SEEKING SAFETY

SEEKING SAFETY
A Treatment Manual
for PTSD
and Substance Abuse

LISA M. NAJAVITS

THE GUILFORD PRESS

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Library of Congress Cataloging-in-Publication Data

Najavits, Lisa.
Seeking safety: a treatment manual for PTSD and substance abuse / by Lisa M. Najavits.
p. ; cm. — (Guilford substance abuse series)
Includes bibliographical references and index.
ISBN 978-1-57230-639-4 (pbk.)
1. Cognitive therapy—Handbooks, manuals, etc. 2. Post-traumatic stress disorder—Patients—
Rehabilitation—Handbooks, manuals, etc. 3. Substance abuse—Patients—Rehabilitation—Handbooks,
manuals, etc. 4. Adult child abuse victims—Rehabilitation—Handbooks, manuals, etc.
I. Title. II. Series.
RC489 .C63 N34 2002
616.89′142—dc21
00-066273
 To my parents,
Magda Najavits (1929–1980)
and Joseph Najavits (1918–1996),
who sought to live the ideals in these pages
 Preface


I am the third generation of women in my family who overcame posttraumatic stress disorder
(PTSD). My mother and grandmother were Hungarians who survived the Holocaust in the
most dismal ways, experiencing repeated trauma, with my mother only 10 years old when it
began. In New York City in 1987, a stranger slashed my face with a razor in an attempted
rape. I note these histories because the work that follows comes from the emotional work re-
quired to overcome those traumas—both what I observed in my mother and grandmother,
and what I experienced myself. I mention this background too because this book is an at-
tempt (in an irrational, time-reversing way) to alleviate their suffering, which I sensed as a
child and felt responsible to solve. I am also very aware, however, that many of the patients
we treat have vastly worse histories. At this late date, the book is an attempted solution that I
hope can help other people. Perhaps the only gratification that can come from suffering is to
learn from it and try to transform it into something that can help others. If I could reverse
time, my wish would be for my family to have been given so much more help than they re-
ceived, when the fields of trauma and its treatment were still highly undeveloped.
I feel lucky to have had the opportunity to develop this project over the past several
years. We are currently in a very exciting phase of development of new psychotherapies, and
specifically of advances in the treatment of PTSD and substance abuse. It is quite remarkable
to think of how young these fields are. The term “alcoholism” was coined only 150 years ago;
Alcoholics Anonymous (AA) was founded in 1935; the first AA-based treatment program for
substance abuse, the Minnesota Hazelden program, began only in the 1950s (Miller, 1995);
and the National Institute on Drug Abuse (NIDA), which funded the current project, was es-
tablished only in the 1970s. Indeed, the psychotherapeutic treatment of substance abuse was
viewed as “wasteful” for the first half of the 20th century (Najavits & Weiss, 1994a), and it is
only in the past decade or so that considerable effort to link substance abuse with mental ill-
ness has emerged. Similarly, PTSD was only classified as a psychiatric disorder for the first
time in 1980, and for most of the 20th century it went in and out of awareness as a field of
study (Herman, 1992). Much like a patient in therapy, therefore, these fields have progressed
through different states of mind over time.

vii
viii Preface

In this book I have tried to articulate a model of treatment that I truly hope will help oth-
ers. It represents a hybrid of influences from various sources, empirical testing with patients
for over 6 years on several projects, and a great deal of trial and error (see Chapter 1). It is
also in an early phase of development. Although it was the first treatment for this dual diagno-
sis with a published empirical evaluation (Najavits, Weiss, Shaw, & Muenz, 1998e), that eval-
uation was a basic pilot study. There is vastly more to explore, including how this model fares
across a variety of settings, patient characteristics, therapists, and modalities, and whether it
is specific to this dual diagnosis. Several studies have been completed at this point, and oth-
ers are under way. Despite its early stage of development, it has thus far had some very posi-
tive results, both in research and clinically with therapists and patients who have used it (see
Chapter 1).
I note too that although a manual can have the appearance of providing “all the answers”
(and this one perhaps more than most because of its degree of structure, as well as the large
number of pages and handouts), I am extremely aware that there are no easy answers. In fact,
it’s a little ironic that I’ve written a manual, as I’ve always believed that the therapist is vastly
more important than the therapy model. Thus what I’ve tried to do is to provide therapists
with a lot of resources that they might not be able to amass easily on their own. But the thera-
pist ultimately is the therapy; as it’s been said, “Who can separate the dancer from the
dance?” I have no illusion that these materials in incompetent hands will do much good; con-
versely, I do not believe that in competent hands, good outcomes are necessarily due to such
manuals. A manual is a tool, and, like any tool, it can be used to help or to harm. A skill as
seemingly benign as “asking for help” can be done in a way that helps patients feel either em-
powered or diminished.
I recognize too that this treatment is based in my own coping strategies. It is action-
oriented and informational, yet also (I hope) sensitive to the emotional pain that brings peo-
ple into treatment. In talking with colleagues some time ago, we realized that each of us had
developed a treatment that reflected our own particular way of coping in the world, with all
of the biases inherent in that.
It was very important to me in writing this book to attempt to draw not only from the
cognitive-behavioral therapy (CBT) tradition, but also in part from the psychodynamic. In
part this derives from the exceptional privilege that I have had to study both CBT and
psychodynamic models during my training in graduate school and internship (and beyond),
but it also derives from my work as a therapist in which neither treatment alone feels com-
plete. The richness of each has much to offer the other. As one colleague said when reading a
draft of this book, the psychodynamic element was “sneaked in the back door.” Although the
treatment draws primarily on CBT, I hope that it draws on some of the wisdom of
psychodynamic theory as well. Given the focus on substance abuse, there is also strong re-
spect for twelve-step and other self-help traditions.
I am also extremely aware of what this treatment cannot do. It cannot prevent the relent-
less tendency for people to victimize each other; it cannot fight the massive forces that over-
whelm some of the most disadvantaged patients (from bad neighborhoods to insufficient sys-
tems to poverty); it cannot make up for the fact that the deepest learning, regardless of
treatment manuals, requires an enormous investment of societal, patient, and therapist re-
sources. Trauma is an extreme form of bad luck—the bad luck of being born into the wrong
Preface ix

family or being in the wrong place at the wrong time. It gets to the essence of the uncertainty
of being alive, in which things can go remarkably wrong, without reason or fairness. Sub-
stance abuse is a disorder of loss of control as well, and when combined with trauma, it is a
huge battle to fight.
Finally, I am acutely aware that change remains a mysterious process. It is difficult to
know who will succeed, and even harder to know why. Many things provide the impetus—a
therapist, a book, something said in a particular way on a particular day—but in the end what
really promotes change is unknown. It is clear, however, that the process requires everything
patients and therapists can bring to it. Two of my favorite quotes describe how incredibly dif-
ficult change is. The first is an early 20th-century view; the second is more recent.

Do you think it is easy to change?

Alas, it is very hard to change and be different.
It means passing through the waters of oblivion.
—D. H. Lawrence, from the poem “Change” (1971)

How do people change? God splits the skin with a jagged thumbnail from throat to
belly and then plunges a huge filthy hand in, he grabs hold of your bloody tubes and
they slip to evade his grasp but he squeezes hard, he insists he pulls and pulls till all
your innards are yanked out and the pain! We can’t even talk about that. And then he
stuffs them back, dirty, tangled and torn. It’s up to you to do the stitching.
—Tony Kushner, from the play Angels in America (1994)

This is not pleasant, but neither is what these patients have lived or the emotional depths
they will need to go to in their recovery. They deserve the best we can give them, and a better
future than their past.

LISA M. NAJAVITS
 Acknowledgments


This work would not be possible without the following people:

 To the mentors with whom I have had the privilege of training: Steve Hollon, PhD;
Hans Strupp, PhD; John Gunderson, MD; and Roger Weiss, MD. Steve and John deserve
special thanks for modeling intellectual rigor: striving beyond clichés; doing the hard work;
and trying to really hear, with an open mind, both the patient and the data. I was lucky to
have exposure to such idealism at crucial points in my career, and to learn about both CBT
and psychodynamic treatments directly from their exemplars. Roger Weiss launched my ca-
reer in substance abuse treatment; provided the impetus for me to write the grant in 1992
that began this project; and throughout was the most consistent person to turn to for guidance
on making everything happen. Finally, Hans has been one of my heroes as a founder of the
field of psychotherapy research, as well as for his kindness and generosity in my career.
 To the patients in the research studies and clinical groups at McLean Hospital, who
truly gave of themselves and who speak in these pages.
 To colleagues in the area of PTSD and substance abuse, for their collaboration and ca-
maraderie: Bonnie Dansky, PhD; Margaret Kramer, PhD; Vivian Brown, PhD; Denise Hien,
PhD; Lisa Litt, PhD; Joe Ruzek, PhD; Caron Zlotnick, PhD; Norma Finklestein, PhD, and
the staff of the WELL Project; Kathleen Brady, MD; Bob Rosenheck, PhD; Frances
Hutchins, PhD; Terry North, MA; and Carey Smith, MA.
 To the therapists who conducted the treatment in the research trials, tolerated vague
drafts and high expectations, and provided helpful feedback: Henrietta Menco, LICSW; Judi
Zoldan, LICSW; Ronda Yeomans, PhD; Monika Kolodjiez, PhD; Rima Saad, MA; Deborah
Fraser, PhD; Kay Johnson, LICSW; Linda Centano, MA; Helen Duane, MA; Barbara
Wolfsdorf, PhD; Celia Winsor, BA; Maryellen Crowley, PhD; and Martha Schmitz, PhD.
 To two long-term research assistants who made exceptional contributions to the pro-
ject: Sarah Shaw, BA, and Amy Dierberger, BA.
 To consultants on the study: Bruce Liese, PhD, “listening angel,” for his early support
of this work; Larry Muenz, PhD, for excellent statistical and life advice; and Kathleen Carroll,
PhD, for methodological issues.

xi
xii Acknowledgments

 To Aaron Beck, MD, and Marsha Linehan, PhD, for their very warm support and their
groundbreaking work in psychotherapy development.
 To Stacey Luftig, for the conversations about writing and for being there through ev-
erything over our 30-year friendship. And to others whose presence has made all the differ-
ence these past few years: Judy Najavits, Fran Grossman, Brian Sands, and Linda Schulman.
 To Lisa Onken and Jack Blaine of NIDA, who made this work possible with their ini-
tiative to fund investigators to develop new treatments, and with Lisa’s particular support of
women investigators.
 To institutions that have deeply influenced me: Barnard College/Columbia University
for education in the humanities; Vanderbilt University for research training; and McLean
Hospital, where this work was conducted. And to two professional societies: the International
Society for Traumatic Stress Studies and the Society for Psychotherapy Research.
 Finally, and most of all, to my husband, Burke Nersesian: for the quotation on page
234, and for his extraordinary, sustaining love. There are no words to describe Burke’s influ-
ence: his brilliance, insight, caring, and sense of fun, as well as his courageous willingness to
talk honestly and truly hear, no matter what. It seems as though there ought to be a term for
the antithesis of trauma, as random and good as trauma is random and bad; Burke’s presence
is that in my life.

This project was supported by grants from NIDA (R03-DA08631, R01-DA08631, K02-
DA00400) and from the National Institute on Alcohol Abuse and Alcoholism (R21-AA12181).
 Contents


Chapter 1. Overview 1
PTSD and Substance Abuse 1
This Treatment 4
Principles of Seeking Safety 5
How the Treatment Was Developed 15
Empirical Results 17
How Seeking Safety Differs from Existing Treatments 19
One Patient’s Experience of PTSD and Substance Abuse 21

Chapter 2. Conducting the Treatment 23

The Treatment Format 23
Adapting Seeking Safety to Different Contexts 26
Preparation 28
Process 29
Conducting the Session 32
Treatment Guidelines 44
Problem Situations and Emergencies 49
Checklist before Beginning the Treatment 52
Materials for All Sessions 52

TREATMENT TOPICS

Introduction to Treatment/Case Management 65

Safety 94
PTSD: Taking Back Your Power 110
Detaching from Emotional Pain (Grounding) 125
When Substances Control You 137

xiii
xiv Contents

Asking for Help 164

Taking Good Care of Yourself 174
Compassion 182
Red and Green Flags 189
Honesty 199
Recovery Thinking 208
Integrating the Split Self 223
Commitment 231
Creating Meaning 240
Community Resources 250
Setting Boundaries in Relationships 265
Discovery 282
Getting Others to Support Your Recovery 293
Coping with Triggers 308
Respecting Your Time 317
Healthy Relationships 328
Self-Nurturing 337
Healing from Anger 345
The Life Choices Game (Review) 362
Termination 369

References 379

Index 391

About the Author 401

 1
Overview

PTSD AND SUBSTANCE ABUSE

PTSD and Substance Abuse: Patients’ Perspective

“The more I use, the more I won’t feel anything. The pain is so bad you just want to die.
There is no other way out. If you talk about it, it will hurt too much. So instead, keep it a
secret. No one will know.”

“When I was sober I was crazy, hiding under the bed.”

These patients have lived what is only beginning to be understood within the mental health
and substance abuse fields—that posttraumatic stress disorder (PTSD) and substance abuse1
co-occur for a very large number of people, particularly women. Their stories also point to
several major themes that are becoming increasingly recognized, based on clinical and scien-
tific evidence:

 The dual diagnosis of PTSD and substance abuse is surprisingly common. The rate of
PTSD among patients in substance abuse treatment is 12%–34%; for women it is 30%–59%.
Rates of lifetime trauma are even more common (Kessler, Sonnega, Bromet, Hughes, & Nel-
son, 1995; Langeland & Hartgers, 1998; Najavits, Weiss, & Shaw, 1997; Stewart, 1996; Stew-
art, Conrod, Pihl, & Dongier, 1999; Triffleman, 1998).
 Becoming abstinent from substances does not resolve PTSD; indeed, some PTSD
symptoms become worse with abstinence (Brady, Killeen, Saladin, Dansky, & Becker, 1994;
Kofoed, Friedman, & Peck, 1993; Root, 1989).
 Treatment outcomes for patients with PTSD and substance abuse are worse than for
1 This treatment was originally developed for patients with substance dependence, the most severe form of DSM-
IV substance use disorders. However, the term “substance abuse” is used throughout the manual, as it is more
commonly used in treatment settings.

1
2 Overview

other dual-diagnosis patients and for patients with substance abuse alone (Ouimette, Ahrens,
Moos, & Finney, 1998; Ouimette, Finney, & Moos, 1999).
 People with PTSD and substance abuse tend to abuse “hard drugs” (cocaine and
opiates); prescription medications, marijuana, and alcohol are also common. Substance abuse
is often viewed as “self-medication” to cope with the overwhelming emotional pain of PTSD
(Breslau, Davis, Peterson, & Schultz, 1997; Chilcoat & Breslau, 1998; Cottler, Compton,
Mager, Spitznagel, & Janca, 1992; Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995;
Goldenberg et al., 1995; Grice, Brady, Dustan, Malcolm, & Kilpatrick, 1995; Hien & Levin,
1994).
 People with PTSD and substance abuse are vulnerable to repeated traumas (Fullilove
et al., 1993; Herman, 1992), and more so than patients with substance abuse alone (Dansky,
Brady, & Saladin, 1998).
 People with both disorders suffer a variety of life problems that may complicate their
clinical profile, including other DSM-IV disorders, interpersonal and medical problems, mal-
treatment of their children, custody battles, homelessness, HIV risk, and domestic violence
(Brady, Dansky, Sonne, & Saladin, 1998; Brady et al., 1994; Brown & Wolfe, 1994; Dansky,
Byrne, & Brady, 1999; Najavits et al., 1998c).
 People with PTSD and substance abuse have a more severe clinical profile than those
with just one of these disorders (Najavits, Weiss, & Shaw, 1999b; Najavits et al., 1998c).
 Among patients in substance abuse treatment, this dual diagnosis is two to three times
more common in women than in men2 (Brown & Wolfe, 1994; Najavits et al., 1998c).
 Most women with this dual diagnosis experienced childhood physical and/or sexual
abuse; men with both disorders typically experienced crime victimization or war trauma
(Brady et al., 1998; Kessler et al., 1995; Najavits et al., 1998c).
 PTSD and substance abuse have consistently been found to co-occur, regardless of the
nature of the trauma or the type of substance used (Keane & Wolfe, 1990; Kofoed et al., 1993).
 A “downward spiral” is common. For example, substance use may increase vulnerabil-
ity to new traumas, which in turn can lead to more substance use (Fullilove et al., 1993). From
patients’ perspective, PTSD symptoms are common triggers of substance use (Abueg &
Fairbank, 1991; Brown, Recupero, & Stout, 1995), which in turn can heighten PTSD symp-
toms (Brown, Stout, & Gannon-Rowley, 1998; Kofoed et al., 1993; Kovach, 1986; Root, 1989).
 Various subgroups have high rates of this dual diagnosis, including combat veterans,
prisoners, victims of domestic violence, the homeless, and adolescents (Bremner, Southwick,
Darnell, & Charney, 1996; Clark & Kirisci, 1996; Dansky et al., 1999; Davis & Wood, 1999;
Jordan, Schlenger, Fairbank, & Caddell, 1996; Kilpatrick et al., 2000; Ruzek, Polusny, &
Abueg, 1998).
 The connection between PTSD and substance abuse appears to be enduring, rather
than simply an artifact of substance use, withdrawal, or overlapping DSM-IV criteria (Bolo,
1991; Kofoed et al., 1993).
 Perpetrators of violent assault use substances at the time of assault in a high percent-
age of domestic abuse (50%) and rape (39%) cases (Bureau of Justice Statistics, 1992).

2 In Kessler and colleagues’ (1995) major study of a community sample, however, rates for men were higher than
for women.
Overview 3

PTSD and Substance Abuse: Therapists’ Perspective

The other half of the clinical equation is the therapist’s perspective. One social worker in pri-
vate practice said,

“I used to feel that I wouldn’t go near substance abuse patients with a 10-foot pole—I
wouldn’t treat them and was pretty judgmental of them. Mostly I didn’t understand them.
But when I became aware that many have a history of trauma I began to feel more com-
passionate. I realized how often they are self-medicating their pain.”

A psychiatrist on the substance abuse unit of a hospital said,

“Where I work, patients are told to get off of substances first—only once they are clean can
they deal with the trauma. They get four substance abuse groups a day but no groups for
PTSD. Some of them feel invalidated, as though their trauma doesn’t matter.”

Clinicians may feel confusion over how to treat such patients. For example:

 “Should the patient talk about painful trauma memories during treatment?”
 “Do I insist the patient must become substance-free before we work on the PTSD?”
 “How can I contain a patient who becomes overwhelmed by PTSD symptoms?”
 “Should I discontinue treatment if the patient keeps using substances?”
 “Does psychotherapy for this population work?”
 “Should I insist that the patient go to Alcoholics Anonymous (AA)?”

