BACKGROUND/RATIONALE:
PTSD and substance use disorder (SUD) are significant issues for OEF/OIF veterans. High rates of PTSD are reported in OEF/OIF troops (from 11.5% in army troops to 19.9% in marines. For SUD, 37% of OEF/OIF veterans seen in the VA have been diagnosed with alcohol dependence or nondependent abuse of drugs. Clients with comorbid PTSD/SUD, compared to those with either disorder alone, have worse treatment outcomes, lower work functioning, more additional Axis I and II disorders, and more medical and legal problems. VA clinicians may be unaware of models to treat both disorders at the same time. Clinicians need training in how to engage these clients (especially the OEF/OIF generation) and how to manage the challenges that arise. Finally, treating both disorders at the same time is believed to be more cost-effective.
Seeking Safety (SS) Therapy. SS is the only model for comorbid PTSD/SUD that is established as effective using standard criteria in the field; has shown positive outcomes in VA settings, and is widely adopted in clinical settings. SS is a present-focused therapy to help clients attain safety from PTSD and SUD. It is manualized, and was designed for group or individual format; males and females; all settings (e.g., outpatient, inpatient, residential); both substance abuse and dependence; and all types of trauma (e.g., combat, military sexual trauma). It has a high level of flexibility, with 25 topics that address cognitive, behavioral, interpersonal, and case management domains, although it can be done in as few as six sessions and still produce positive outcomes. See www.seekingsafety.org for all studies. There are over 17 completed studies on SS, including multisite trials (one in the VA), randomized controlled trials (including one on men veterans recently completed), pilot studies (including three in VA), and a dissemination trial. All of the studies have found positive results in various areas including trauma-related symptoms, SUD, and/or other symptom areas, as well as strong treatment attendance and client satisfaction. In trials with multiple arms (randomized and/or controlled, and multisite), SS consistently outperformed treatment-as-usual.

OBJECTIVE(S):
Project design overview. This implementation demonstration project was designed to train 36 clinicians in SS who would treat at least 72 OEF/OIF veterans, both male and female, in group and/or individual format. Clients were to concurrently receive unrestricted treatment-as-usual. The focus was to be formative evaluation of the acceptability and feasibility of SS among VA staff and OEF/OIF veterans, feedback on how to adapt the model for this population, and the production of written guidelines on ways to improve the use of the model with this population.

METHODS:
Sites: The project was designed to be conducted at VA Boston and VA San Diego as the two study sites, with VA Providence as a study location to also collect data (in proximity to the VA Boston site). VA Providence had to drop out just after the study began due to staffing changes there, and the study was thus conducted at the other two locations (Boston and San Diego).

Sample size. The attained sample size was 41 clinicians and 29 patients who filled out initial measures. Note that the number of clinicians is higher than the number of patients because some clinicians did not have patients that agreed to be part of the study.

Clinician training. SS training was conducted at all three study sites by Dr. Najavits; and clinicians received the SS book and videos, and were offered as-needed telephone and email consultation (i.e., questions/answers on basic implementation issues). As noted, the VA Providence dropped out due to staffing rafter receiving the training. Formative evaluation of the training will be conducted based on detailed notes.

Formative evaluation. The goal was to understand how well SS addresses the needs of OEF/OIF veterans, feedback about adaptations that may be needed for them, and barriers to implementation. Our plan was to assess clinicians using previously developed measures (with those that are validated marked with an asterisk): *Protocol Implementation Questionnaire (PIQ), SS End-of-Treatment Questionnaire (ETQ), SS Safety Knowledge Test, *Evidence-Based Practice Attitude Scale. Clients were to be assessed on the SS End-of-Session Questionnaire (ESQ), the SS End-of-Treatment Questionnaire and basic clinical outcomes (the *Patient Health Questionnaire-9, *Trauma Symptom Checklist 40,*SF-12, *Basis 32, *ASI-lite, *PTSD Checklist-Military). All measures were to be administered at baseline and end-of-treatment, except the PIQ and ETQ (at the end only), and the ESQ, which is given at each treatment session. We also planned to conduct focus interviews with veterans and clinicians who had participated in/conducted at least six sessions of SS, using the SS Qualitative Interview. Also, we had planned to conduct qualitative interviews with program administrators regarding their impressions of the intervention impact within the clinic and issues relevant to sustainability. Session attendance/program retention was to be tracked with administrative data.

Key personnel. Our key personnel on the project team consisted of Dr. Najavits and Ms. Johnson, LICSW in Boston; and Dr. Sonya Norman and Ms. Kendall Wilkins at the San Diego VA.

Timeline. Our original timeline was as follows. Month 1: train clinicians in Seeking Safety; conduct baseline assessments on participants. Month 2-3: telephone and e-mail support to clinicians; and conduct focus groups. Month 4: conduct final assessments on all participants. Month 5: data analysis and writing. See Appendix for delays to the timeline.

