO ___
•Eye doctor? YES ___NO ___ •Gynecologist (women only)? YES ___ NO ___
Eat a healthful diet? (healthful foods and not under- or over-eating) YES ___ NO ___
Have safe sex? YES ___ NO ___
Travel in safe areas, avoiding risky situations (e.g., being alone in deserted areas)? YES ___ NO ___
Get enough sleep? YES ___ NO ___
Keep up with daily hygiene (clean clothes, showers, brushing teeth, etc.)? YES ___ NO ___
Get adequate exercise (not too much nor too little)? YES ___ NO ___
Take all medications as prescribed? YES __ NO___
Maintain your car so it is not in danger of breaking down? YES ___ NO ___
Avoid walking or jogging alone at night? YES___ NO ___
Spend within your financial means? YES___ NO ___
Pay your bills on time? YES___ NO ___
Know who to call if you are facing domestic violence? YES___ NO ___
Have safe housing? YES___ NO ___
Always drive substance-free? YES___ NO ___
Drive safely (within 5 miles of the speed limit)? YES___NO___
Refrain from bringing strangers home to your place? YES___ NO ___
Carry cash, ID, and a health insurance card in case of danger? YES___ NO ___
Currently have at least two drug-free friendships? YES ___ NO ___
Have health insurance? YES___ NO ___
Go to the doctor/dentist for problems that need medical attention? YES__NO__
Avoid hiking or biking alone in deserted areas? YES___ NO ___
Use drugs or alcohol in moderation or not at all? YES ___ NO ___
Not smoke cigarettes? YES ___ NO ___
Limit caffeine to fewer than 4 cups of coffee per day or 7 colas? YES ___ NO ___
Have at least one hour of free time to yourself per day? YES ___ NO ___
Do something pleasurable every day (e.g., go for a walk)? YES___ NO___
Have at least three recreational activities that you enjoy (e.g., sports, hobbies— but not substance use!) ?
YES___ NO___
Take vitamins daily? YES___NO___
Have at least one person in your life that you can truly talk to (therapist, friend, sponsor, spouse)? YES___NO___
Use contraceptives as needed? YES___NO___
Have at least one social contact every week? YES___NO___
Attend treatment regularly (e.g., therapy, group, self-help groups)? YES___NO___
Have at least 10 hours per week of structured time? YES ___ NO ___
Have a daily schedule and “to do” list to help you stay organized? YES___NO___
Attend religious services (if you like them)? YES___ NO___ N/A___
Other: ______________________________ YES ___ NO ___
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YOUR SCORE: (total # of “no’s) ______

Notes on self-care:
Self-Care and PTSD. People with PTSD often need to learn to take good care of themselves. For example, if
you think about suicide a lot, you may not feel that it’s worthwhile to take good care of yourself and may need
to make special efforts to do so. If you were abused as a child you got the message that your needs were not
important. You may think, “If no one else cares about me, why should I?” Now is the time to start treating
yourself with respect and dignity.
Self-Care and Substance Abuse. Excessive substance use is one of the most extreme forms of self-neglect
because it directly harms your body. And, the more you abuse substances the more you are likely to neglect
yourself in other ways too (e.g., poor diet, lack of sleep).
Try to do a little more self-care each day. No one is perfect in doing everything on the list at all times.
However, the goal is to take care of the most urgent priorities first and to work on improving your self-care
through daily efforts. “Progress, not perfection.”

© Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <permissions@guilford.com>
 9
Najavits, LM (2002)
Creating Meaning in PTSD and Substance Abuse
MEANINGS THAT DEFINITION EXAMPLES MEANINGS THAT
HARM HEAL
Deprivation Because you have --I’ve had a hard time, so Live Well. A happy,
Reasoning suffered a lot, you deserve I’m entitled to get high. functional life will make
substances (or other --If you went through what I up for your suffering far
destructive behavior). did, you’d cut your arm too. more than will hurting
yourself. Focus on
positive steps to make
your life better.
I’m Crazy You believe that you --I must be crazy to be Honor Your Feelings.
shouldn’t feel the way feeling this upset. You are not crazy. Your
you do --I shouldn’t have this feelings make sense in
craving. light of what you have
been through. You can
get over them by talking
about them and learning
to cope.
Time Warp It feels like a negative --This craving won’t stop. Observe Real Time.
feeling will go on forever. --If I were to cry, I would Take a clock and time
never stop. how long it really lasts.
Negative feelings will
usually subside after a
while; often they will go
away sooner if you
distract with activities.
Actions Speak Show distress by actions, --Scratches on my arml Break Through the
Louder than Words or people won’t see the show what I feel Silence. Put feelings
pain. --An overdose will show into words. Language is
them. the most powerful
communication for
people to know you.

Beating Yourself In your mind, you yell at --I’m a loser. Love—Not Hate--
Up yourself and put yourself --I’m a no-good piece of Creates Change.
down. dirt. Beating yourself up does
not change your
behavior. Care and
understanding promote
real change.
The Past is the Because you were a --I can’t trust anyone. Notice Your Power.
Present victim in the past, you are --I’m trapped. Stay in the present: I am
a victim in the present. an adult (no longer a
child); I have choices (I
am not trapped); I am
getting help (I am not
alone).
 10
The Escape An escape is needed (e.g., --I’ll never get over this; I Keep Growing.
food, cutting) because have to cut myself. Emotional growth and
feelings are too painful --I can’t stand cravings; I learning are the only real
have to smoke a joint. escape from pain. You
can learn to tolerate
feelings and solve
problems.
Ignoring Cues If you don’t notice a --If I just ignore this Attend to Your Needs.
problem it will go away. toothache it will go away Listen to what you’re
--I don’t abuse substances. hearing; notice what
you’re seeing; believe
your gut feeling.
Dangerous You give yourself --Just one won’t hurt. Seek Safety.
Permission permission for self- --I’ll just buy a bottle of Acknowledge your urges
destructive behavior. wine for a new recipe and feelings and then
find a safe way to cope
with them.
The Squeaky Wheel If you get better you will --If I do well, my therapist Get Attention from
Gets the Grease not get as much attention won’t notice me. Success. People love to
from people --No one will listen to me pay attention to success.
unless I’m in distress. If you don’t believe this,
try doing better and
notice how people
respond to you.
It’s All My Fault Everything that goes --The trauma was my fault Give Yourself a Break.
wrong is due to you. --If I have a disagreement Don’t carry the world on
with someone, it means I’m your shoulders. When
wrong. you have conflicts with
others, try taking a 50-50
approach (50% is their
responsibility, 50% is
yours).
I am My Trauma Your trauma is your --My life is pain. Create a Broad
identity; it is more --I am what I have Identity. You are more
important than anything suffered.. than what you have
else suffered. Think of your
different roles in life,
your varied interests,
your goals and hopes.

© Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <info@seekingsafety.org> or permissions@guilford.com