Just as new knowledge has arisen about patients, new knowledge is also growing about treat-
ment:

 Most clinical programs treat PTSD or substance abuse, but rarely both. Yet an inte-
grated model—treating both disorders at the same time—is recommended by both clinicians
and researchers as more likely to succeed, more cost-effective, and more sensitive to patient
needs (Abueg & Fairbank, 1991; Bollerud, 1990; Brady et al., 1994; Brown et al., 1995;
Brown, Stout, & Mueller, 1999; Evans & Sullivan, 1995; Fullilove et al., 1993; Kofoed et al.,
1993; Najavits, Weiss, & Liese, 1996c; Sullivan & Evans, 1994). Patients too favor integrated
treatment of these disorders (Brown et al., 1998).
 The majority of patients with PTSD and substance abuse do not receive PTSD-
focused treatment (Brown et al., 1998, 1999).
 Many patients are never even assessed for both PTSD and substance abuse (Fullilove
et al., 1993; Kofoed et al., 1993). It is common for patients to report multiple substance abuse
treatments during which they were never asked about trauma, never informed that they met
the diagnosis of PTSD, and never told that PTSD is a treatable disorder for which specific
treatments exist. Similarly, some mental health clinicians do not routinely assess for sub-
stance abuse.
 It can be difficult to predict patients’ course of recovery. Paradoxically, both abstinence
4 Overview

and continued use of substances may make PTSD symptoms either better or worse, depend-
ing on the patient (Brown et al., 1998; Najavits, Shaw, & Weiss, 1996b).
 Treatment can be effective, but is often difficult and may be marked by unstable treat-
ment alliances, multiple crises, erratic attendance, and relapse to substance use (Brady et al.,
1994; Brown, Stout, & Mueller, 1996; Root, 1989; Triffleman, 1998).
 Both in the culture at large and among clinicians, views of patients with substance
abuse and/or PTSD may be quite negative. Countertransference reactions are common
(Herman, 1992; Imhof, 1991; Imhof, Hirsch, & Terenzi, 1983; Najavits et al., 1995). Patients
are sometimes perceived as “crazy,” “lazy,” or “bad,” both by others and by themselves.
 Treatments that are effective for PTSD or substance abuse separately may not be
advisable when the two disorders occur together. For example, PTSD treatments such as
benzodiazepines or exposure therapy may not be indicated if a patient is addicted to sub-
stances; substance abuse treatment such as twelve-step groups may not work when a pa-
tient has PTSD (Ruzek et al., 1998; Satel, Becker, & Dan, 1993; Solomon, Gerrity, & Muff,
1992).
 Patients with this dual diagnosis may have intensive case management needs, which
may go beyond the training of some clinicians and sometimes lead to “burnout” (Najavits et
al., 1996b).
 The need for cross-training is common: The cultures, assumptions, and treatments for
substance abuse and PTSD can be quite different, and most therapists do not have equal ex-
pertise in both (Evans & Sullivan, 1995; Najavits, 2000; Najavits et al., 1996c). Substance
abuse counselors are not typically trained to work on severe mental health problems, and
thus PTSD may be ignored or misunderstood. Similarly, most mental health therapists are
not trained to work on substance abuse.

More on the Relationship between PTSD and Substance Abuse

The key points above summarize a growing body of research that has emerged primarily over
the past decade, and is still undergoing continued validation. Although a full discussion of
this work is beyond the scope of this book, further materials are recommended at the end of
this book (see the entries marked by an asterisk in the References list). In addition, one pa-
tient’s experience of PTSD and substance abuse is provided at the end of this chapter to illus-
trate the experience of this dual diagnosis.

THIS TREATMENT

This book describes a psychotherapy treatment for PTSD and substance abuse comprised of
25 topics. It is the first treatment for PTSD and substance abuse with published outcome re-
sults (Najavits et al., 1997, 1998e). It offers a variety of features designed to be maximally
helpful to clinicians on the front lines of treatment, where time is short, the demands are
great, and the need for something that works is imperative.
The creative contribution that this treatment, it is hoped, provides is its adaptation of
cognitive-behavioral therapy (CBT) to this population. The goal was to mold a therapy that
Overview 5

would best fit patients’ needs by listening to them very closely in the context of treating them,
reading available literature, and conducting empirical research on the treatment.
The treatment’s 25 topics are evenly divided among cognitive, behavioral, and interper-
sonal domains, with each addressing a safe coping skill relevant to both disorders. Each topic
is designed to be independent of the others, thus allowing maximum flexibility for patients
and therapists to choose the order of topics.
The treatment can be conducted on either a group or an individual basis, both of which
have evidenced positive outcomes thus far in studies (Hien & Litt, 1999; Najavits, 1996,
1998; Zlotnick, 1999). It has also been applied in clinical settings to a wide variety of patients
(e.g., women, men, adults, adolescents, prisoners, war veterans, outpatients, inpatients,
inner-city patients, suburban patients, minorities). Data thus far indicate positive satisfaction
with the treatment in several of these subpopulations, but outcome results are still being col-
lected. (See Chapter 2 for more on using the treatment in different treatment contexts.)
Below, the principles of the treatment are described, followed by additional key features,
what is not part of the treatment, how it was developed, its empirical testing, and how it dif-
fers from other treatments.

PRINCIPLES OF SEEKING SAFETY

This treatment is based on five central ideas: (1) safety as the priority of this first-stage treat-
ment; (2) integrated treatment of PTSD and substance abuse; (3) a focus on ideals; (4) four
content areas: cognitive, behavioral, interpersonal, and case management; and (5) attention to
therapist processes. These five principles are described below, followed by additional fea-
tures of the treatment and a summary of what is not part of the treatment.

Safety as the Goal of This First-Stage Treatment

The title of this book, Seeking Safety, expresses the basic philosophy of the treatment. That is,
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: discontinuing
substance use, reducing suicidality, minimizing exposure to HIV risk, letting go of dangerous
relationships (such as domestic abuse and drug-using “friends”), gaining control over extreme
symptoms (such as dissociation), and stopping self-harm behaviors (such as cutting). Many of
these are self-destructive behaviors that reenact trauma, particularly for victims of childhood
abuse, who represent a large segment of people with this dual diagnosis (Najavits et al.,
1997). Even though the trauma may have occurred long ago, patients treat themselves in
ways that repeat it, ignoring their needs and perpetuating pain (albeit sometimes in the guise
of trying to satisfy short-term impulses). These patients have typically been abused and are
now abusing themselves; this is not coincidence, but rather represents a meaningful connec-
tion between their disorders. “Seeking safety” refers to helping patients free themselves from
such negative behaviors and, in so doing, to move toward freeing themselves from trauma at a
deep emotional level.
Just as violations of safety are life-destroying, the means of establishing safety are life-
6 Overview

enhancing: learning to ask for help from safe people, utilizing community resources, explor-
ing “recovery thinking,” taking good care of one’s body, rehearsing honesty and compassion,
increasing self-nurturing activities, and so on. It is these skills that this treatment attempts to
teach.
The treatment thus fits what has been described as first-stage therapy for each of the dis-
orders. Experts within the PTSD and substance abuse fields have independently described
an extremely similar first stage of treatment. For example, within the PTSD domain,
Herman’s (1992) model of a first-stage recovery group is defined by a focus on safety and self-
care as the primary therapeutic tasks, a present-time orientation, homogeneous membership
(all patients have the same primary diagnoses), low tolerance for conflict within the group, an
open-ended format, didactic intent, and a moderate level of cohesion among members. Like-
wise, for substance abuse, Kaufman and Reoux (Kaufman, 1989; Kaufman & Reoux, 1988) de-
picts the first stage of treatment as “achieving abstinence,” including assessing the extent and
impact of substance use, developing a plan for abstinence, reviewing the patient’s recent drug
use and craving at each session, and diagnosing and treating coexisting psychiatric illness.
These suggestions are echoed by other writers as well (Brown, 1985; Carroll, Rounsaville, &
Keller, 1991; Evans & Sullivan, 1995; Marlatt & Gordon, 1985; Sullivan & Evans, 1996). In
the topic Safety, a more extensive description of the stages of healing from both PTSD and
substance abuse is provided. To summarize here briefly, the three stages are as follows (using
Herman’s terms):

Stage 1: Safety
Stage 2: Mourning
Stage 3: Reconnection

This treatment addresses only Stage 1. The first stage, safety, is in and of itself an enormous
therapeutic task for some patients. Thus, if patients remember nothing else from the treat-
ment, the hope is that they will “take home” the idea of safety above all. It is addressed over
and over in numerous ways, including the Safe Coping Sheet (see Chapter 2), the list of Safe
Coping Skills (in the topic Safety), the Safety Plan (in the topic Red and Green Flags), the
Safety Contract (in the topic Healing from Anger), and the report of unsafe behaviors at each
session’s check-in, for example.
The concepts of safety and first-stage treatment are designed to protect therapists as well
as patients. By helping their patients move toward safety, therapists are protecting them-
selves from the sequelae of treatment that could move too fast without a solid foundation:
worry over the patients’ well-being, vicarious traumatization, medico-legal liability, and dan-
gerous transference and countertransference dilemmas that may be evoked by inappropriate
treatment (Chu, 1988; Pearlman & Saakvitne, 1995). Thus “seeking safety” is, it is hoped,
both patients’ and therapists’ goal.

Integrated Treatment of PTSD and Substance Abuse

The treatment is designed to continually address both PTSD and substance abuse. That is,
both disorders are treated at the same time by the same clinician. This integrated model con-
Overview 7

trasts with a sequential model in which the patient is treated for one disorder, followed by
treatment of the other; a parallel model, in which the patient receives treatment for both but
by different treaters; or a single model, in which the patient receives only one type of treat-
ment (Weiss & Najavits, 1998).
An integrated model is consistently recommended as the treatment of choice for this
dual diagnosis (Abueg & Fairbank, 1991; Bollerud, 1990; Brady et al., 1994; Brown et al.,
1995; Evans & Sullivan, 1995; Fullilove et al., 1993; Kofoed et al., 1993). In practice, however,
most settings do not treat the two disorders simultaneously (Abueg & Fairbank, 1991;
Bollerud, 1990; Evans & Sullivan, 1995). If patients enter a PTSD or general psychiatric
setting, they usually address only trauma issues. If they enter a substance abuse setting, they
are usually encouraged to work only on the substance abuse (Abueg & Fairbank, 1991;
Bollerud, 1990; Evans & Sullivan, 1995). Indeed, one patient reported that she had to lie
about her substance abuse to enter a PTSD program because the program did not accept pa-
tients with substance abuse—a not uncommon policy. In many settings clinical staff may be
reluctant to assess for the “other” disorder (Bollerud, 1990; Fullilove et al., 1993), sometimes
because they are unsure how to treat it if it is discovered. Patients’ own shame and secrecy
about trauma and substance abuse can also reinforce treatment splits (Brown et al., 1995).
Whereas dual-diagnosis treatment settings may, by design, attend to co-occurring disorders,
they also tend to provide generic rather than specialized treatment by diagnosis. Yet the
treatment needs of a patient with schizophrenia and substance abuse may be quite different
from those of a patient with PTSD substance abuse, for example (Weiss, Najavits, & Mirin,
1998b).
Integration is ultimately an intrapsychic goal for patients as well as a systems goal: to
“own” both disorders, to recognize their interrelationship, and to fall prey less often to each
disorder triggering the other. Thus the content of this treatment provides opportunities for
patients to discover connections between the two disorders in their lives—in what order they
arose and why, how each affects healing from the other, and their origins in other life prob-
lems (such as poverty).
In addition, therapists are guided to use each disorder as leverage to help patients over-
come the other disorder. Patients rarely emphasize each disorder equally. Some want to talk
at length about PTSD and believe that their substance abuse is not really a problem. Others
acknowledge substance abuse, but are afraid to address PTSD. The wish to deny aspects of
one’s experience is much more characteristic of these disorders than of many other Axis I dis-
orders (e.g., major depression or generalized anxiety disorder). The shame and secrecy sur-
rounding trauma and substance use, and fear of others’ judgment, converge toward substan-
tial disavowal. The denial can be intrapsychic, as in dissociative phenomena, or external, as in
dishonesty about substance use. In any event, it requires deft therapeutic skill to continually
help patients maintain focus on both disorders.
Integration of the treatment also occurs at the intervention level. Each topic can be ap-
plied to both PTSD and substance abuse. For example, Setting Boundaries in Relationships
can apply to PTSD (e.g., leaving an abusive relationship) and to substance abuse (e.g., asking
one’s roommate to stop growing marijuana plants in the house). Integration is also created by
fluid movement among the four target areas of the treatment—cognitive, behavioral, inter-
personal, and case management. Weaving in and out of these areas helps patients recognize
8 Overview

the links among their thoughts, actions, and relationships, and between their internal experi-
ence and their functioning in the external world.
It is important to note that “integration” means attention to both disorders at the same
time in the present. It is not asking patients to talk in detail about the past; indeed, that is spe-
cifically not part of this treatment (see the section below, “What Is Not Part of This Treat-
ment”). Rather, it means helping patients learn what the two disorders are and why they co-
occur; exploring their interrelationship in the present (e.g., using crack last week to cope with
PTSD flashbacks); understanding the course of the disorders in recovery (e.g., with absti-
nence, PTSD may feel worse before it feels better); increasing compassion by viewing sub-
stance abuse as an attempt to cope with the pain of trauma; and teaching safe coping skills
that apply to both. In short, patients are encouraged to see that healing from each disorder re-
quires attention to both disorders. However, it does not mean telling patients, “You have to
get clean first before you can deal with your PTSD,” or “Once you deal with your PTSD your
substance abuse will go away” (messages patients sometimes hear in treatment programs). In-
stead, the idea is to gain control over the notorious downward spiral in which each disorder
sets off the other. Themes common to both disorders are highlighted as well, such as “se-
crecy” and “control” as hallmarks of both.

A Focus on Ideals
It is difficult to imagine two mental disorders that individually, and especially in combination,
lead to such demoralization and loss of ideals. In the PTSD field, this loss of ideals has been
written about, for example, in Janoff-Bulman’s (1992) work on “shattered assumptions” and
Frankl’s (1963) work on the “search for meaning.” As one patient said, “I feel as though every-
one is born good but the world destroys that. I keep thinking, ‘What is the meaning of being
alive?’ and I can’t come up with an answer.” Trauma can raise an existential dilemma: Having
experienced suffering and evil, do survivors remain sunken at that level, continuing to trade
in distrust, destruction, and isolation (toward both self and others)? Or do they rise above it
and create a new dialogue of honesty, integrity, connection, and higher values? These con-
trasts recur as themes throughout various literatures on trauma, whether of Holocaust vic-
tims, war veterans, crime victims, or child abuse survivors (Frankl, 1963; Herman, 1992;
Shay, 1994). Some research has found that trauma survivors who are able to create positive
meanings from their suffering fare better than those who do not (Janoff-Bulman, 1997). And
many patients report feeling more upset about a loss of ideals, such as trust, than about par-
ticular external conditions, such as poverty or lack of a job.
With substance abuse, there is also a loss of ideals. Life has become narrowed in focus,
and in its severe form one is living “at the bottom”—surrounded by people who cannot cope,
pushing away reality, losing connections to normal life (job, home, relationships), lying about
substance abuse, unable to face emotional pain. It is striking that the primary treatment for
substance abuse for most of the 20th century, AA, is the only treatment for a mental disorder
with a heavily spiritual component. The AA goal of living a life of moral integrity is an anti-
dote to the deterioration of ideals inherent in substance abuse.
Thus this treatment explicitly seeks to restore ideals that have been lost. The title of each
topic is framed as a positive ideal—one that is the opposite of some pathological characteris-
Overview 9

tic of PTSD and substance abuse. For example, Honesty combats denial, lying, and the “false
self.” Commitment is the opposite of irresponsibility and impulsivity. Taking Good Care of
Yourself is a solution for the bodily self-neglect of PTSD and substance abuse. The quotation
in each topic is an attempt to be inspiring, and the language throughout the treatment em-
phasizes values such as “respect,” “care,” “integration,” “protection,” and “healing.” The
hope is that, by aiming for what can be, patients will summon the motivation for the incredi-
bly hard work of recovery. If they are being asked to give up substances, something better
needs to be offered in their place.