FINDINGS/RESULTS:
SS appears to be highly feasible and acceptable to both OEF/OIF patients and to their clinicians. All ratings by both patients and clinicians were strongly and consistently positive. The positive views of SS are especially notable, given that the patient sample was quite highly impaired, based on characterization of the sample at baseline on various metrics. Moreover, the clinician sample was primarily trainees, which also suggests that the model appears to provide a helpful resource even for relatively new clinicians. Nonetheless, SS could be adapted to be more tailored for the OEF/OIF cohort. Examples of areas for potential tailoring raised by participants include: changing the quotations and clinical examples; reducing the reading level; providing more interactive exercises; providing a summary of key points to help them absorb the material (especially if TBI is present); use of modern media to convey the material rather than purely text (e.g., use of audio summaries, video material, providing the information on CDs); providing the material over more sessions to help them process it. We also found that clinicians significantly improved in their knowledge of SS and PTSD/SUD treatment principles from beginning to end of the SS training (conducted in a 1 day format). No iatrogenesis nor average negative ratings were found. We specifically provided scaling on satisfaction measures to explicitly query for negative impacts to address this question. The SS model appears to be highly relevant to men as well as women (as most of our OEF/OIF were men), and also to minorities (the majority of the patients were minorities).

IMPACT:
SS appears feasible for OEF/OIF patients and clinicians, achieving high and consistent satisfaction in this project. Future research on SS with OEF/OIF could address actual outcomes, the impact of tailoring SS for OEF/OIF veterans, and studies of clinician training methods. Results of this project must be viewed in light of study limitations, including a smaller sample size than originally planned; and lack of adherence ratings.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Lang AJ, Norman SB, Means-Christensen A, Stein MB. Abbreviated brief symptom inventory for use as an anxiety and depression screening instrument in primary care. Depression and anxiety. 2009 Jan 1; 26(6):537-43. [view]
2. Norman SB, Inaba RK, Smith TL, Brown SA. Development of the PTSD-alcohol expectancy questionnaire. Addictive Behaviors. 2008 Jun 1; 33(6):841-7. [view]
3. Simmons AN, Paulus MP, Thorp SR, Matthews SC, Norman SB, Stein MB. Functional activation and neural networks in women with posttraumatic stress disorder related to intimate partner violence. Biological psychiatry. 2008 Oct 15; 64(8):681-90. [view]
4. Norman SB, Stein MB, Dimsdale JE, Hoyt DB. Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychological medicine. 2008 Apr 1; 38(4):533-42. [view]
5. Desai RA, Harpaz-Rotem I, Najavits LM, Rosenheck RA. Seeking safety therapy: clarification of results. Psychiatric services (Washington, D.C.). 2009 Jan 1; 60(1):125. [view]
6. Campbell-Sills L, Norman SB, Craske MG, Sullivan G, Lang AJ, Chavira DA, Bystritsky A, Sherbourne C, Roy-Byrne P, Stein MB. Validation of a brief measure of anxiety-related severity and impairment: the Overall Anxiety Severity and Impairment Scale (OASIS). Journal of affective disorders. 2009 Jan 1; 112(1-3):92-101. [view]

Book Chapters

1. Najavits LM, Schmitz M, Johnson KM, Smith C, North T, Hamilton N, Walser R, Reeder K, Norman SB, Wilkins K. Seeking Safety for men: Clinical and research experiences. In: Katlin LJ, editor. Men and Addictions: New Research. Hauppauge, NY: Nova Science Publishers; 2009. Chapter 2. [view]

Conference Presentations

1. Najavits LMN. A New Model For PTSD and Substance Abuse. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2008 Nov 1; Chicago, IL. [view]
2. Najavits LMN. A New Model for PTSD and Substance Abuse. Paper presented at: Substance Abuse and Mental Health Services Administration Centers for Medicare and Medicaid Services on Medicaid and Mental Health Services Annual Conference; 2008 Oct 15; Milwaukee, WI. [view]
3. Najavits LMN. Key Informant Survey on PTSD and Substance Abuse. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2008 Nov 1; Chicago, IL. [view]
4. Najavits LMN. Marines with Co-occurring PTSD and Substance Abuse. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2008 Nov 1; Chicago, IL. [view]
5. Najavits LMN. PTSD and Substance Abuse. Paper presented at: New England Association of Drug Court Professionals Annual Conference; 2008 Oct 1; Boston, MA. [view]
6. Najavits LMN. Seeking Safety Therapy. Paper presented at: Sweden Maria Ungdom Resource Center Annual Meeting; 2008 Nov 1; Stockholm, Sweden. [view]
7. Najavits LMN. The Link Between PTSD and Substance Abuse. Paper presented at: American Academy of Addiction Psychiatry Annual Meeting; 2008 Dec 1; Boca Raton, FL. [view]

DRA: Military and Environmental Exposures
DRE: Treatment - Observational
Keywords: Drug abuse, Dual diagnosis – substance abuse and mental health, PTSD
MeSH Terms: none