Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD
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Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD.

Zlotnick C., Johnson J., Najavits L.M.
Behavior Therapy: 2009, 40, p. 325–336.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Zlotnick at czlotnick@butler.org. You could also try this alternative source.

Seeking Safety is a prominent therapy for the common combination of substance dependence and post-traumatic stress disorder, yet in this study of imprisoned women in the USA it did not significantly augment outcomes from the prison's own substance use treatment. Asking 'Why not?' generates interesting explanations.

Summary This US study tested the applicability and impacts among imprisoned women of the Seeking Safety cognitive-behavioural therapy programme The key principles are:
• safety as the overarching goal (helping clients attain safety in their relationships, thinking, behaviour, and emotions);
• integrated treatment (working on both PTSD and substance abuse at the same time);
• a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse;
• four content areas: cognitive, behavioural, interpersonal, case management;
• attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues).
The 25 topics covered in the programme are: Introduction/Case Management; Safety; PTSD: Taking Back Your Power; 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; Detaching from Emotional Pain (Grounding); Life Choices; and Termination.
intended for people suffering both substance dependence and post-traumatic stress disorder – a severe anxiety disorder consequent on a highly traumatising or distressing event such as sexual abuse. Seeking Safety is a present-focused therapy which in an integrated manner aims to help these people attain safety both from the effects of trauma and from substance abuse, the latter through abstinence.

The study was open to women due to be released within 12 to 16 weeks who met diagnostic criteria for substance dependence (based on the month before they were imprisoned) and for post-traumatic stress disorder. They were recruited from a residential substance use treatment programme in a minimum security wing of a women's prison. Among the 49 who joined the trial, a history of (often childhood) sexual and physical abuse was the norm, as was prior imprisonment and alcohol dependence. They were randomly allocated to just the usual prison residential programme or additionally to Seeking Safety. In this implementation, Seeking Safety was conducted in 90-minute small group sessions, typically three times a week for six to eight weeks, and after leaving prison weekly individual 'booster' sessions were on offer for 12 weeks. It supplemented the prison's own residential treatment – an intensive group psychoeducational programme, entry to which was voluntary, though to stay in the programme women had to attend all components. These spanned 30 hours a week typically over three to six months and adopted a 12-step approach. While content was extensive, Including case management, drug counselling, and psychoeducational groups on: women's health; domestic violence; managing emotions; relapse prevention; career exploration; anger management; and parenting. no sessions specifically addressed trauma and there was no post-release continuity option.

Main findings

The Seeking Safety sessions in prison were welcomed by the women. Of the 103 asked to join the study, just nine turned it down, all allocated to the programme began it, they voluntarily attended nearly 16 sessions, and satisfaction ratings were high. But largely it was thought due to a disordered post-prison life and competing priorities, on average they attended just three of the 12 post-release sessions.

The main issues were whether as well as being welcomed, this extra intervention contributed to improvements in substance use, legal problems and psychological health. The baseline for substance use was the month before being imprisoned, and for other measures, the month before the study intake interview. The women were then re-assessed shortly before release and three and six months later. These interviews revealed no statistically significant differences between the considerable gains made by the women whether or not they had been offered Seeking Safety sessions. The consistent pattern was that after both options, women improved significantly from intake to each follow-up point on each domain measured. However, exploratory extra analyses showed that after leaving prison Seeking Safety participants continued to improve their psychological health (both in general and trauma-related), while those not offered these sessions lost some of the gains made in prison. The gaps this opened up between the two groups were not wide and consistent enough to be statistically significant, but did suggest that improvements were better sustained after the extra Seeking Safety inputs.