Four Content Areas: Cognitive, Behavioral, Interpersonal,

and Case Management
CBT is the basis for this treatment because it so directly meets the needs of first-stage,
“safety” treatment. Beck, Emery, and Greenberg (1985) have described several key features
of CBT. It is present- and problem-oriented, to reduce current symptoms. It is brief, time-
limited, and structured, with the goal of strong treatment gains over a short time frame. It is
educational, with emphasis on rehearsal of new skills. It is directive and collaborative, guid-
ing patients (much as a good parent would) while emphasizing patients’ mature contribution
to their own treatment. These processes provide, in the very format of the treatment, an anti-
dote for the powerlessness and lack of control inherent in PTSD and substance abuse. CBT
also teaches self-control strategies, to help patients acquire functional behaviors that may
never have been developed or may have deteriorated due to substance abuse and PTSD (e.g.,
problem solving, cognitive control, relationship skills, self-care). Such coping skills are specif-
ically recommended by experts on PTSD and substance abuse (Ouimette et al., 1999). CBT
offers explicit training in relapse prevention, which is commonly used to prevent substance
abuse relapses (Beck, Wright, Newman, & Liese, 1993; Carroll et al., 1991; Marlatt &
Gordon, 1985) and is directly applicable to PTSD as well (Foy, 1992). Finally, according to re-
search, CBT has been found to be one of the most promising approaches, independently, for
PTSD (Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Ruzek et al., 1998; Solomon et
al., 1992) and substance abuse (Carroll et al., 1991; Maude-Griffin et al., 1998; Najavits &
Weiss, 1994a).
In the behavioral topics, patients are encouraged to commit to action. The “behavioral
bottom line” is taught: that it is not sufficient to talk about action, but real action, however
small, is essential. At each session, patients make a commitment of one concrete step to pro-
mote healing (see Chapter 2). Therapists are encouraged to listen to patients’ behavior more
than their words to hear them most effectively (e.g., self-destructive behavior as a “cry for
help”). With the Safe Coping Sheet, patients are guided to “own” their actions—that is, no
matter what happens in their lives, they can learn to cope without substances.
The importance of cognition is addressed through standard cognitive therapy interven-
tions, such as identification of beliefs and restructuring. In addition, patients are guided to
explore the meaning of substances in the context of their PTSD (e.g., self-medication? com-
pensation? slow suicide? revenge?). Cognitive distortions (Burns, 1980) are identified for
PTSD and substance abuse (such as “Deprivation Reasoning,” “Beating Yourself Up,” and
“Time Warp”) and contrasted with healthier meaning systems (such as “Live Well,” “Honor
10 Overview

Your Feelings,” and “You Have Choices”). The topic Compassion is used as a means to con-
nect cognition and emotion: to understand, at a deep level, the reasons behind one’s actions
rather than judging them. Thus PTSD does not mean “crazy” but rather overwhelming emo-
tional pain; substance abuse does not mean “bad” but rather a misguided attempt to solve a
problem. In short, the meanings patients create for their lives may vary widely. One may tell
the sad story of someone who was destroyed by life; another may tell the uplifting story of
someone who overcame adversity. The goal of the cognitive topics is thus to help patients
shift their meaning systems toward self-respect and adaptation.
Originally, the treatment was solely cognitive and behavioral. The interpersonal and case
management domains were added after it became apparent, from work with patients, that
these were equally important. Interpersonal topics now constitute a third of the topics, and
case management is begun in the first session and addressed at every session throughout the
treatment. The interpersonal domain is an area of special need because most PTSD arises
from trauma inflicted by others (in contrast to natural disasters or accidents, for example;
Kessler et al., 1995). Whether the trauma was childhood physical or sexual abuse, combat, or
crime victimization, all have an interpersonal valence that may evoke in the survivor distrust
of others, confusion over what can be expected in relationships, and concern over re-
enactments of abusive power (Herman, 1992; Shay, 1994) both as victims and as perpetrators.
Similarly, substance abuse is often precipitated and perpetuated by relationships. Many pa-
tients grew up in homes with substance-abusing family members, and substance use may be
an attempt to gain acceptance by others (Miller, Downs, & Testa, 1993) and manage interper-
sonal conflict (Marlatt & Gordon, 1985). As Trotter (1992) has noted, patients with PTSD and
substance abuse are often much more concerned with interpersonal issues than with issues of
autonomy (e.g., work functioning), which may represent a later developmental step.
Thus the interpersonal topics of the treatment seek to help patients maximize the pres-
ence of supportive people and let go of destructive people. There is an option to invite signifi-
cant others to a session to help support patients’ recovery (in Getting Others to Support Your
Recovery). Patients are encouraged to communicate honestly when it is safe to do so, but also
to recognize that they can only change themselves at this point, and that trying to change oth-
ers while in early recovery is not usually a productive focus. They are guided to explore paral-
lels between their relationship with themselves and with others (e.g., it is common to have
problems setting boundaries both internally within oneself and externally with others), and to
notice extreme relationship dynamics that reevoke trauma (e.g., overcompliance, enmesh-
ment) and substance abuse (e.g., “friends” who keep offering substances).
The case management component arose from data in the Seeking Safety pilot study that
showed many patients’ having received few treatment services prior to joining the program
(Najavits et al., 1998e; Najavits, Dierberger, & Weiss, 1999a). This was the opposite of what
had been expected, which was that they would be heavy utilizers of treatment. Some people
with PTSD and substance abuse may indeed receive a lot of treatment, particularly if they are
connected to a treatment system such as Department of Veterans Affairs (VA) services or in-
patient hospitalization (e.g., Brown & Wolfe, 1994). In contrast, patients for our study were
recruited via newspaper advertisements, which likely drew a different sample. Most required
significant assistance in getting the care they needed (psychopharmacology, job counseling,
housing, etc.). An extensive discussion of the rationale and methods for case management is
Overview 11

provided in the topic Introduction to Treatment/Case Management. In short, it is assumed

that psychological interventions can work only if patients have an adequate treatment base.

Attention to Therapist Processes

Techniques per se are inert; they come alive in the person of the therapist. Indeed, research
shows that for patients with substance abuse in particular, the effectiveness of treatment is
determined as much or more by the therapist as by theoretical orientation or patient charac-
teristics (Luborsky et al., 1986; McLellan, Woody, Luborsky, & Goehl, 1988; Najavits, Crits-
Christoph, & Dierberger, 2000; Najavits & Weiss, 1994b). Even separating a treatment into
content and process may be an artificial distinction (Strupp & Binder, 1984). The therapist
represents the form the treatment takes and can magnify or diminish its impact. And the
more severe the patients, the more negative therapist processes are likely (Imhof, 1991;
Imhof et al., 1983).
Therapist processes emphasized in this treatment include building an alliance; having
compassion for patients’ experience; using the various coping skills in one’s own life (i.e., not
asking the patient to do things that one cannot do oneself); giving patients control whenever
possible (as loss of control is inherent in trauma and substance abuse); modeling what it
means to try hard by meeting the patient more than halfway (e.g., “heroically” doing anything
possible within professional bounds to help the patient get better); and obtaining feedback
from patients about their genuine reactions to the treatment. The flip side of such positive
therapist processes is negative countertransference, including harsh confrontation; sadism;
inability to hold patients accountable, due to misguided sympathy; becoming victim to
patients’ abusiveness; power struggles; and, in group treatment, allowing a patient to be
scapegoated. As Herman (1992) has suggested, therapists may unwittingly repeat the roles of
trauma—victim, perpetrator, or bystander. Attention is also directed to what might be termed
“the paradox of countertransference” in PTSD and substance abuse. That is, PTSD and sub-
stance abuse appear to evoke opposite countertransference reactions, and it is difficult for
therapists to balance these. PTSD tends to evoke sympathy and identification with patients’
vulnerability, which if taken too far may lead to excessive support and overindulgence rather
than encouraging accountability and growth. Substance abuse tends to evoke concern and
anxiety over patients’ substance use, which, if extreme, becomes harsh judgment and con-
frontation. Therapists typically land too much on one or the other side of these opposites.
Thus the goal is for the therapist to integrate praise and accountability, which are viewed as
the two central processes in the treatment.
Therapist processes in this treatment are addressed through several features in each
topic: a therapist “Orientation” that provides background about the topic and discussion of
countertransference issues; a “Tough Cases” segment that presents typical treatment chal-
lenges for the therapist to rehearse; and an “End-of-Session Questionnaire” that obtains pa-
tient feedback about each session (see Chapter 2).
In addition, despite its highly structured approach, the treatment is designed to adapt
flexibly to therapist preferences. For example, some therapists enjoy using CBT forms in ses-
sions, while others dislike them; they are provided but always optional. Many topics have
multiple subtopics from which to choose; and instead of a strict protocol, various ways to ad-
12 Overview

dress the material are suggested. There is no required order of topics, and there are a variety
of formats in which to conduct the treatment (see Chapter 2). In short, respect for therapists’
individual styles and support for their very difficult role are emphasized throughout.

Additional Features of the Treatment

In addition to the five main principles above, several additional features of the treatment can
be described.

Use of educational research strategies. Several strategies are derived from educational
research to maximize learning (Najavits & Garber, 1989), including contrast-set teaching
(comparing extremes such as safe vs. unsafe coping, supportive vs. destructive people); role
preparation (e.g., explicitly telling patients how to make the most of the treatment); teaching
for generalization (e.g., asking patients to teach a new skill to a partner who can cue them to
use it); structured treatment (e.g., each session follows a consistent format); affectively engag-
ing themes and materials (e.g., the quotation for each topic), and memory enhancement de-
vices (e.g., a list of Core Concepts of Treatment—see Chapter 2).
A focus on potential rather than pathology. To increase patients’ (and therapists’!) hope-
fulness, the treatment emphasizes the present and future more than the past, and stresses pa-
tients’ strengths more than their pathology. It is necessary to be aware of patients’ deficits;
however, in an early-stage treatment in which the goal is to help patients attain safe function-
ing, focusing on the past or pathology appears to demoralize patients. Thus the stance is to
keep an optimistic frame, aim high (believing that patients truly can get better), and use
praise rather than negative reinforcement to promote change. Specific techniques include
having patients report good coping at each session’s check-in, teaching compassion rather
than self-blame, allowing patients to return to treatment no matter what (except in the case of
physical danger), and delaying exploration of past trauma and interpretive psychodynamic
work until later stages of treatment (see “What Is Not Part of This Treatment,” below).
Attention to language. The treatment is designed to use simple, everyday words; to avoid
jargon; to use humanistic rather than scientific terms; and, when possible, to convey patients’
experience with quotations in their own words. For example, “rethinking” is used rather than
“cognitive restructuring”; “commitment” rather than “homework”; “honesty” rather than “as-
sertiveness”; and “emotional pain” rather than “psychiatric symptom.” To focus on strengths
rather than pathology, virtually every term that began as a negative was reframed after it be-
came clear that negative language made patients feel worse about themselves. Thus the stan-
dard CBT phrase “cognitive distortions” was reworked as “creating meaning.” Also, thera-
pists are encouraged to allow patients to decide what language fits them. For example, some
patients with PTSD prefer the term “healing” to “recovery” because they believe that no
matter how well they become, trauma has changed them forever; thus PTSD is an existential
issue rather than a “medical illness” that one “recovers” from. Finally, language is gender-
neutral whenever possible, so that both women and men can relate to the material. Patient
examples from both genders and from a variety of types of trauma are provided throughout.
Emphasis on practical solutions. The treatment attempts to provide materials that are
highly practical in nature: lists of national resources; extensive handouts for each topic; the
Overview 13

broad list of Safe Coping Skills; specific in-session exercises to try (e.g., an actual script to re-
hearse grounding). The goal is that patients will never need to believe “There is nothing I can
do.” If one tool doesn’t work, the idea is to use another.
Relating the material to patients’ lives. With so much written material, it is a challenge to
keep the treatment therapeutic rather than didactic or intellectual. Ways to do so include re-
lating the material to current and specific problems in patients’ lives; and, whenever possible,
directly rehearsing skills both in and outside of the session so that patients, in the words of
the famous educator John Dewey, “learn by doing” (Dewey, 1983).
Clinical realism. Although the material conveys how sessions will ideally go, there is also
a great deal of attention to the realities of front-line clinical work. Thus “Clinical Warnings”
are given for material that may be upsetting to some patients; “Suggestions” for each topic ad-
dress issues that may emerge when using the treatment; “Tough Cases” are provided for each
topic to present some challenging comments patients tend to make; a section on “What
Didn’t Work” when developing this treatment is provided at the end of Chapter 2. Moreover,
there is emphasis throughout on understanding the limits of patients’ lives and, when imple-
menting strategies, avoiding simplistic solutions (such as “positive thinking” in the cognitive
topics).
An urgent approach to time. The conjoint influences of managed care, the typically short
retention in treatment of many patients with substance abuse (Crits-Christoph & Siqueland,
1996), and the severity of patients with this dual diagnosis lead to a sense of urgency in trying
to help them quickly. Indeed, Seeking Safety was initially tested as a short-term (3-month)
group treatment with a single therapist, to evaluate whether gains could be achieved within
these limits (Najavits et al., 1998e). It can and, it is hoped, will be conducted over a longer
time frame if the setting allows it, but for most patients, there is too little time and a great deal
to accomplish. Thus sessions are highly focused to make the best use of time available, and
time outside of sessions is utilized whenever possible to promote recovery (e.g., making case
management calls during the session, completing commitments between sessions). One of
the key skills the therapist needs to master is “redirection” to help keep the sessions goal-
directed.
Making the treatment interesting to patients. Considerable attention has been devoted to
making the treatment accessible and engaging with devices such as the Life Choices Game;
recording therapeutic audiotapes in the session; providing self-exploration questions on
patient handouts; the use of metaphors; and a quotation to start each topic. Such efforts may
be particularly important for patients with PTSD and substance abuse, who represent a more
impaired, treatment-resistant group than those with substance abuse alone (Brady et al.,
1994; Najavits et al., 1996b, 1998c). Their clinical presentation, especially early in treatment,
may be marked by poor concentration, dissociation, and impulsiveness, which can limit the
impact of traditional verbal therapy. Several writers have commented on the need to “hook”
these patients into treatment (Abueg & Fairbank, 1991; Jelinek & Williams, 1984; Kofoed et
al., 1993). The high dropout rate from substance abuse treatment in general (Craig, 1985)
warrants strong efforts to make treatment stick. CBT is sometimes perceived as mechanistic,
superficial, and inattentive to feelings (Clark, 1995; Gluhoski, 1994), so it appears especially
important to make treatment as creative as possible. Moreover, this utilizes a primary defense
in PTSD—the use of fantasy—as a tool for recovery (Herman, 1992).
14 Overview

Substance abuse as a priority. Substance abuse treatment and mental health treatment
have, for most of the 20th century, been two different cultures. Each has derived its own
strategies from clinical experience with many patients over time. For therapists who are new
to substance abuse treatment, there is often a steep learning curve. Some of the approaches
to substance abuse in this treatment include making it a priority at each session; conveying
that while the goal is to understand substance use incidents, there is never an excuse for us-
ing (i.e., it is always possible to cope in a better way); using urinalysis and breathalyzer test-
ing; validating mixed feelings about giving up substances; recognizing that giving up sub-
stances will not feel good; understanding how substances “solve” particular PTSD and other
problems in the short term (although they do not work in the long term); understanding the
biological basis of addiction; recognizing denial and other defenses typical of substance
abuse; setting abstinence as the goal, but harm reduction as a means to that end if needed;
and strongly encouraging twelve-step self-help groups while never forcing patients to attend
them.

What Is Not Part of This Treatment

There are two main areas that this treatment explicitly omits: exploration of past trauma and
interpretive psychodynamic work. Exploration of past trauma is, in and of itself, a major in-
tervention for PTSD in a variety of treatments, including mourning (Herman, 1992), expo-
sure therapy (Foa & Rothbaum, 1998), eye movement desensitization reprocessing (Shapiro,
1995), the counting method (Ochberg, 1996), the rewind method (Muss, 1991), and thought
field therapy (Figley, Bride, & Mazza, 1997). By directly processing trauma memories, they
no longer hold such emotional power over the patient. For example, in exposure therapy (Foa
& Rothbaum, 1998), the patient describes the trauma in detail (“imaginal exposure”), perhaps
audiotaping the trauma narrative and listening to it outside of sessions, as well as confronting
feared reminders of trauma (“in vivo exposure,” such as driving over a bridge where an as-
sault occurred). As patients face these trauma triggers, they are flooded by overwhelming
emotion—typically anxiety, sadness, or anger—that gradually dissipates with repeated expo-
sure to them. It follows a classic behavioral model of exposure to feared stimuli. It is highly
effective for PTSD (Foa & Rothbaum, 1998; Marks et al., 1998) in as few as nine sessions or in
prolonged versions for more complex cases. The “mourning” phase described by Herman
(1992) is similar, but draws on psychodynamic influences, emphasizing a review of the pa-
tient’s life before the trauma, creation of meaning to understand what happened, emphasis on
how trauma affected relationships, and trauma imagery.
There are several reasons why exploration of trauma memories is not part of Seeking
Safety. Primarily, it is not yet known whether it is safe and effective for patients who are ac-
tively abusing substances. Numerous experts have recommended that for substance abusers,
such work not begin until they have achieved a period of stable abstinence and functionality
(Chu, 1988; Keane, 1995; Ruzek et al., 1998; Solomon, Gerrity, & Muff, 1992). The concern is
that if patients are overwhelmed by painful memories from the past, their substance use
could worsen in a misguided attempt to cope. Moreover, Seeking Safety was initially tested in
a time-limited group format, which did not appear to be an appropriate context in which to
conduct exposure methods for victims of repeated early trauma, who represent a large num-
Overview 15

ber of patients with this dual diagnosis (Najavits et al., 1997). Even small mention of trauma
experiences has been found to trigger other patients, and in a short-term group treatment
there may be insufficient time to fully process the material.
It can be noted, however, that when Seeking Safety has been conducted as an individual
therapy over a longer time frame, it has been combined with exposure therapy and, at least
thus far, appears to be a highly compatible mix of treatments. A pilot study using this combi-
nation in a sample of men is described in “Empirical Results” later in this chapter (Najavits,
Schmitz, Gotthardt, & Weiss, 2001), and initial guidelines for combining the treatments are
described in the section “Treatment Guidelines” in Chapter 2. However, until further
research explores the use of exposure techniques with a broad range of this dual-diagnosis
population, it is not included as part of Seeking Safety.
Interpretive psychodynamic work is also specifically avoided in Seeking Safety. There is
little, if any, processing of the patient’s relationship with the therapist or, in group treatment,
of members’ relationships with each other. There is also no exploration of intrapsychic mo-
tives or dynamic insights. Although these powerful interventions are likely to be helpful in
later stages of treatment, they are believed too advanced and potentially upsetting for pa-
tients at this stage. See the topic Safety for more on this issue.

HOW THE TREATMENT WAS DEVELOPED

This treatment was begun in 1993 under a grant from the National Institute on Drug Abuse
(NIDA) Behavioral Therapies Development Program. The goal was to design the treatment and
to conduct a pilot study to scientifically evaluate its impact on patients. The sample was to be all
women, given their very high prevalence of this dual diagnosis and the format was to be time-
limited group therapy (selected for cost-effectiveness). At that point, there had not been a single
published treatment study on patients with PTSD and substance abuse, and existing treatment
resources were either brief articles (Abueg & Fairbank, 1991; Bollerud, 1990), were not empiri-
cally evaluated (Abueg & Fairbank, 1991; Bollerud, 1990; Evans & Sullivan, 1995; Trotter,
1992), did not provide session materials (Abueg & Fairbank, 1991; Bollerud, 1990; Evans &
Sullivan, 1995; Trotter, 1992), and/or were not cognitive-behavioral (Bollerud, 1990; Evans &
Sullivan, 1995; Trotter, 1992).
The content of the treatment draws on the traditions of several literatures: substance
abuse treatment (Beck et al., 1993; Carroll et al., 1991; Marlatt & Gordon, 1985; Miller,
Zweben, DiClemente, & Rychtarik, 1995), PTSD treatment (Chu, 1988; Davis & Bass, 1988;
Herman, 1992; van der Kolk, 1987), CBT (Beck, Rush, Shaw, & Emery, 1979), women’s treat-
ment (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991; Lerner, 1988), and educational research
(Najavits & Garber, 1989).
The process of developing the therapy involved an enormous amount of trial and error
over several studies: the initial pilot study, using a group format (Najavits et al., 1998e); a con-
trolled trial against a “treatment-as-usual” control condition, using a group format (Najavits,
1996); a controlled trial comparing it to relapse prevention therapy for inner-city women with
substance abuse, using an individual format (Hien, 1997); a pilot study in a women’s prison
using a group format (Zlotnick, 1999); and a pilot study with men in an individual format. It
16 Overview

was also used in three VA clinical settings, which provided input on male war veterans (C.
Smith, personal communication, April 10, 2000; T. North, personal communication, October
12, 1999) and female war veterans (J. Ruzek, personal communication, September 15, 1998).
On these projects, working closely with numerous therapists conducting the treatments was
crucial in refining the manual and learning that what seemed to make sense on paper needed
a great deal of work to get conveyed effectively to others. I conducted the first two treatment
groups in the initial pilot study and thereafter supervised other therapists in running them,
listened to tapes of many sessions, and worked closely with therapists to identify what did
and did not work. Patients’ response to various aspects of the treatment and their suggestions
on what to change also provided important feedback. The manual was reviewed by several
experts in the field as well.
Two related studies were conducted to provide additional input. The first was a survey of
50 CBT psychotherapists, asking them to report their reactions to treatment manuals, rate
various components of manuals, identify favorite manuals, rate their opinions on controver-
sies about manuals, and report how they use manuals (Najavits, Weiss, Shaw, & Dierberger,
2000). Second, a study was conducted comparing 30 women with PTSD and substance abuse
to 30 women with substance abuse alone, on a battery of many different measures (Najavits et
al., 1999b). The goal was to explore variables that might help to distinguish people who devel-
oped both disorders from those with just one (e.g., evaluating coexisting psychiatric prob-
lems, risk and protective factors during childhood, cognitive distortions, treatment history,
and coping style).
There were several major changes to the treatment, based on this trial-and-error and
information-gathering process. These are described here, as it may be helpful to elaborate
what was tried but did not work in clinical settings.

 Conducting full modules (eight consecutive sessions) of cognitive, behavioral, and in-
terpersonal sessions. Originally the treatment was conducted in blocks of cognitive, behav-
ioral, and interpersonal sessions (eight each, with all sessions in predetermined order) in an
attempt to have patients truly master each domain. Indeed, at one point a separately de-
signed Safe Coping Sheet was used for each of these modules. However, this did not work
well. Patients preferred the diversity of moving among domains rather than being “stuck” in
one for several weeks, and they increased their learning by interweaving the domains rather
than separating them. Thus, the current format allows patients and therapists to select any or-
der for the treatment topics.
 Topics framed in negative terms. Topics were labeled, for example, Cognitive Distor-
tions and The Damaged Self; these are now Creating Meaning and PTSD: Taking Back Your
Power. Throughout the treatment, material that had been framed as pathology has been either
deleted or reworked to offer a contrast with healthy coping (e.g., compassionate vs. harsh self-
talk; the split vs. integrated self). This was found much more supportive and motivating for
patients.
 Assigning group partners. Patients were assigned randomly to another person in the
group treatment to keep a “buddy system” (someone to go to AA with, someone to call if they
missed a session, someone to do the commitments with). Patients gave this treatment compo-
nent a very low rating, and it seemed to create serious boundary problems.
Overview 17

 Homework. Originally, homework followed the standard cognitive therapy model: It was
written, it was called “homework,” and it was required. These are now all changed: It can be any
concrete, defined assignment that moves a patient forward (see Chapter 2); it does not need to
be written (many patients never liked school, and written homework reevoked failure experi-
ences for them); it is called a “commitment”; and it is strongly encouraged but never required.
 Providing most of the written material to therapists rather than patients. Originally,
the idea was to keep the handouts simple, one-page summaries with the bulk of information
in the therapist guide. However, after experimentation, it appeared that patients greatly
appreciated having a lot of written material to return to outside of sessions, and that this also
alleviated the burden of therapists’ having to convey a large amount of information.
 Patient goal setting at the beginning of treatment. Patients were asked to identify their
goals for treatment at the first session—that is, “Write your personal goals for your life: what
you would like to accomplish, what you would like to learn, how you would like to live.” Al-
though this has worked with other patients, it did not appear to work with this population.
They tended not to have a vision of the future (indeed, this is a defining criterion of PTSD),
had difficulty articulating goals, and then often felt bad for not being able to do so. They were
able, however, to set very short-term goals (i.e., the commitments between sessions).
 Writing an autobiography of PTSD and substance abuse. It is a standard exercise in
relapse prevention (Marlatt & Gordon, 1985) to write an autobiography of one’s substance
abuse. When asked to write their history of both PTSD and substance abuse, however, some
patients felt extremely triggered and a few did not return to treatment. Indeed, writing about
one’s history of PTSD is a formal part of exposure therapy for PTSD and is now known to
evoke extreme anxiety. It is thus unsafe as a routine part of this treatment, although if
carefully planned, combining the two treatments—Seeking Safety and exposure—may be
productive (Najavits et al., 2001).
 Linking every substance use incident to PTSD. A naive early stance was trying to iden-
tify each incident of substance use as reflective of PTSD. There are many reasons why people
with the dual diagnosis use substances in addition to attempting to manage their PTSD (e.g.,
habit, being around people who are using, and biological factors).

EMPIRICAL RESULTS

This treatment has been empirically evaluated in four studies thus far: outpatient women,
inner-city women, men, and women in prison (Hien, Cohen, Litt, Miele, & Capstick, under
review; Najavits et al., 1998c, 2001; Zlotnick, Najavits, & Rohsenow, under review). It is
currently being evaluated in several other studies as well: adolescent girls (Najavits,
1998), women veterans (Rosenheck, 1999), women in substance abuse treatment (Brown,
Finkelstein, & Hutchins, 2000), outpatient women (Najavits, 1996), and women in residential
treatment (Detrick, 2001). In some studies the treatment is conducted in a group format,
while others use an individual format.
Results for the pilot study are described in detail in a journal article (Najavits et al.,
1998c). Briefly summarized, a total of 27 women were enrolled in that project, of whom 17
(63%) completed the “minimum dose” of 6 sessions of the group psychotherapy. All patients
18 Overview

met current DSM-IV criteria for both PTSD and substance dependence on the Structured
Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams,
1994), and all had active substance use in the month prior to intake. (Note that substance de-
pendence is the most severe form of substance use disorder.) In addition, 65% of patients met
criteria for one or more personality disorders. Most patients in the study had a history of re-
petitive physical and/or sexual abuse in early childhood, which, as later became clear from
emerging research reports, characterizes the majority of women with this dual diagnosis
(Najavits et al., 1997). All women reported five or more lifetime traumas, with first trauma at
an average age of 7 years. Ninety-four percent reported sexual abuse, 88% physical abuse,
and 71% other criminal victimization. Rates of DSM-III-R substance dependence disorders
were 41% drug dependence, 41% alcohol dependence, and 18% both. Breakdown by type of
drug was 59% alcohol, 29% cannabis, 24% cocaine, 6% anxiolytics, 6% sedatives, and 6% non-
prescription sleeping pills. The sample was 88% white and 12% black. Most were unem-
ployed (59%), and most had children (59%).
A large data set was collected before, during, and after the treatment to study several key
questions: How much did patients’ PTSD and substance abuse symptoms change over time (as
well as numerous other areas of functioning)? How satisfied were they with the treatment?
What did they like and dislike about it? Why did some patients remain and others drop out?
Results were obtained on the 17 patients who met the minimum dose of 6 sessions, as the
intent of the pilot study was to assess the impact of the treatment on them. Patients attended
an average of 67% of available sessions. Based on assessments at pretreatment, during treat-
ment, at end of treatment, and at 3-month follow-up, results showed significant improve-
ments in substance use, trauma-related symptoms, suicide risk, suicidal thoughts, social ad-
justment, family functioning, problem solving, depression, cognitions about substance use,
and didactic knowledge related to the treatment. Patients’ alliance and satisfaction with treat-
ment were very high. Interestingly, the 17 patients who met the minimum dose of treatment
were more impaired than dropouts on a wide variety of measures, yet were also more en-
gaged in the treatment. All results are clearly tentative, however, due to the lack of a control
group, multiple statistical comparisons, and the absence of assessment of dropouts.
In a pilot study on five outpatient men, a combination of Seeking Safety and exposure
therapy for PTSD were combined in individual format (Najavits et al., 2001). Patients were
offered a total of 30 sessions over 5 months, with the patient and therapist together deciding
on the number of sessions of each treatment based on patients’ needs and preferences. The
average number was 21 Seeking Safety sessions and 9 exposure therapy sessions. All of the
men had been traumatized as children (with an average age of first trauma at 8.8 years); all
had had chronic PTSD and substance dependence for many years. Results showed significant
improvements by the end of treatment in a wide variety of areas, including drug use, trauma
symptoms, dissociation, anxiety, hostility, suicidal thoughts and plans, family/social function-
ing, global functioning, and sense of meaning. Treatment attendance, alliance, and satisfac-
tion were all extremely high. The study is limited by the absence of a control condition, small
sample, and lack of control over external treatments.
Two other studies provide initial results. The study of women in prison evaluated 17 women
in a minimum-security setting, using group-modality Seeking Safety treatment, with 25 sessions
over 3 months (Zlotnick et al., under review). All participants met criteria for current PTSD and
substance dependence, and all had histories of repeated physical abuse, sexual abuse, or both
Overview 19

(average age of 8 at first trauma). The most common drug of choice was cocaine. All women who
were offered treatment began treatment. Results showed that the attendance rate was 83% of
sessions, and measures of client satisfaction and alliance were high. Of the 17 women, 9 (53%)
no longer met criteria for PTSD at the end of the 3-month treatment; at a follow-up 3 months
later, 46% still no longer met criteria for PTSD. PTSD symptoms decreased significantly from
pretreatment to posttreatment, and this was maintained at the 3-month follow-up. During in-
carceration, random urinalysis showed none of the women using a substance. A follow-up 6
weeks after release from prison indicated that 29% were using an illegal substance, and at 3
months after release the rate was 35%. A significant decrease in drug and alcohol use and legal
problems was found from pretreatment to both 6 weeks and 3 months after release. The recidi-
vism rate (return to prison) was 33% at 3-month follow-up, typical of this population. Partici-
pants rated the treatment equally helpful for PTSD and substance abuse.
The study of 100 low-income, inner-city women compared Seeking Safety in individual
format to relapse prevention treatment (RPT) in a randomized controlled trial, with a
“treatment-as-usual” (TAU) nonrandomized control condition. Twenty-five sessions were
conducted over a 3-month period, and all participants met current criteria for PTSD and sub-
stance use disorder (Hien et al., under review). At the end of treatment, participants in both
Seeking Safety and RPT had significant reductions in substance use frequency and intensity,
PTSD symptoms, and psychiatric symptom severity, whereas those in the TAU comparison
group did not show any significant changes. Improvements in PTSD severity were sustained
at the 6-month follow-up point but not at 9 months for women in both Seeking Safety and
RPT. Although statistically significant improvements in substance use and psychiatric sever-
ity were not maintained for either of the treatments at the 6-month follow-up, trends in the
direction of lower substance use and psychiatric severity were found. Results were inter-
preted to suggest that carefully conducted cognitive-behavioral interventions can substan-
tially decrease current symptoms of both PTSD and substance use disorder in a relatively
brief period with a very hard-to-reach population.
For further information about Seeking Safety, go to the website www.seekingsafety.org. It
provides updates on new research, journal articles that can be downloaded, information on
training therapists, and resources for conducting research on the treatment.

HOW SEEKING SAFETY DIFFERS FROM EXISTING TREATMENTS

Psychotherapy is currently in a period of proliferation in which many new treatments are

emerging. Thus it is important to distinguish a new treatment from existing ones. Although
this treatment draws on the traditions of many existing treatments (discussed above), it was
developed to meet needs that did not appear to be addressed thus far. Broadly speaking,
Seeking Safety differs from existing treatments in its combination of theory (i.e., safety as the
target goal), its emphasis on humanistic themes (e.g., safety, compassion, honesty), its attempt
to make CBT accessible and interesting to patients who may be difficult to reach, its strong
focus on case management, its format (e.g., the use of quotations), its provision of detailed
therapist and patient materials for each topic, and its attention to process issues. Several
manualized and empirically studied treatments that would appear to be most closely related
are described below, along with how this treatment differs from those. Moreover, all of the
20 Overview

treatments below are highly relevant for patients with PTSD and substance abuse, and thera-
pists are encouraged to read the treatment manuals for them. See the entries marked with an
asterisk in the References list.

Cognitive-behavioral therapy (CBT). CBT is one of the most widely used, manualized,
empirically studied treatments. It has been adapted in recent years for PTSD (see Ruzek et
al., 1998) and for substance abuse (Beck et al., 1993; Carroll et al., 1991). However, none of
these were designed for the combination of PTSD and substance abuse. In addition, the char-
acteristics of Seeking Safety described above are not typically part of CBT. The same applies
to two “close cousins” of CBT, relapse prevention (an offshoot of CBT developed for sub-
stance abuse) and coping skills training (see, e.g., Monti, Abrams, Kadden, & Cooney, 1989).
Dialectical behavior therapy (DBT). This treatment uses a coping skills approach and
has recently been adapted for substance abuse (Linehan et al., 1999). However, it is designed
for patients with borderline personality disorder and does not describe or address PTSD. Al-
though some patients have both borderline personality disorder and PTSD, these are sepa-
rate disorders (Herman, 1992; Linehan et al., 1999). Indeed, in the pilot study on Seeking
Safety, only 29% of patients met criteria for borderline personality disorder; paranoid person-
ality disorder was more prevalent at 47% (Najavits et al., 1998e). DBT is also a much longer,
more intensive treatment, with a full year of treatment in both group and individual concur-
rent therapies totaling over 3 hours per week, plus as-needed phone coaching (Linehan et al.,
1999). Seeking Safety was designed as a lower-cost treatment (e.g., short-term group treat-
ment with one leader) that can be expanded to more intensive, lengthy, and individual for-
mats if patients have access to more care. The format of DBT, the skills it teaches, and its lan-
guage and level of abstraction are also different.
Exposure therapy for PTSD. This is a widely used, empirically based behavioral treatment
for PTSD. Its main technique is exposure to trauma memories and triggers, which by design is
not part of Seeking Safety (as discussed above under “What Is Not Part of This Treatment”),
although it can be combined with it. Also, it is briefer (9–12 sessions) and does not address sub-
stance abuse, case management, or in-depth work on coping skills (although it sometimes uti-
lizes some CBT interventions) (Foa & Rothbaum, 1998).
Motivational enhancement therapy. This treatment for substance abuse (Miller &
Rollnick, 1991) seeks to engage and retain patients in treatment by focusing on positive inter-
personal therapy processes (e.g., “roll with resistance,” “express empathy,” “avoid argumenta-
tion”). It is manualized and has shown positive results in empirical studies (Project MATCH
Research Group, 1997; Miller & Rollnick, 1991). However, it does not rehearse coping skills,
does not address dual diagnosis or PTSD in particular, and is not cognitive-behavioral.
Twelve-step treatment. While twelve-step treatments such as AA are highly compatible
with this and many other psychotherapy treatments, they focus on substance abuse only (not
PTSD); advocate an abstinence model only; are not designed to be led by professional treat-
ers; and do not provide explicit rehearsal of coping skills. Some psychotherapy adaptations of
twelve-step models (Mercer, Carpenter, Daley, Patterson, & Volpicelli, 1994) provide the lat-
ter two characteristics, however.
Treatments for PTSD and substance abuse. Several treatments have been developed for
this dual diagnosis. In addition to Seeking Safety, three others have undergone pilot empirical
testing: Dansky and colleagues’ concurrent treatment of PTSD and cocaine dependence
Overview 21

(Dansky, Back, Carroll, Foa, & Brady, 2000), Triffleman and colleagues’ substance dependence
PTSD therapy (Triffleman, Carroll, & Kellogg, 1999), and Donovan and colleagues’ “Tran-
scend” program (Donovan, Padin-Rivera, & Kowaliw, in press). The treatment by Dansky and
colleagues (2000) is a 16-session model that adapts a combination of Foa’s exposure therapy for
PTSD (Foa & Rothbaum, 1998), relapse prevention techniques (Carroll, 1998; Project MATCH
Research Group, 1997), and psychoeducation about PTSD and cocaine dependence. It differs
from Seeking Safety in its inclusion of exposure techniques, its shorter length, the range of sub-
stances being addressed (i.e., cocaine only), its format, and particular skills. Triffleman and col-
leagues’ (1999) treatment differs from Seeking Safety in its inclusion of in vivo exposure for
PTSD, its format, and particular skills. Donovan and colleagues’ (2001) treatment is a 12-week
program developed for veterans comprised of 10 hours a week of group treatment and manda-
tory attendance in a substance abuse rehabilitation program, as well as supplementary activities
(e.g., volunteer community service) and a 6-week focus on skills development and on trauma
processing, based on a combination of concepts derived from constructivist, existential, dy-
namic cognitive-behavioral and twelve-step theories. It differs from Seeking Safety in its design
as an intensive partial-hospital program, its particular skills, and its focus on trauma processing.
Finally, five other models have not yet been empirically tested or offer detailed treatment mate-
rials (e.g., session-by-session plans and patient handouts). These are books by Trotter (1992) and
Evans and Sullivan (1995), both in the twelve-step tradition; an article by Abueg and Fairbank
(1991) describing a behavioral model developed in a VA setting; Bollerud’s (1990) article on an
eclectic model for inpatient care; Meisler’s (1999) book chapter on group treatment for PTSD
and alcohol abuse; and a book by Miller and Guidry (2001).

ONE PATIENT’S EXPERIENCE OF PTSD AND SUBSTANCE ABUSE

It seems fitting to end this introductory chapter with a patient’s own account of PTSD and
substance abuse. For treaters new to this population, it may be helpful to see the disorder
through a patient’s eyes; and, for all clinicians, it is a reminder of the complexity of these
cases. The excerpt below was written by a woman treated as part of the pilot study on this
treatment. She gave permission for this to be reprinted, and all identifying information has
been deleted.