The authors' conclusions

Results from the featured study contrast to other studies comparing Seeking Safety to usual treatments, which consistently found significant and numerous relative benefits from the programme as measured at the end of treatment. However, comparing these trials is complicated by differences in what counted as 'usual treatment'. In the featured study, usual treatment had the added advantage of attendance being mandatory and the case management component of Seeking Safety was not implemented. Also, women who experienced the programme and the clinicians trained in it may have created spill over benefits for usual treatment participants with whom respectively they were housed and who they also treated. Nevertheless, particularly in relation to psychological health, there were signs of more persistent and even cumulating benefits from Seeking Safety which were not apparent after usual prison treatment. Whether these were due to Seeking Safety's distinctive features or to the offer of aftercare is unclear. It was also encouraging that among women with such intense needs, satisfaction with Seeking Safety was high and that greater attendance was associated with greater improvement in trauma-related and drug use symptoms.

Findings logo commentary The generally equally encouraging results from the prison's usual treatment and Seeking Safety must be seen in the context of the extended, intensive, and potentially powerful intervention to which Seeking Safety was added as a relatively minor and – since the core case management role was conceded to the prison programme – perhaps peripheral add-on. It also seems possible that the influence of this add-on was overwhelmed not just by the prison programme, but by the motivation of women prepared to spend months in this programme, and by a radical change of environment consequent upon the women's release from prison. The appreciation shown by of the women who attended Seeking Safety sessions at least raises the possibility that they got something positive out of these which was not adequately or perhaps at all measured by the study. And the hint of more sustained and cumulative improvement gains greater credibility because it chimes with what has been found in other studies of cognitive-behavioural therapies for substance use. These current findings do however reinforce doubts over whether Seeking Safety's focus on post-trauma distress consistently adds much to other well specified and equally extensive treatments without such a focus.

Despite its prior record in comparison with usual treatments, in one study Seeking Safety did not outshine a well structured alternative treatment focused on substance use, even in respect of the trauma-related and psychological health dimensions which the programme was designed to address. In general, supplementing substance use treatment with treatment for anxiety (including that generated by past trauma) has produced patchy results, sometimes improving substance use outcomes, sometimes the reverse or not at all, sometimes creating greater mental health gains, and sometimes not. It seems that in many cases (but certainly not all), remission of the aggravating influence of substance over-use, and perhaps too the non-specific strands of substance use treatment such as being cared for, listened to, and paid attention, are enough to mitigate depression and anxiety. For these findings and for an extended discussion of related UK policy and practice related to such patients see this Findings analysis.

Adding to the doubts about its specific effectiveness, in at least one study of trauma-affected female substance use treatment patients, Seeking Safety proved equivalent in effectiveness to another add-on (women's health education groups) not designed to affect psychological health or substance use at all, but to act as a 'placebo' offering extra attention and expectation of benefit, but no structured treatment.

Seeking Safety is one of several programmes intended for the same constellation of trauma-related and substance use disorders; for more see this US clinical guide and this review specifically addressing civilian post-traumatic stress and substance use disorders. There is some evidence that well specified and well integrated approaches of these kinds to trauma and substance use are preferable to treatments described as 'usual' in the relevant studies, but as yet is unclear which if any is the most effective.

One possibly significant advantage Seeking Safety has over some alternatives is its focus on the present; it does not require the client to recount, relive or be exposed to analogues of their past traumatic experiences. In this respect it seems unlikely to trigger greater distress. In the study referred to above which found Seeking Safety did not improve outcomes relative to women's health education groups, it was also the case that it generated no more (in terms of numbers of women and severity) adverse consequences like symptom aggravation.

The featured study provides an object lesson in the need for adequate control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. groups when assessing the effectiveness of interventions. An earlier study from the same researchers in what seems to have been the same prison and testing the same in-prison treatments produced 'promising' results which (with other work) suggested that "a treatment targeting [post-traumatic stress disorder] and substance abuse may be helpful for women with notable clinical severity and life problems". But this study had no comparison group of women who had not been allocated to Seeking Safety. When in the featured study this trial was replicated with a comparison group, it became clear that Seeking Safety's targeting of post-traumatic stress disorder was for these women of doubtful extra benefit.

Last revised 17 June 2011

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