“As far back as I can remember—I wasn’t even walking or talking yet—and my oldest
brother was physically hurting me. I was 3½ years old when I can remember the first sex-
ual abuse by my brother. That was the first time I recalled feeling the paralyzing anxiety
that I’ve suffered ever since. I was constantly abused by my brother physically, sexually,
and emotionally from those early years to about 6 or 7 years old. During those years my
mother was emotionally distant from me. I always felt she hated me. From both my mother
and brother, I was often ridiculed and embarrassed. My father sexually abused me too. He
suffered from a brain tumor when I was between the ages of 4 and 9. He was always in
and out of hospitals during that time. Sometimes he would come home in a manic state or
in a depression or very disoriented and confused. I recall him being very physically abu-
sive towards my older brother. He confused and frightened me very much. During those
years a neighbor forced me to have oral sex with him. And also my brother’s friend would
22 Overview

often beat me up. I constantly lived in fear. I felt that I was such a bad person and every-
thing was my fault. I couldn’t stand people even looking at me. My father died when I
turned 9 years old. After he died I did not remember any of this. I blanked out my whole
childhood and it wasn’t until the last few years that the memories started to come back.
“I remember growing up always feeling people hated me and wanted to hurt me. I
was always so nervous around other people. By the time I was 11 years old I started
drinking. It made me less nervous and more sociable. By 12 years I was doing drugs.
Downs, speed, acid, pot, and also drinking. Back then I tried them for curiosity reasons,
plus I felt better—that’s why I did the different drugs. My first boyfriend was 16 years old
was when I was 12 years old. He was good friends with my older brother and had lived
with us at times. The first time I experienced intercourse was right after I turned 13 years
old and my boyfriend raped me. He tried to smother and choke me. It was an awful expe-
rience and there was no one I could tell. I also have two other brothers, one older and one
younger, but they were not abusers. They didn’t do anything to try to stop it, but I don’t
know how much they knew what was going on.
“By 14 I met another boyfriend who was 22 years old. He turned me on to heroin.
We both got addicted. I went away to get off the heroin and he was in a bad fire. I was told
that I was evil and could not see him again. After that my anxiety was really out of control.
Between 15 and 17 I did a lot of downs and speed. I hated myself and just wanted to die. I
was also raped at gunpoint by three men at 16 years old. By 17 I felt I went through every
drug out there and yet knew that nothing was going to help me.
“At 17 my anxiety was so bad that I couldn’t leave the house, and felt I couldn’t go on.
At this point I didn’t think there were any options but to kill myself. I finally got up the
courage to take 98 barbiturates. I survived the suicide attempt, but after that I went back
to drinking and smoking pot. I mainly wanted the pot to help me sleep at night and the
booze to control my anxiety. When I was about 23 I moved to the South, thinking that if
only I get out of town everything would be all right. I proved that wrong. I got into an
abusive relationship down there. Finally, I got such a bad beating it broke my jaw. I came
back here, and kept drinking and smoking pot through my late 20s.
“Then I was introduced to AA. I went into a halfway house. After 3½ months, I left. I
felt I could manage my life again. However it wasn’t long before I went into another half-
way house, only staying 6 weeks this time. I met someone else in my early 30s. We both
did cocaine together. Another very abusive relationship—we stayed together till one night
he almost killed me and I ended up in the hospital. I still went back to him, and although
he didn’t physically hurt me again, he emotionally abused me. I felt terrorized a lot of the
time I was with him. When I was 35 we broke up for good. I am in therapy now. I began to
realize the abusive pattern I was in. And now through therapy I am beginning to under-
stand why my life was the way it was. I am now 38 and am taking Antabuse for a backup,
so I won’t drink during this very difficult time of dealing with my memories and anxiety.
However, I am still smoking pot and hope that I can learn to feel in control of my dreams
and my anxiety. I am proud that I have survived longer than my brother who abused
me—he got addicted to heroin and cocaine since he was about 18 till the day he killed
himself at 36.”
 2
Conducting the Treatment

This chapter provides general strategies for conducting the treatment, followed by therapist
sheets and patient handouts that are used for all sessions. It may be helpful to look through the
treatment topics first and then come back to this chapter. An article on training therapists to
use this treatment offers additional suggestions (Najavits, 2000), as do two videos on the treat-
ment of patients with PTSD and substance abuse (Najavits et al., 1998a, 1998b). Note that the
guidelines below were developed as part of training therapists to conduct the treatment uni-
formly in research studies; they can be adapted or loosened based on the treatment context.

THE TREATMENT FORMAT

The treatment was designed to be extremely flexible to adapt to a wide variety of clinician
preferences, patients, and treatment contexts. At the same time, it is highly structured to
make the best use of time available. Below are a few points on the format.

Topics can be conducted in any order. Each topic is designed to be independent of the
others, allowing patients and therapists to choose the order of topics. The topics are thus in-
tentionally not numbered. If you are planning to conduct the full treatment, however, it is
suggested that the topics Introduction to Treatment/Case Management and Safety be covered
first to provide a foundation. Other topics you may want to conduct early in treatment are
PTSD: Taking Back Your Power (if patients do not know what PTSD is), When Substances
Control You (if patients are actively using substances), Detaching from Emotional Pain
(Grounding) (one of the key skills), and Commitment (as it addresses issues relevant to the
commitment at each session’s check-out). It is recommended that patients be encouraged to
select the order of topics, as they are most motivated when they feel control over their treat-
ment. A simple process is to hand them a copy of the List of Treatment Topics (Handout 3 at

23
24 Conducting the Treatment

the end of this chapter) and ask which one they would like to do next. This can be done either
at the end of the current session or at the beginning of the next one. For highly motivated pa-
tients, you may want to provide handouts to read at home prior to the next session. For group
treatment, it is simplest to have the therapist select the order of topics to avoid a lengthy
group decision process.
The treatment can be longer or shorter than 25 sessions. The treatment provides 25
topics, but was designed to be adaptable to either fewer or more than 25 sessions. Some
patients may receive only a few sessions due to insurance constraints or short-term hospi-
talization, for example, while intensive or long-term programs may offer many sessions.
The treatment has been used clinically for as little as one session and for as long as 1 year.
Due to such variability, each topic was developed with two considerations in mind. First,
each is independent of the others, not requiring any previous knowledge base or assuming
any minimum number of sessions. This means that a therapist can use just one topic or a
few topics if this is all that time allows. Second, each topic was written with a large amount
of material so that it can be conducted over several sessions. The topic Creating Meaning,
for example, contains a very long handout that usually takes a number of sessions to cover
fully. Thus, if more than 25 sessions are available, the treatment can be expanded and con-
ducted in a more in-depth manner. Specific suggestions on how to utilize the treatment un-
der different conditions are provided below in “Adapting Seeking Safety to Different Con-
texts” and “Conducting the Session.”
In general, it is hypothesized that the more time available to work on each topic, the
better, particularly for severely impaired patients. When PTSD and substance abuse have
been chronic for many years, it may take considerable therapeutic work to achieve clinically
meaningful and enduring positive outcomes. Research remains to be done, however, to deter-
mine the optimal dose of treatment. The Seeking Safety pilot study (Najavits et al., 1998e) had
as its goal to test whether significant gains could be achieved in a short time frame (a maxi-
mum of 25 sessions over 3 months). Indeed, it was found that the sample of patients who met
the minimum dose of treatment of 6 sessions or more showed significant improvements on a
variety of measures (see “Empirical Results” in Chapter 1). However, one of patients’ and
therapists’ main critiques of the 25-session treatment was that they wanted it to continue lon-
ger. Other treatments of severely impaired populations tend to provide lengthy and intensive
amounts of therapy (e.g., Linehan’s DBT for patients with borderline personality disorder
and substance dependence provides over 3 hours of treatment per week for a year, plus as-
needed telephone coaching; Linehan et al., 1999).
The therapy is designed to be integrated with other treatments. Although the treatment
can be conducted as a stand-alone intervention, the complexity of patients’ needs usually sug-
gests that they be in several treatments at the same time (e.g., pharmacotherapy, individual
therapy, twelve-step groups). Thus, not only was the treatment designed to be used in con-
junction with other treatments, but it includes a very heavy case management component to
help engage patients in them. See the topic Introduction to Treatment/Case Management for
more on this.
The treatment can be conducted in a wide variety of formats. The treatment has been
conducted in a variety of formats, including 50-minute sessions, 90-minute sessions, group
treatment, individual treatment, closed groups (all patients begin and end treatment at the
same time), open groups (running continuously, with patients joining at any point), with one
Conducting the Treatment 25

leader or two, and with varied pacing (twice weekly, once weekly, or the first half of the ses-
sions twice weekly and the next half once weekly). In short, it appears to be adaptable to dif-
ferent formats. However, while clinical impressions have been positive, research is needed to
evaluate outcomes using the different formats. The published research study on the treat-
ment (Najavits et al., 1998c) was conducted under constrained conditions to evaluate gains
within the typical limits of managed care treatment. It used a group format held twice per
week for 12 weeks, each session lasting 1½ hours, with up to eight patients, one therapist,
and a modified closed-group model (no new patients joining after Session 5). Other empirical
results on Seeking Safety thus far are from three studies using different formats: A study using
it in an individual format with 1-hour sessions for inner-city women (Hien & Litt, 1999), a
study using it in group format with 1.5-hour sessions for women in prison (Zlotnick, 1999),
and a study using an individual format with 1-hour sessions for men. Initial results for both
appear positive (see “Empirical Results” in Chapter 1).
The treatment may be applicable to a wide range of patients with PTSD and substance
abuse. The treatment has been applied to a wide variety of patients, including women, men,
mixed gender (in group treatment), adults, adolescents, prisoners, veterans, outpatients, inpa-
tients, inner-city patients, suburban patients, and minority patients. Initial data thus far indi-
cate positive satisfaction with the treatment in several of these subpopulations, although out-
come results are still being collected.
The treatment is highly structured. The structure of the treatment is designed to model,
within each session, how to make good use of time, how to “contain” appropriately, and how
to set goals and stick to them. For patients with PTSD and substance abuse, who are often im-
pulsive and overwhelmed, the predictable structure of the session helps them know what to
expect. It offers, moreover, in its very process, a mirror of the careful planning, organization,
and focus that are needed for recovery from these two disorders. It is notable that in testing
the treatment, patients reported feeling easily comfortable with the structure and helped by
it. A number of therapists, however, had a more difficult time getting used to it (particularly
those whose training was primarily in unstructured treatments). If therapists are unsure
whether the structure works, it may be helpful to try following it and then asking patients for
feedback about how it feels to them.
Patients do not necessarily have to meet full formal criteria for current PTSD and sub-
stance abuse. Although the treatment was tested on patients who met DSM-IV criteria for
both current PTSD and substance use disorder (e.g., Najavits et al., 1998e), it has also been
used clinically on patients who did not fully meet these criteria. These included, for example,
patients with a history of trauma but no diagnosis of PTSD, patients with PTSD alone (no
substance abuse), and patients with a history of both disorders but only one currently. Such
patients reported that the treatment felt relevant for them. Most patients also had additional
diagnoses other than PTSD and/or substance abuse (e.g., major depression, personality disor-
ders, other anxiety disorders). Indeed, it appears helpful to encourage patients to apply the
treatment’s coping skills to whatever problems are most important to them right now (with
the therapist’s guidance). The substance abuse material may be especially relevant for other
impulse control disorders (e.g., eating disorders, gambling, workaholism, sex addiction,
Internet addiction). Thus a patient who is currently struggling with PTSD and gambling ad-
diction could explore the topics in relation to these two areas. The patient might be told,
“When you see mention of ‘substance abuse,’ think of your gambling instead.” However, it is
26 Conducting the Treatment

important to note that research has not yet evaluated the impact of the treatment on disorders
other than PTSD and substance abuse, so it is not yet known what results can be expected.
Also, patients should be referred to all treatments necessary for other disorders (e.g., eating
disorder treatment); use of this treatment is clearly not a substitute for known effective treat-
ments for such disorders.

ADAPTING SEEKING SAFETY

TO DIFFERENT CONTEXTS

Due to the diversity of treatment settings, the range of patients with this dual diagnosis, and
constraints on treatment, there are many different ways to adapt the treatment. Some guide-
lines are suggested below; however, these are largely clinical rather than research-based at
this point.

If you have only one or a few sessions. Consider one or more of the following topics,
which are perhaps the most essential:

 Safety
 PTSD: Taking Back Your Power
 When Substances Control You
 Detaching From Emotional Pain (Grounding)
 Asking for Help

Base your selection on patients’ urgent needs and/or preferences. For example, if this is the
first time a patient is learning about PTSD, consider conducting the PTSD topic over one to
three sessions, focusing on education about the disorder and planning for how the patient can
obtain longer PTSD treatment later. In addition, to “boost” the power of the intervention, ask
the patient to read handouts outside of sessions to make better use of the limited time avail-
able. Finally, consider conducting individual rather than group treatment, as the former al-
lows more focused attention on the patient.
If you have more than 25 sessions available. Allow, if possible, at least two sessions per
topic, with more as needed based on the patient’s and your own judgment. Thus, for example,
if the topic is Recovery Thinking, the patient can receive the handouts for this topic at the
first session, but then return to them at the next session. This allows for in-depth rehearsal of
the skills and more processing of the commitment between sessions. Indeed, some topics
have been conducted for three or more sessions in a row. The treatment has also been used
over the course of a year, with patients repeatedly cycling through the topics and reporting
satisfaction with this. As one patient said, “Each time, I find something new to explore.”
However, if conducting the treatment over a large number of sessions, you may eventually
want to omit topics that the patient has mastered or approach topics in a less formal way
(loosening the structure of sessions). The key in using the material over longer periods is to
elicit patients’ input on what is most appealing to them. Also, if more than 25 sessions are
available, you may want to do a combination treatment (e.g., adding motivational enhance-
ment therapy or exposure therapy). This is particularly relevant for individual treatment. If
Conducting the Treatment 27

adding exposure techniques, however, see the safety parameters described below in “Treat-
ment Guidelines.”
If patients have difficulty reading. Some patients may be illiterate, may be slow readers,
or may simply dislike handouts. In such cases, it is recommended that the therapist summa-
rize the material briefly for the patient and try to weave the topic in throughout the session.
This has been done successfully for some patients in the study of women in prison (Zlotnick,
1999), the study of inner-city women (Hien, 1997), and the study of adolescent girls (Najavits,
1998). However, it has been found important that therapists not stray too far from the mate-
rial. Sometimes, without the handouts as an anchor, the sessions have appeared to lose focus
altogether. Also, it is suggested that the therapist initially try to encourage patients to read the
handouts, and only omit handouts if patients truly cannot read or repeatedly refuse to read
them. In group treatment, patients who are able to read might read sections out loud to those
who cannot. It is suggested, however, that the therapist not read material out loud, as this
may appear too much like school rather than therapy.
If you are treating a specific subpopulation. Some therapists work solely with military
veterans, the homeless, patients with HIV, minority patients, adolescents, or prisoners. There
are many subpopulations with this dual diagnosis. Try to take the materials and add examples
that relate to your patients. For example, if you are working with minority patients, you may
want to add examples based on racial discrimination (e.g., “How would you cope if someone
makes a racist comment to you?”). If you are working with veterans, you may want to relate
the material to war (e.g., “Can you fight a ‘war’ against substance abuse within yourself? How
does your military training apply to fighting the ‘enemy’ of substance abuse?”). However, try
not to make major changes (e.g., omitting whole topics) until you have tried the material “as
is” and obtained patients’ feedback. Sometimes topics that you think might not work in your
population (e.g., Self-Nurturing for male veterans) have been successfully applied. Listen to
patients’ reactions and adapt the treatment accordingly.
Examples of different applications.
1. Maria, social worker in a day program. Maria is conducting the treatment in group
format twice per week. Most patients have from a few weeks to a year. They are quite
impaired, so she decides to have a “topic of the week,” allowing two sessions per
topic. On Monday she introduces the topic and gives all the handouts for it. They
cover part of it and then return to more on Wednesday. Patients who are in the pro-
gram for a shorter stay receive only some of the topics, while patients staying longer
receive topics multiple times.
2. Rick, substance abuse counselor on a short-term inpatient unit. Rick works on a detoxi-
fication unit where patients may have anywhere from a few days to a few weeks for
treatment. He decides to do individual sessions with patients. He selects topics based
on his assessment of each patient’s most urgent needs. One patient, Martha, is having
a lot of flashbacks and dissociation, but has only 2 days of inpatient treatment before
discharge. He decides just to help her with grounding skills. He then refers her for
outpatient PTSD treatment at a local mental health clinic.
3. Dr. Klein, outpatient clinician treating a patient with unlimited sessions. Dr. Klein is an
outpatient clinician seeing a patient three times per week for individual therapy over
several years. The patient has a severe history of early childhood trauma and
polysubstance abuse. The patient’s spouse is willing to pay for treatment, so there are
28 Conducting the Treatment

no insurance constraints. The patient has expressed an interest in working both on

coping skills and on discussion of trauma memories, and Dr. Klein, after careful as-
sessment of the patient, agrees that this is likely to be helpful. Initially, they work
solely on Seeking Safety topics to build a foundation of coping skills. After 2 months of
this, when the patient has demonstrated an ability to utilize the skills, they add expo-
sure therapy sessions and use a treatment manual designed for that (see, e.g., Foa &
Rothbaum, 1998). Note that Dr. Klein is only doing this work with the necessary
safety parameters built in (see “Treatment Guidelines,” below, for a list of these). They
set up a plan that they will try to alternate sessions between exposure and coping
skills, but will flexibly decide at each session, based on how the patient is doing. If the
patient is not doing well, they will return to coping skills until the patient can safely
discuss trauma memories again.

PREPARATION

The following suggestions may help you prepare for the treatment. See also the “Checklist
before Beginning the Treatment” and “Materials for All Sessions” at the end of this chapter.

Read the entire book before conducting the treatment. Like reading a map before start-
ing a trip, reviewing the entire book provides perspective to integrate the individual compo-
nents. Moreover, much of the material is applicable across the whole treatment. For example,
the topic When Substances Control You provides ideas relevant to any session in which a pa-
tient reports having used substances.
Obtain treatment-related materials. Before beginning the treatment, it is helpful to amass
lists of local resources for case management purposes. Also, the topic Community Resources
provides toll-free numbers to obtain free resource materials from national organizations (e.g.,
patient pamphlets, posters, fact sheets on substances of abuse, monographs) on a variety of top-
ics, including substance abuse, HIV, trauma, mental health, and domestic violence. Finally, you
may want to consider joining some of the professional or advocacy organizations that focus on
trauma or substance abuse. See Handout 1 in the topic Community Resources.
Consider cross-training needs. The key areas of the treatment are substance abuse,
PTSD, and CBT. If any of these are unfamiliar, you may want to seek specialized training or
supervision. Helpful background reading is marked by an asterisk in the References list. Also,
know what is beyond the bounds of your expertise, and either refer patients elsewhere as
needed or obtain consultation. This may include, for example, domestic violence,
psychopharmacology, and treatments for other diagnoses (e.g., eating disorders, obsessive–
compulsive disorder, and panic disorder). Finally, make sure you acquire a “feel” for the dis-
orders PTSD and substance abuse. In addition to listening closely to patients, one of the best
ways to acquire this is to watch movies or read books that convey the direct experience of the
disorders; brief lists of these are provided at the end of the References list.
Prepare for treatment challenges in advance. See “Treatment Guidelines” and “Problem
Situations and Emergencies” below, which suggest decisions to make before beginning treat-
ment. Also, you may want to think through the “Tough Cases” examples provided for each
Conducting the Treatment 29

topic. If possible, conduct role plays on some of them with a colleague or supervisor to prac-
tice your responses.
Attend at least one AA or other twelve-step meeting. It is strongly recommended that
you attend at least one twelve-step meeting if you haven’t already. Anyone is welcome at open
meetings, and you do not need to identify yourself as a professional. As much of substance
abuse treatment in general, and this treatment in particular, relies on self-help groups, know-
ing intimately what they are like can help you to address patients’ concerns realistically. If
possible, attend a “speaker meeting” or “speaker discussion meeting,” in which members de-
scribe their history of substance abuse; this conveys, more powerfully than any objective de-
scription, how substance abuse affects people’s lives. You might also want to try a “step meet-
ing” in which one of the twelve steps is discussed. See the topic Community Resources for
how to locate twelve-step group meetings.
Get support. It is widely advised that when working with severe patients, therapists seek
a network of support for the emotional challenges that arise. Indeed, for substance abuse,
some clinicians attend twelve-step support groups for nonaddicted “significant others” as a
means to do this (e.g., Al-Anon or Adult Children of Alcoholics). In trauma work as well, ob-
taining collegial support is strongly emphasized (Herman, 1992).
Apply the treatment topics to your own life. Consciously applying the skills to your life is
one of the best ways to experientially understand what patients are likely to go through. This
is not meant to sound patronizing but rather to suggest that directly testing the coping skills
of this treatment on your own issues can provide invaluable insight for your therapeutic work.
For example, the skill of rethinking sounds easy but is typically very difficult, and the more
important the situation, the harder it is to do. In a similar vein, it can be informative to try
giving up for a period of time a “substance” that you enjoy (e.g., chocolate, cigarettes, wine) to
experience in a small way what patients go through.
For research only. If you plan to conduct a research study using this manual, it is sug-
gested that you conduct a training case with a real patient, or group of patients, using all 25
topics, prior to collecting data. Also, you can contact my research program using the address
or fax number listed at the end of the Seeking Safety Feedback Questionnaire (see the topic
Termination).

PROCESS

Encourage patients to discover any method that works. There is no one right way to
cope; there are only methods that work better or worse for a particular patient. Similarly,
there is no knowledge base patients must master in this treatment; a variety of strategies are
offered, and patients can choose what does and does not work for them. If a patient says that
certain skills don’t work, rather than debating the merit of a particular skill, it’s more helpful
to validate the patient’s experience (e.g., “That’s OK; not every skill works for everyone”) and
then move on to what does work (e.g., “What do you think might work for you?”, “Do you see
any other strategies on the Safe Coping Skills list that you could try?”).
Go deep. One of the main reasons an intervention does not work is that the therapist is
making assumptions rather than fully understanding the patient’s emotional and practical ob-
30 Conducting the Treatment

stacles. Giving easy advice (“Just ask for help!,” “Set a boundary with him!,” “You need to be-
lieve that you’re a good person”) may be extremely unhelpful. If a patient has difficulty with a
skill, it usually requires some amount of time in the session to explore and truly understand
the patient’s dilemma. Questions might include, “Why do you think it’s hard to ask people for
help when you feel down?”, “Is it equally hard with everyone?”, “What is your fear of what
might happen?”, “What would it feel like if you asked for help and didn’t get it?” In short, to
avoid trivializing the patient’s experience, allow time to explore the patient’s inner world be-
fore “fixing” it.
Use empathy to deescalate patients who are upset. It is not unusual for patients to esca-
late into intense emotions. The most effective way to calm such a patient is to be comforting
and soothing. It is not helpful at that point to try to discuss any real issues rationally, to give
the patient feedback, or to try to have the patient understand your point of view. Empathy
and validation are key (Miller et al., 1995): “I really hear that you’re upset,” “I totally under-
stand that this topic upset you, and we don’t have to stay with it,” “The only thing that matters
right now is to help you feel better,” “I know it’s not easy for you right now.”
What the patient says is worth twice as much as what the therapist says. Any insight
the patient arrives at will be remembered and used far more than if the therapist says ex-
actly the same thing. If the patient says, “Maybe I could try to get some exercise each day,”
it is more likely to lead to action than if the therapist says, “Maybe you could try to get
some exercise each day.” This is not to diminish the importance of the therapist, but rather
to say that eliciting from the patient works far better than telling the patient. There are sev-
eral implications of this idea. First, instead of offering a statement, it is usually more mean-
ingful to ask a question. For example, rather than saying, “I think your marijuana use is an
attempt to decrease your anxiety,” turn it into a question to allow the patient to explore it:
“Is it possible that your marijuana use is a way to decrease your anxiety?” (See Beck et al.,
1985, for the concept of “Socratic questions.”) Second, in terms of sheer quantity, the ther-
apist should be talking much less of the time than patients during the session. Third, rather
than giving patients answers, first see whether they can come up with them. For example,
instead of “A helper card is designed to give you a list of names to call,” ask, “Do you know
what a helper card is?”
Praise and accountability are key processes. The treatment is grounded in two funda-
mental, and equally important processes: praise and accountability. “Praise” refers to the
need to continually notice what is good about patients—what they have done right, what
their strengths are. Praise is, quite simply, the most powerful tool to reinforce behavior
(Rimm & Masters, 1979). “Accountability” is the need to hold patients to the highest possible
standards of behavior: to spur patients to follow through on their commitments, to respect-
fully confront lying or inappropriate behavior, to take notice of substance use and other harm-
ful actions, and generally to establish an atmosphere of integrity. In some sense, accountabil-
ity is the opposite of praise—where praise is the nurturing parent, accountability is the
disciplinarian. Either one without the other will not work. Indeed, many patients have had
unhealthy extremes of one or the other when growing up.
It may be helpful to remember that patients with PTSD and substance abuse are, on an
emotional level, developmentally delayed. It cannot be assumed that they recognize what
they are doing; indeed, they often resemble teenagers who need clear guidance. Thus the
Conducting the Treatment 31

therapist is not neutral in this treatment, but provides direct feedback, both positive (“I am so
impressed that you were able to do that!”) and negative (“I think it is a serious mistake to get a
job as a bartender”). However, the feedback is nonconfrontational. This means that the thera-
pist does not insist on a point of view, coerce, or convey blame or judgment, none of which
works nearly as well as a supportive style (Miller, Benefield, & Tonigan, 1993). For patients
with early childhood PTSD, harsh confrontation can feel like a reexperience of emotional
abuse. A very common therapist error is solely to praise patients’ efforts; unless they are also
given constructive feedback to improve, they will not grow beyond where they are. With all
patients, find some suggested improvement to help them move forward in their abilities. For
example, in a role play, patients should be praised for good rehearsals, but it is equally impor-
tant to offer constructive feedback. If a patient’s role play is so effective that it cannot be im-
proved upon, select a more difficult one.
Give patients control. PTSD and substance abuse are, by their nature, disorders of loss
of control. In PTSD, one never chose for the trauma to happen; with substance abuse, one has
lost control over one’s use. Thus, whenever possible, it is helpful to give patients control as a
means to help them reassert control over their lives. In contrast, when a therapist tries to con-
trol the patient, it typically leads to defensiveness and unproductive power struggles (see
Miller & Rollnick, 1991, for an extended discussion of this issue). Specific ways to give pa-
tients control include always allowing them to say “no” to any particular topic or exercise, and
allowing them to choose for themselves whatever they reasonably can (e.g., their commit-
ments; what external treatments to attend; and all major life decisions, as long as they are safe
decisions). Empowering them toward their own authority is an implicit agenda of the treat-
ment. Often the therapist must encourage patients to take control, as passivity and learned
helplessness may be much more familiar.
Redirect and focus to use time well. One of the key skills the therapist needs to master is
redirection to help keep the session from meandering into unproductive work. In later-stage
treatment, working with a looser format may be helpful, but at this point letting patients talk
at length without focus will typically not achieve demonstrable results. Ways to redirect pa-
tients gently include questioning (e.g., “I can hear that you’re concerned about your aunt; do
you think the topic Asking for Help might be helpful in dealing with that?”); reminding (e.g.,
“That’s important material, but I’m concerned that if we don’t move to other patients’ check-
ins, we won’t have time for discussion”); and agenda setting (e.g., “It sounds like there’s a lot
going on for you this week. I think your use of alcohol to sleep at night might be the best area
for us to focus on”). If a patient repeatedly dominates a group treatment, a one-to-one discus-
sion with the patient before or after group treatment may be needed.
Validate patients’ criticisms of you and the treatment. When a patient criticizes you or
this treatment, the most helpful approach is to take it seriously, view it as valid on some level,
and see if there’s a better way to adapt your work to the patient’s needs. It is not helpful to be-
lieve that the patient is wrong, to conclude that it’s just “pathology,” or not to respond. Some
amount of a patient’s criticism is likely to be about the patient’s pathology, but, paradoxically,
the best way to determine how much is the patient’s is first to explore it as being true. More-
over, in early-stage treatment it may not be helpful to try to resolve complaints, but rather
just to validate that patients have some good reason for feeling the way they do. Although the
therapist may silently note that the reason may be transferential or misdirected, just calmly
32 Conducting the Treatment

expressing empathy is typically the best strategy at this stage of treatment. When patients
achieve greater stability, they are more likely to be able to work on relational issues in treat-
ment. Moreover, many patients with PTSD may have learned never to express negative feel-
ings toward others; thus criticism may be a good sign, signifying that the therapist has created
a safe atmosphere for patients to experiment with self-expression. Finally, remember that val-
idating the patient does not mean agreeing with the patient; one can validate the patient’s
feelings without agreeing with the patient’s view. It also does not mean getting “walked over”
by the patient (see the discussion of praise and accountability, above). Note that in this treat-
ment, criticism may be especially likely to emerge in the check-out or on the End-of-Session
Questionnaire (see Handout 6 in this chapter).
Keep your statements brief and essential. Among the most common therapist difficul-
ties are the tendency to talk too much or to become “chatty” (i.e., to sound like a friend
rather than a therapist). The best way to avoid talking too much is to decide on a policy of
limiting your statements to brief ones and striving for a ratio of about 4:1, that is, in a 50-
minute session, the patient(s) talk for a total of 40 minutes, and you take up no more than a
total of 10 minutes. If you keep to these guidelines, it will be impossible to fall into “lec-
ture mode” in which you are talking at the patient rather than listening very closely and
responding to the patient. Moreover, don’t diffuse the session with questions or statements
that are “just out of curiosity” or to explore an issue that is not a high priority in the pa-
tient’s life right now. To heighten real growth, view therapy as sacred time in which every
statement matters. Even if a patient initiates a chatty topic (e.g., about the weather or
sports), you do not need to continue it into a conversation unless you have filtered it in
your mind as the most relevant thing you could be talking about right now with this pa-
tient. Remember only to make statements that are brief and directly relevant to patients’
most urgent clinical needs.
In group treatment, protect patients from triggering each other. Both PTSD and sub-
stance abuse are “trigger” disorders: Patients can be set off very quickly into painful trauma
symptoms or substance cravings (see the topic Coping with Triggers). There are numerous
benefits to a group treatment approach with this population, but one of the dangers is that pa-
tients may trigger each other in harmful ways. For example, a patient who is allowed to de-
scribe the “gory details” of a past trauma or substance use experience is likely to create severe
anxiety in other patients. The safety of the group requires the leader to steer patients toward
a focus on current coping, what can be done now, and how the future can be better.
Reminding patients of the Core Concepts of Treatment (Handout 2 in this chapter) may be
helpful.

CONDUCTING THE SESSION

The flow of the session is summarized in the Session Format (the Therapist Sheet at the end
of this chapter), which can be photocopied as a reminder to the therapist during sessions. No-
tice that each session is a sequence of four steps: (1) check-in, (2) the quotation, (3) relating
the material to patients’ lives, and (4) check-out. Several additional components are optional.
Suggestions on each component are provided here, followed by general comments. Note that
the check-in and check-out are summarized on Handout 1 in this chapter.
Conducting the Treatment 33

1. Check-In

The check-in serves as a “temperature check.” It allows patients to let you know how they are
doing, identifies issues that you can incorporate into the main content of the session, and pro-
vides a consistent start to each session. A few guidelines on the check-in may be useful, how-
ever, as it can also stray in unhelpful directions.

Any unsafe incident since the last session needs to be prioritized in the current session.
Listen carefully when patients report the “unsafe behaviors” part of the check-in. If a patient
has used a substance since the last session (or had any other serious unsafe incident, such as
self-cutting, domestic violence, or HIV risk behavior), this needs to be prioritized in the cur-
rent session. Note that the check-in remains very brief, but the unsafe incident is noted and
then related to the topic (see “Keep the check-in to 5 minutes,” below). Almost always, there
is a way to connect the patient’s incident and the topic. For example, if the topic is Asking for
Help and the patient has reported using a substance, the focus might be: “Did you try calling
anyone before you drank on Tuesday?”, “What would need to happen for you to be able to
call someone when you feel like drinking next time?”, “Whom could you have called?”, and
so forth. If the topic is Integrating the Split Self, the focus could be questions such as, “Was
there any ‘dialogue’ in your mind about using—that is, different sides of yourself?”, “How can
you strengthen the side of you that does not want to use?” In short, virtually any dangerous
incident can be addressed without losing focus on the topic at the same time. In very rare in-
stances, you may need to switch topics if you or the patient simply cannot make a connection
to it. For example, if the patient has had food stamps cut off that week and the topic is De-
taching from Emotional Pain (Grounding), you may want to turn instead to another topic that
feels more relevant to managing the crisis, such as Community Resources.
Why “good coping” is part of the check-in. As part of the check-in, patients are asked to
name at least one brief example of good coping since the last session. This encourages pa-
tients to respect their strengths and reinforces a central principle in behavioral treatment:
that praising positive behavior is one of the most powerful method of growth (Rimm & Mas-
ters, 1979). Particularly for childhood trauma survivors, noticing strengths provides a coun-
terbalance to a past that was typically suffused with devaluation. It also counteracts the ten-
dency to define patients by their pathology and highlights how resourceful they can be.
Patients need to generate the “good coping”—not therapists. It is a common tendency for
therapists to identify good coping for patients (e.g., “The fact that you showed up for this ses-
sion is good coping!”). But it is much more valuable to train patients to be able to generate it
themselves. In conducting this treatment, even the most severely impaired patients were able
to identify good coping when it was expected and guided—but never given—by the therapist.
Examples of guiding include “Is there anything at all you can think of, no matter how small?”,
“People usually do something right during the whole week—what was it for you?”, or “Take a
look at the list of Safe Coping Skills—did you do any of those this week?” The latter may be espe-
cially useful, as patients are always able to find at least one thing on the Safe Coping Skills list
they have done during the week. The list is provided in the topic Safety. Finally, note that
occasionally a patient will name something destructive (e.g., “I used heroin and that helped me
feel better”); if this occurs, you may want to reiterate the purpose of the exercise and remind the
patient that only safe coping counts for this part of the check-in.
34 Conducting the Treatment

Keep the check-in to 5 minutes per patient. This appears to be the single most difficult as-
pect of the format for therapists to master. Viewing the check-in as a “temperature check” or
“snapshot” rather than as therapy per se may be helpful: The goal is simply to ascertain how
patients are doing and whether there are any key issues to come back to later in the session.
It is not intended as the major focus of the session; as a place for therapeutic interventions; or,
in group treatment, as a time for patients to interact with each other. The 5-minute limit is
crucial in group treatment, where exceeding it will leave little time for the main part of the
session. Specific ways to keep the check-in to 5 minutes include the following (some of which
also may also be helpful for maintaining focus during other parts of the session):

 Do not ask any questions during the check-in other than the five questions. Sometimes
the therapist wants to find out more about an important issue the patient is raising. In
this case, the therapist can make a note to return to the topic in more detail in the main
part of the session. Tell patients this so that they’ll know their issue will get addressed
(e.g., “Dave, I hear that you’re in conflict over that job decision; let’s come back to that
later in the session”). Needless to say, take careful notes so that you remember to do so
(particularly for group treatment, where you may have multiple patient issues to re-
turn to). Note that the case management segment of the check-in may raise some ma-
jor issues that may need attention not only later in the session, but perhaps also in an
ad hoc individual case management session for patients with urgent needs (see the
topic Introduction to Treatment/Case Management).
 Do not provide reflections or interpretations during the check-in. These spur the pa-
tient to keep talking. Limit yourself to comments of simple praise (“That’s great!”),
concern (“I’m worried about your substance use”), or very brief suggestions (see “Give
brief feedback” below).
 Provide minimal review of patient’s commitment. Simply find out whether it was done,
offer a brief statement of praise (or concern, if not done), and allow the patient to offer
one or two sentences about how it went. This is particularly necessary in group treat-
ment due to the number of patients. Even in individual treatment, the main idea of the
commitment is for patients to keep moving forward in their lives, but not typically to
solve problems in detail (see the discussion of this below).
 In group therapy, train patients not to speak during anyone else’s check-in. For exam-
ple, you could say, “This is Karen’s time, and we need to give her the space to speak
right now.” Also, you may want to mention the 5-minute limit at the first session so
that patients will not feel cut off, but rather understand that this guideline allows
enough time for all parts of the session and for the most crucial issues to be addressed.
If a patient does not remember to end after 5 minutes, you can gently enforce the rule
(e.g., “Chris, I really hear that there’s a lot going on for you this week, but I hope you
don’t mind if we move on to the next person so he’ll have time too”). Other patients
generally feel relieved by such limits, as it conveys that the leader has maintained bal-
ance among the needs of the group.
 In general, remember that there will always be more to talk about than can be covered
in the session. Allowing a patient to talk at length during the check-in may feel thera-
peutic, but, as mentioned above, ultimately it does not appear to promote the highest
level of therapeutic work with this population during the early phase of treatment.
Conducting the Treatment 35

Also, keep in mind that although initially many therapists have a hard time keeping
the check-in to its simple “temperature check” purpose, patients have no trouble with
it. Once it becomes routine and expected, it is easy to do.

Remind patients of parts of the check-in they have forgotten. For example, patients may
neglect to mention substance use because they feel ashamed about it, or they may say they
used but may not mention specific amounts or types of substances. Helping patients learn to
be honest without shame or judgment is part of the treatment, so such omissions need to be
cued.
Give brief feedback, both positive and negative, during patients’ check-in. Find oppor-
tunities to enthusiastically praise any gains patients have made that are revealed during the
check-in (e.g., “That’s great!”). However, if a patient reports unsafe behavior, it is equally
important to convey genuine concern, and, if applicable, provide brief constructive sugges-
tions (e.g., “I’m worried about your continued use of marijuana every day; can we make
that part of our discussion later in the session?” or “Could you write down phone numbers
of people to call the next time you have a craving?”). Responding briefly with both praise
and supportive concern will, it is hoped, inspire patients to be open about their true ups
and downs.
For group treatment, if a patient is late, allow the patient to check in but do not provide a
catch-up summary. The rationale is that you and group members will want to know how the
patient is doing, but spending time catching up reinforces lateness and disrupts the flow of
the session. Ask the patient to check in, but do not have other patients repeat their check-ins.
Then tell the patient what issue is being discussed and keep going. The patient can find out
what was missed later, outside of the session.

2. The Quotation
The purpose of the quotation for each topic is to engage patients emotionally and to provide a
brief point of inspiration that they might remember for the future. Ask the patient (or a volun-
teer, in group treatment) to read it out loud, and then ask, “What is the main point of the quo-
tation?” If you ask a broader question, such as “How do you feel about that quotation?” or
“What does the quotation mean to you?”, you may end up with a 10-minute free association
by a patient that will frustrate any attempt to move forward in the session. The quotation is a
simple 1- to 2-minute device to launch the session, but if not directed, just like the check-in,
it can become the entire focus of the session with a patient who is highly expansive. Patients
will sometimes bring in quotes of their own, and these can be incorporated or not as you see
fit. Locating quotations that are meaningful to you can also enhance the process. Each treat-
ment topic offers a suggestion for linking the quotation to the topic, but you can adapt this to
your own style.

3. Relate the Topic to Patients’ Lives

Relating the topic to the patient’s life is the heart of the session, both emotionally and practi-
cally. Each topic offers specific ideas on how to do this. The following are more general com-
ments.
36 Conducting the Treatment

Note that each session has a similar protocol: (1) Ask patients to look through the hand-
outs; and (2) relate the material to current and specific problems in patients’ lives. Each of
these elements is discussed below.

A. Ask Patients to Look through the Handouts

Often more material is provided than can be covered in a single session. This is by de-
sign—the goal was to provide enough material so that therapists could select what ap-
pealed to them, what felt clinically relevant to their particular patients, and what could sus-
tain a longer treatment than the 25 sessions tested in the research version of the treatment.
In particular, PTSD: Taking Back Your Power and When Substances Control You are very
long because they address the two disorders targeted in the treatment and are highly com-
plex topics. Thus many topics have multiple handouts from which you may want to select
just one (for a patient who needs to focus in depth on one area), or which can be combined
as needed. The therapist’s clinical judgment always remains the key to high-quality thera-
peutic work. Providing many options, it is hoped, allows therapists maximal flexibility. The
pace should not feel rushed to patients, as though it is a race to check items off the list
rather than listening to their clinical needs. Use of the materials should still feel like ther-
apy as you know it, but with the addition of prepared handouts to make your job easier.
Therapists in the research study found that once they got used to the material by trying it
once or twice, it felt natural.
Some specific suggestions if you feel that a topic has too much reading:

 Ask patients to select parts of the handout they would like to cover. You may want to
state what the possible handouts are, or ask patients to look them over and then de-
cide.
 Go slower. Space the material over several sessions. Indeed, many topics were never
designed to be covered in a single session (e.g., Creating Meaning has a very long
handout).
 Go over one handout at a time, only proceeding to the next if the current one has been
thoroughly processed.
 Have the patient skim the handouts to get a feel for them rather than reading them
fully.
 Select handouts that you believe are relevant, based on your knowledge of the patient.
 Do one or two handouts now and return to others later in treatment as patients’ needs
become clearer.
 Ask patients to read some handouts outside of the session (e.g., as the patients’ commit-
ment).
 Give patients handouts before the session. You could ask them to arrive 10–20 minutes
before the session and leave the handouts for them to read. Or, at the end of the cur-
rent session, give them the handouts for the next session to read during the week.
 Briefly summarize main points for patients, for example, for those who cannot read.
 For groups: Ask patients to take turns reading aloud a line or two, perhaps asking them
to raise their hands when a particular section applies to them.
Conducting the Treatment 37

In work with therapists on using the manual, several ways not to use the materials be-
came quickly apparent. These included spending most of the session with the patient reading
silently; making the session sound like school by focusing on the handouts rather than the pa-
tient; or the opposite, ignoring the handouts altogether. In other cases, the therapist would do
most of the talking rather than integrating the patient’s concerns into the session; would make
it an intellectual process without connection to emotions; would rush through (quantity over
quality); or would keep the discussion at an abstract level rather than connecting it to specif-
ics in the patient’s life.
In sum, with so much prepared material, a genuine danger is losing the patient! Use the
handouts to try to convey key points and adapt your coverage based on patients’ level. Re-
view handouts in ways that are as engaging as possible; and, most of all, use them therapeuti-
cally. The handouts should serve as a vehicle to help patients move toward real change.

B. Relate the Material to Current and Specific Problems in Patients’ Lives

The reason for “current and specific problems” is that although there may be a myriad of pa-
tient concerns, the priority should be to focus on helping patients achieve safety in the pres-
ent; the more specific the conversation, the more helpful it is likely to be. Below are ways to
do this.

Find out what the patient finds most relevant in the topic. After patients have looked
through a handout (or parts you have selected), ask questions such as the following:

 “What do you think the handout is trying to convey?”

 “Any thoughts or reactions to this?”
 “How does this relate to your life?”
 “Are there any current situations in your life where this might be helpful?”
 “How does this relate to your PTSD and substance abuse?”
 “Have you ever tried this strategy before? If it didn’t work, what went wrong?”
 “Do you like or dislike this way of looking at it?”
 “If you could actually use this strategy, how do you think you’d feel?”

In addition, as you get to know the patient, you can incorporate relevant issues that you
know of: “Margaret, I know that you’ve been struggling recently with urges to use crack. Do
you think that grounding could help? What grounding techniques might you try? Tell me
about a situation that might come up for you this week and how you could use grounding.”

Identify patient problems to work on. Several principles may help. One was mentioned
above, under “Check-In”: Prioritize any recent unsafe behavior a patient has disclosed. Sec-
ond, whatever the topic is, try to explore how patients are currently not able to do that skill.
For example, for the topic Honesty, explore situations where patients are dishonest. For the
topic Coping with Triggers, explore situations where patients are not able to successfully cope
with triggers. Third, stay focused on the “big picture” priorities of treatment. These are to
help patients (1) eliminate substance use; (2) reduce PTSD symptoms; and (3) increase safety
38 Conducting the Treatment

(from HIV risk, domestic violence, self-harm, etc.). Because patients often have many life
problems, current crises, and overwhelming feelings, it is easy to start feeling unsure of
where to aim the session. Keeping these “big picture” priorities in mind may help to select
from the variety of issues patients raise. Fourth, select “hot” problems—ones that are con-
nected to patients’ emotions. If a session feels bland or superficial, it is often because patients
are not emotionally engaged in the issue at hand. Fifth, select problems that patients want to
address. Sixth, focus on the present, not the past. There are many important issues about the
past that patients want to discuss. However, in this early-stage treatment, it is considered
most helpful to focus on the present, doing whatever can be done to make the present and fu-
ture better. Seventh, identify a specific problem to work on. If patients bring up global topics
(e.g., “I hate myself ” or “Life is hopeless”), guide them to identify a specific problem (e.g.,
“Did something happen this week to make you feel this way?”, “When you feel this way, how
do you try to cope with the feeling?”). The most unproductive way to respond is to get into a
philosophical debate (e.g., “But you really are a good person!” or “Life isn’t hopeless”).
Finally, select problems of moderate difficulty. If problems are too easy, patients will not grow
from working on them; if problems are too hard, they are unlikely to get very far. To gauge
this, it is sometimes helpful to ask patients to rate (0–10) how difficult a problem feels.
Decide how to work on patients’ problems. The key principle for working on patients’
problems is “Show it rather than say it.” This means finding a way to actually have the patient
rehearse a new skill rather than abstractly talking about it. For example, in the topic Recovery
Thinking, a recommended exercise is to do a rethinking demonstration. In general:

 For cognitive topics, have patients say aloud how they would rethink an issue.
 For interpersonal topics, have patients role-play out loud how they would address an
interpersonal problem
 For behavioral topics, have patients do a walk-through, stating out loud exactly what
actions they would take to solve a behavioral problem.

A variety of ways to help patients actively work on new skills are described below.

 Rehearse out loud. Ask a patient to identify a specific situation in which the skill might
help, and then have the patient practice it out loud. This is particularly useful in the
cognitive sessions, where the goal is to have patients change an internal dialogue. For
example, on the topic Compassion, you might ask, “When you got fired from your job
this week, how could you have talked to yourself compassionately about that?”
 Question and answer. Ask patients questions to see what they do and do not know; it is
one of the best ways to introduce a topic. You may want to do this before having them
look at a handout. It is particularly useful in group treatment as a way to engage the
group. For example, in the topic PTSD: Taking Back Your Power, you might ask, “Does
anyone know what PTSD is?”, “Does anyone know what the letters ‘PTSD’ mean?”,
“What are the main symptoms of PTSD?”
 Conduct an in-session exercise. Some topics lend themselves to actually guiding pa-
tients through an experience rather than talking about it. For example, in the topic De-
taching from Emotional Pain (Grounding), the recommended way to demonstrate
Conducting the Treatment 39

grounding is to guide patients through a 10-minute exercise and see whether it helps
them feel better.
 Role play. This is one of the most popular methods, particularly for interpersonal top-
ics. You should usually play the “other person” in the role play, so as to adapt the exer-
cise to the patient’s issues (e.g., persist in offering a drink even after the patient has
said “no” once). If you let another patient play the other person, monitor the role play
carefully to prevent it from going off track.
 Do a walk-through. Present situations and ask how they might be handled. This is the
method used in the topic The Life Choices Game (Review), for example, and also ap-
plies whenever you want to direct the patient to areas they need to work on. On the
topic Setting Boundaries in Relationships, you might say, “Maria, I understand that
you’re having a hard time asking your partner for safe sex. How could you apply the
ideas on the handout to set a boundary on that?”
 Identify role models. Ask patients to try to think of someone who already knows the
skill and explore what that person does. For example, on the topic Commitment, you
can ask, “Do you know any people who follow through on promises? Could you talk to
them and find out how they do it?”
 Involve safe family/friends. There are several ways in which family members and/or
friends can be involved to help patients. For the topics Getting Others to Support Your
Recovery and Red and Green Flags, patients are offered the opportunity to invite safe
(e.g., non-substance-abusing) significant others to attend a session. Also, for many con-
crete skills, you can ask patients to teach them to people in their lives who can cue
them to use the skills when needed (such as how to do grounding).
 Replay the scene. Ask patients to identify something that went wrong and then go
through it again as if they could relive it (e.g., “What would you do differently this
time?”, “How could you make it go better if you could do it again?”). The Safe Coping
Sheet is exactly designed for this process (see below), or you can do it more informally.
You may want to ask patients to go through the exercise “in slow motion”—noticing ev-
ery detail of what they were thinking, feeling, and doing.
 Discuss. For every topic, ideas to generate discussion are offered.
 Make a tape. Create an audiotape for patients to use outside of sessions as a way to lit-
erally “change old tapes.” Some topics specifically recommend this (e.g., Compassion),
but it can be done in any session by just recording helpful suggestions and advice re-
lated to the topic. Taping the session itself and allowing patients to take it home and
listen to it is another option. Be sure to check out confidentiality and safety issues, how-
ever, as tapes could be subpoenaed in a legal trial or heard by unsafe family members
(e.g., in domestic violence situations).
 Process obstacles. This means asking patients to anticipate what might happen if they
tried to implement a skill. For example, in Setting Boundaries in Relationships, you
might ask, “What might your partner say if you requested safe sex?” or “What is your
worst fear in saying ‘no’ to your friend?”
 Review key points. Ask patients to summarize the main points of the handout, and then
use this as a point of departure to work on the skill. For example, “What do you think
the handout is trying to convey?”
40 Conducting the Treatment

Mention both PTSD and substance abuse at every session. Because the treatment targets
these two disorders, it is important, each and every session, to mention both. Even if you de-
cide to delve in depth into some other issue (e.g., the patient’s need to find housing), it is im-
portant to train the patient to keep noticing, working on, and integrating both disorders. Note
that the term “trauma” can be used throughout the treatment, rather than “PTSD,” depend-
ing on the patient and the context. Clearly, you will want to conduct more extensive interven-
tions on these issues, but they are given here to illustrate how PTSD and substance abuse can
be added to any topic.
For a patient who needs help with housing, for example, some ways to incorporate PTSD
and substance abuse are provided below:

PTSD. “I hear that it’s hard to look for housing. It sounds like you’re feeling rather
hopeless—this is very common in PTSD. I am hopeful, however, that if we work on
it together, it will happen!”
Substance abuse. “I definitely understand that housing is your priority right now. Do you
think a sober house could help you stay clean? With substance abuse, we know that
relapse is common.”

Optional: The Safe Coping Sheet

The Safe Coping Sheet (Handout 4 in this chapter) is a clinical tool for patients to process
events that went wrong in their week, but more than this, it conveys a powerful therapeu-
tic philosophy: One can cope safely with any situation that happens in life. Thus the Safe
Coping Sheet is not just a pencil-and-paper exercise, but rather conveys several key mes-
sages: (1) Difficult life situations happen to everyone, (2) It is your coping that counts
above all, (3) Safe coping leads to positive consequences, and unsafe coping leads to nega-
tive consequences. When things go wrong, it is important to slow down and look con-
sciously at coping strategies. People with PTSD tend to feel powerless, as though life just
happens to them; the Safe Coping Sheet conveys that one’s active choices are what matter.
People with substance abuse act on impulse; the Safe Coping Sheet encourages deliber-
ately choosing how to handle a situation. In short, the sheet encourages learning from
experience and making it better next time. If you decide to use the sheet, below are sev-
eral notes to keep in mind.

Attempt only one in-depth Safe Coping Sheet per session. There will usually only be time
to address one patient situation in any session, to allow enough in-depth attention to it. It is
also important to note that the filled-in examples of the Safe Coping Sheet are very brief, due
to space limitations. This may make the exercise look simplistic, but when done well, it is a
very meaningful experience for many patients. When using the sheet in the session, the com-
plexity of the patient’s problem thus requires a great deal of brainstorming. Sometimes sev-
eral pages are needed to capture the full range of both the “old way” and the “new way” on
the sheet. Also, it is recommended that therapists try it out at least once, even if they do not
typically like CBT forms in sessions.
Notice that patients rate safety, not feelings, at the bottom of the sheet. In standard CBT
Conducting the Treatment 41

forms such as the Daily Record of Dysfunctional Thoughts (Beck et al., 1979), patients rate
changes in feelings. In contrast, the Safe Coping Sheet asks patients to rate safety. This is
done because, for patients with PTSD and substance abuse, feelings may not change for a
long while even if patients are doing all the right things—but just increasing their level of
safety is the first step in recovery. For example, when patients stop using substances they may
feel terrible (depressed, deprived, alone), but not using is still the right thing to do. Indeed,
patients with PTSD and substance abuse are often too focused on feelings and make poor de-
cisions because they use feelings rather than safety as their guide. (The very nature of sub-
stance abuse is the use of substances to feel better.) Note that rating feelings arose in CBT for
depression (Beck et al., 1979). Depression is a mood disorder, and it makes sense for such pa-
tients to rate feelings because feelings are the essence of the illness. With PTSD and sub-
stance abuse, this is not the case.
Encourage patients to generate options. In using the Safe Coping Sheet, you may want
to ask questions such as, “Everyone makes mistakes, but the idea is to learn from them. What
could you do differently next time?”, “If you could relive that night, how could you cope dif-
ferently to stay safe?”, “Is there anything you could work on to help things go better next
time?” Remember that patients do not have to agree that they actually would do the New
Way if the situation came up again (although this would be nice), but just need to get into the
habit of thinking about their options. In asking patients to rate safety with the New Way, it is
useful to ask, “If you were to cope in this New Way, how safe do you think it would be?” By
rehearsing, over and over, how they can cope more safely, they can strive toward greater self-
esteem and increased control over their lives.
Focus on the session topic in the “Your Coping” row of the sheet, if possible. For most
topics, the last page of the handouts provides an example of the Safe Coping Sheet applied to
that topic. Because the sheet can be completed in so many different ways (e.g., using behav-
ioral, cognitive, and/or interpersonal skills), focusing it this way reinforces the topic. For ex-
ample, a patient’s situation might be “My parents told me not to visit, and I feel depressed.”
If the topic is Asking for Help, you might ask, “Can you get help from anyone on this prob-
lem?” If the topic is Recovery Thinking, you might ask, “What did you say to yourself when
they said that?” and “Is there any other way to think about it?” If the topic is Coping with
Triggers, you might ask, “Are your parents a trigger for you? If so, how can you protect your-
self from that trigger?” However, drawing on a wide variety of safe coping skills is always an
option if this focused method does not work.

4. The Check-Out
For the same reasons as with the check-in, maintaining the frame of treatment in the check-
out is helpful. This means that no new issues get addressed and there are no interventions on
the therapist’s part other than eliciting the three parts of check-out.

A. “Name One Thing You Got Out of Today’s Session”

The first question helps solidify patients’ learning. Moreover, it provides the therapist with
feedback about the session’s impact.
42 Conducting the Treatment

B. “What Is Your New Commitment?”

The commitment is, essentially, a homework assignment. It is designed to convey, in both name
and intent, an almost spiritual ideal of continually moving forward in one’s life. For more about
the nature of commitment in general, see the topic Commitment (which also provides specific
ideas to motivate patients to complete their commitments). The Commitment to Recovery
(Handout 5 in this chapter) provides a written record for both patient and therapist. Note that
the terms “homework,” “practice exercise,” “skill practice,” and “promise” were all tried in this
treatment in earlier versions, but “commitment” was found to be the most inspiring term. Also,
you may want to convey to patients that at least one study of CBT found that patients who
completed their homework assignments improved three times as much as patients who did not
(Burns & Auerbach, 1992). Some notes on making use of commitments are as follows.

When selecting a commitment, customize it to the patient. At the end of each topic is a
list of Ideas for a Commitment. But the overarching goal is to help patients choose any com-
mitment that is most relevant for them that week, whether or not it is on the list. Thus, if you
have spent the session discussing a patient’s lack of medical care, making an appointment
with a doctor may be the most important goal for that patient in the week ahead. Patients can
do any ideas on the handout in addition to or instead of this customized commitment. For
each topic, at least one or two ideas are action-oriented rather than written assignments be-
cause it was found in testing the treatment that some patients were averse to written assign-
ments and then felt guilty if they didn’t complete them. Other patients, in contrast, found
writing a great solace and growth activity. In group treatment, the commitment can help
build group cohesiveness by clarifying what each patient is striving to accomplish. Ideally, a
patient can generate a commitment that feels relevant and do-able, but if the patient has diffi-
culty generating an idea, the therapist can suggest one. Examples of customized commit-
ments include the following:

 Read a book (e.g., “Find a book on anger at a local library or bookstore and read it”).
 Seek information (e.g., “Call up two local colleges to find out about admission require-
ments”).
 Identify a role model (e.g., “Ask people in your life how they decide who is safe to
trust”).
 Discover (e.g., “Try calling a hotline and see how it feels”; note that the topic Discov-
ery provides an extensive discussion of this type of work).
 Self-monitor (e.g., “Fill in a blank schedule of how you are spending your time”).
 Review the handouts (e.g., “Write a summary of what you learned in today’s session
and how you will apply it to your life,” or “Reread the handout and circle what you
want to work on”).

Review the commitment very briefly at the next session. The commitment is generally
not intended to become a major part of the next session. Rather, it provides a simple interven-
tion to encourage the patient to keep moving forward in concrete ways outside of sessions. If
the patient completes it, a brief statement of praise is all that’s needed; if the patient does not
Conducting the Treatment 43

complete it, a simple “I’m sorry to hear that” usually suffices, along with a plan to redesign
the commitment at the end of the session to adapt it to the patient’s level. For example, if the
patient did not call the doctor, the redesign might involve having the patient call the doctor
right after the session, or asking a friend to help make the call. If a commitment is an essential
goal (e.g., using condoms for safe sex), you may want to make it the focus of the session and
integrate it with the session topic. If a patient has done a written commitment, it is a nice
touch to ask the patient if you can read it outside the session and then mark brief feedback
comments on it and return it at the next session; writings are usually short, so this is not very
time-consuming. If you are conducting individual treatment and want to spend more time on
the commitment, you could ask questions such as “What did you learn from doing it?” or
“Any problems or successes with it that you would like to discuss?”
Follow up with patients who repeatedly do not complete their commitments. Ask such
patients why they did not complete them. Repeated excuses should not be accepted at face
value, but used as opportunities to move patients toward improvement. For example, “Robin,
you say you didn’t have time, but you spent a lot of time going clothes shopping. Maybe you
are neglecting your own recovery at this point?” Or, “Rima, here’s a suggestion to help re-
member to do the practice exercise: Can you write it down and post it on your refrigerator?”
Also, try the suggestions in the topic Commitment for further ideas. Other resources include
the article by Burns and Auerbach (1992) and the homework noncompliance form in Beck
and colleagues (1979). These discuss the importance of homework for positive outcomes, a re-
view of research, and ideas for improving compliance.

C. “What Community Resource Will You Call?”

This question is a reminder to the patient of whatever case management goals currently need
to be addressed. These goals were likely identified early in treatment (in the topic Introduc-
tion to Treatment/Case Management) and are still being worked on. This is a common situa-
tion for patients with many needs or who have difficulty following through on their case man-
agement goals. Or, it may refer to new case management goals that have arisen during the
course of treatment. For example, in conducting the topic Healing from Anger, it may be that
the patient could benefit from joining an anger management group. The therapist might thus
give the patient a new referral to help the patient connect with such a group. Note that the
Commitment to Recovery (Handout 5 in this chapter) offers a place to write down this com-
munity resource goal, in addition to the commitment itself. Finally, note that the term “com-
munity resource” is used with patients rather than “case management,” as the former is a
more appealing, less bureaucratic term.

Optional: The End-of-Session Questionnaire

This questionnaire (Handout 6 in this chapter) is designed to offer the patient an opportunity
to convey both positive and negative reactions to the session. In early recovery from PTSD
and substance abuse, patients may feel more able to express views of the treatment on paper
rather than out loud to the therapist. For the therapist, it can be extremely helpful to obtain
such feedback. In group treatment, it is strongly suggested that patients be asked not to put
44 Conducting the Treatment

their name on the sheet; it has been found that anonymous responses are more likely to be
fully honest. In individual treatment, this is not an option; there the therapist can delay look-
ing at the responses until after the patient has left.

TREATMENT GUIDELINES

Several treatment policies gave been found helpful when conducting the treatment.

In advance, establish your policy about being contacted outside of sessions. See the topic
Introduction to Treatment/Case Management for a discussion of this issue. A handout for this
topic provides a place to inform patients in writing about your policy.
Obtain urinalysis. For therapists not familiar with substance abuse treatment, urine test-
ing almost uniformly evokes negative reactions: “I trust my patients,” “My patients will feel
insulted if I ask them,” “If patients have PTSD, observed urine testing will be a repetition of
their abuse,” “I can tell when patients are lying,” “I don’t know how to get patients tested,”
“It will destroy the therapeutic alliance.” Yet urine testing is standard in many substance
abuse treatment programs and is widely accepted as the only sure way for the therapist to ob-
tain valid information about the key issue in treatment: Is the patient still using? Many pa-
tients with substance abuse do lie at times, no matter how much they may not want to, no
matter how much they like you, and no matter how experienced you are as a clinician. Some-
times therapists believe they know their patients well enough to detect a lie, but experience
with substance abuse treatment indicates that this is not true—when patients want to conceal
substance use, they often succeed.
The second major reason for testing—in addition to providing clear and necessary infor-
mation—is that more often than not patients actually feel helped if you require testing. It con-
veys that you care enough to want to know what is really going on (which is especially healing
for patients who were neglected in the past, where no one at home noticed or cared what
they were doing). Moreover, it gives them added incentive to stay “clean.” Many patients say
that if not for urine testing, they would have used substances much more. Just knowing they
had to get tested made them try harder. Thus it usually increases rather than decreases the
therapeutic alliance. Many clinicians are surprised to find that patients with PTSD are typi-
cally highly agreeable to urine testing. In the pilot study on this treatment, there were virtu-
ally no negative reactions to observed urine testing, except in a very few cases where patients
felt triggered and the procedure had to be modified to omit direct observation. In direct ob-
servation, a same-sex staff person accompanies the patient into the bathroom—a necessary
step, because there are many ways to cheat when providing a urine sample. One exception to
patients’ compliance with urine testing is when a serious contingency depends on urine test
results (e.g., legal or job-related). Such patients obviously may have a strong motive to resist
testing (Weiss et al., 1998a).

 Find out how to obtain testing. Most insurance companies and most public mental
health coverage (e.g., Medicare, Medicaid) will pay for urine testing. To find where pa-
tients can get tested, you can try local hospitals, look in the Yellow Pages, or call a local
Conducting the Treatment 45

substance abuse treatment program to find out how their patients are tested. There are
also quick, easy-to-use tests that can be used at your site without formal training (http:/
/www.avitarinc.com). See Handout 1 in the topic Community Resources, under “Sub-
stance Abuse,” for additional resources.
 Present testing in a matter-of-fact way. It may be helpful to explain that urine testing is
a standard procedure in many substance abuse clinics and allows the most effective
monitoring. Despite their best intentions, many patients with substance abuse feel
ashamed if they have used and may want to hide the truth; these are understandable
consequences of substance use, but can impede treatment. If you present it in a way
that conveys your comfort with the topic, it will seem normal to them. Just as patients
learn the boundaries of treatment (they cannot stay longer than the session time, they
need to pay their treatment bills, etc.), so too the urine testing will become part of the
routine conduct of treatment. It may also be helpful to explore the idea that trust must
be earned—it is not automatic—and urine testing is one way to earn such trust.
 Provide specific parameters. Specify where patients can get tested, the frequency (typ-
ically once or twice a week), the duration (e.g., 3 months), and the format (e.g., random
or by appointment). Random testing is particularly effective. It means that you will call
patients on a particular day and they are obliged to get tested within 24 hours; each
week you randomly pick the day. Random testing means that patients cannot plan
their substance use to avoid a “dirty” urine (one that evidences substance use). For ex-
ample, if patients know they will be tested every Thursday they may not use cocaine
from Tuesday to Thursday, so as to appear “clean.” Also, make sure patients under-
stand if there are any consequences for a “dirty” urine.
 Use “dirty” urines as an opportunity to help the patient. Evidence of substance use
should not be used in this treatment as a reason to discontinue treatment, blame the
patient, or convey judgment. Rather, it becomes the basis for discussing how the pa-
tient can find better ways to cope than substance use. Even if a patient lied (had a
“dirty” urine yet said there was no use), this can be empathically discussed. Such a dis-
crepancy may sometimes be caused by the urine’s capturing a previous drug use inci-
dent; it is thus necessary to know how long each substance tends to stay in the urine
(e.g., cocaine typically stays 2 days while marijuana typically stays 30). However, a dis-
crepancy is very rarely a mistake at the lab (no matter how much patients try to say it
is!). If you are conducting group treatment, it is advised that “dirty” urines be dis-
cussed on a one-to-one basis in a brief (5- to 10-minute) individual meeting, rather
than discussed in the group. The latter is sometimes done in substance abuse treat-
ment settings, but in the case of patients with PTSD, this could increase their already
very high levels of humiliation and shame. Their low self-esteem is likely to be made
worse by public criticism, and they may drop out of treatment if exposed to such an in-
tervention.

Strongly encourage HIV testing. All patients should undergo HIV testing as both PTSD
and substance abuse are known to increase patients’ risk of high-risk behaviors. See Handout
1 in the topic Community Resources for national resources on HIV/AIDS that both you and
patients can call.
46 Conducting the Treatment

Establish a policy about patients’ contact with each other outside of sessions (for group
treatment). If patients express a wish to have contact outside of sessions, it is suggested that
the therapist confirm each patient’s preference on this. Many patients with PTSD have diffi-
culty setting boundaries; after a few negative experiences while testing this treatment, this
policy appeared to provide a helpful safeguard.
Take an active approach to keep patients in treatment. In contrast to some patient popu-
lations that heavily utilize treatment, patients with substance abuse are some of the most dif-
ficult to retain, with rates as low as 5% of eligible patients entering treatment and 50% com-
pleting treatment (Craig, 1985; Najavits & Weiss, 1994a; Rounsaville, Glazer, Wilber,
Weissman, & Kleber, 1983). Ways to engage and retain patients include calling when a pa-
tient is a no-show, sending a letter (without mention of substance abuse or PTSD, for confi-
dentiality reasons), contacting family members (if you obtain patients’ written permission to
do so), and offering incentives (e.g., babysitting, snacks).
Keep any discussion of patients’ trauma history to safe parameters. Some patients do not
want to discuss their trauma history, while others may bring it up. It is suggested that for the
former, therapists respect patients’ defenses and not attempt to discuss trauma memories. As
discussed in Chapter 1, exploration of trauma memories is not part of Seeking Safety. How-
ever, in cases where the patient brings up trauma memories, the situation is more compli-
cated. Issues include whether the patient brings it up in group versus individual therapy,
whether the patient has any individual therapy where it can be discussed, how safe it is for
the patient to talk about it, how late in the session the patient raises it, whether the patient
worsens if it is discussed, and how available the therapist is for emergency contact if the pa-
tient deteriorates. As discussed in Chapter 1, discussion of trauma memories is itself a treat-
ment intervention (called “exposure” or “mourning”) and goes beyond the scope of this man-
ual. However, some patients will bring it up, and it is important to respond in helpful ways.
Some specific suggestions are as follows.

 Group therapy. If a patient brings up trauma details in a group context, it is strongly

suggested that the therapist limit this in a kind way so as to protect other patients from
being triggered. For example: “You are bringing up very important material, but it is
not safe for the group to hear details about trauma, as it can trigger people. Let’s meet
one-on-one after the session to help you identify a safe place to talk about it.” Or “I am
very sorry to interrupt you, but as described in the Treatment Agreement, we need to
keep discussion of trauma details outside of group sessions.” (The Treatment Agree-
ment is provided in the topic Introduction to Treatment/Case Management.) If neces-
sary, interrupt the patient—remember that your priority is the group’s safety, not social
politeness.
 Individual therapy. If a patient clearly initiates wanting to discuss trauma and you are
in an individual session, it can be helpful to allow some space for that to happen. By al-
lowing the patient to talk about it, you are validating how important it is; you have the
opportunity to offer empathy and support, and hearing about it can help inform your
treatment with that person. If you close off all discussion of trauma material that the
patient initiates, the patient is likely to get the message that “It doesn’t matter” or “My
therapist can’t handle it.” However, the danger is always that the patient may become
Conducting the Treatment 47

overwhelmed and not be able to handle the intensity of feelings that are stirred up.
Thus some suggestions include the following:

1. Prepare the patient for the possibility that talking about trauma may be upsetting
and may also have delayed effects once the session is over (e.g., nightmares).
2. Do not let the patient talk very long before assessing safety. For example, ask,
“Does this feel safe to keep talking about?” or “How does it feel to tell me about
this?”
3. If the patient becomes extremely upset, you can provide gentle education that un-
til sufficient coping strategies are in place to cope with the feelings, it is better to
wait until later in treatment. You may then want to redirect the patient back to the
session topic or do grounding (see the topic Detaching from Emotional Pain).
4. Have a plan in place for emergency procedures if the patient does have a reaction
outside the session. For instance, whom will the patient page or call? Will the pa-
tient go to an emergency room if it leads to dangerous behavior?
5. Ask the patient at the next session whether the previous session’s discussion of
trauma had any negative effects that felt too intense to handle. If the patient re-
ports increased substance use or other negative behavior, “hear” this as a sign that
it was likely too intense for the patient at this time. In such cases, you may want to
stop all discussion of trauma material and return solely to coping skills until the
patient is stable.
6. Be sure that the decision to discuss trauma is explicit and conscious. Sometimes
patients will start mentioning trauma-related material and quickly go very deeply
into it. They may get in over their heads and wonder how they got there. Thus, as
soon as a patient brings it up initially, say something like, “You are bringing up
something very important here. Let’s decide together whether it’s safe for us to go
into this more, or whether we should delay it.”
7. Be sure to plan for at least 10 minutes at the end of the session to redirect the pa-
tient to grounding or safe topics. The patient should never leave the session disso-
ciating, crying, or extremely upset (e.g., above a 5 on a 0–10 scale). Thus it is also
important at the end of the session to inquire whether the patient feels safe to
leave.
8. Do not let the session become totally focused on past trauma material. It is one
thing to allow a brief space for it (e.g., 10–15 minutes total in a session). If it takes
up the whole session, you will not have time to cover the session topic or work on
coping skills. Even if you do plan to combine exposure therapy with Seeking
Safety (see Chapter 1), it appears most helpful to allow separate sessions for each
of these to have sufficient time.
9. Remember that even if the patient wants to talk about trauma material, ultimately
it is up to you as the therapist to assess whether this is safe and to make a decision
about allowing it. Patients in early recovery are virtually always unaware of the
full impact of talking about trauma.
10. Some patients talk about their trauma with a quality of “compulsiveness” or “recy-
cling,” rather than genuinely communicating experiences and feelings. You may
48 Conducting the Treatment

want to limit such discussion, as it may not be helpful to allow them to talk at
length until later in treatment when they can explore these issues.
11. Do not go “digging” for patients’ trauma memories.
12. The “mourning phase” is the time for processing of trauma material for most pa-
tients who have current substance abuse (see Chapter 1). However, some patients
may be able to tolerate and benefit from exposure therapy even in early substance
abuse recovery. As noted in Chapter 1, at least two research studies (Back et al.,
2001; Najavits et al., 2001) have shown it to be beneficial for some patients. You
may want to consider making it part of your work with carefully selected patients.
However, training in that modality, reading a manual, and/or supervision are
needed if you have not done this work before. Or you may want to refer the pa-
tient elsewhere for such treatment concurrent with your work (this is also possible
for group patients). However, make sure the individual therapist is fully informed
about the patient’s current and lifetime substance abuse and history of other dan-
gerous behaviors.

 Assessment. The general principle for assessment is to keep assessment of patients’

trauma history to a minimum. This may seem odd, considering the need to address
trauma and PTSD. However, it is suggested that once it is known that a patient generally
has a history of trauma and/or current PTSD, inquiry into the patient’s specific history
should be limited. Some therapists are trained to elicit a full trauma history at the start of
treatment, but this can cause patients to feel overwhelming distress without any way to
cope with it. Indeed, eliciting a full trauma history is essentially like conducting an expo-
sure therapy session—but without any of the safeguards and preparation that are part of
that treatment! Moreover, successful treatment does not depend on comprehensive
knowledge of a patient’s trauma history. Some recommendations:
1. If you already know the patient has a severe trauma history and you know the nature
of it in a general way (e.g., sexual abuse), you may not need to inquire further at this
point. However, you could ask, “Is there anything you’d like me to know about your
traumas in the past?” to allow the patient to control the flow of information.
2. If you know nothing about the patient, consider using a self-report trauma question-
naire filled out right before the session. Patients may be more likely to report trauma
on pencil-and-paper measures than in an interview, as it may be less upsetting to
them (Najavits et al., 1998d). If the measure is completed just before the session,
any negative reactions to it can be discussed.
3. If you do not want to use a pencil-and-paper self-report measure, consider asking
just a few simple questions. For example, “Have you ever been through a very diffi-
cult life experience, such as combat, a hurricane, or a crime?”, “Do you have a his-
tory of physical abuse?”, “Do you have a history of sexual abuse?” Tell patients that
they need to answer only “yes” or “no” and that details are not necessary.
4. If the patient becomes upset with any of the above, stop for now. You can do a lot of
work in treatment by just focusing on the patient’s current problems (e.g., sub-
stance abuse, case management, managing negative feelings, etc.).
Conducting the Treatment 49

5. Try to make use of information already available in the patient’s chart. Asking
trauma questions is sometimes unnecessary if the patient has already provided his-
torical information; check for that first. However, remember that trauma may never
have been asked about (Kofoed et al., 1993), so if there is no mention of trauma in
the chart, it may be important to ask the patient.

Patients can return to treatment at any time. Indeed, the goal is to keep trying to get pa-
tients back into treatment even after a long absence. Thus in this treatment there is no “4
weeks missed and you’re out” rule (Linehan, 1993) or anything similar. Early-stage PTSD
treatment typically allows for dropping out and returning without penalty (Herman, 1992).
The only exception to this is if a patient presents serious safety issues (see next paragraph).
Remove a patient from treatment only under certain circumstances. Removing a patient
from treatment is very rare. Reasons for removing a patient from treatment typically fall
within two categories: (1) The patient is a danger to other patients or to staff (e.g., selling
drugs to patients, threatening staff); or (2) the treatment appears to be making the patient
worse (e.g., is stirring up feelings that cannot be safely contained). Signs that the patient is
becoming worse include use of substances not previously used, increasing the quantity of
substance use, and increased self-harm behavior. Note that if a patient violates the Treatment
Agreement by a single incident (e.g., selling a drug to another patient, physically threatening
someone), the therapist can either work with the patient to develop a contract to allow one
more chance and then monitor the patient closely, or, if the incident is very serious, can im-
mediately withdraw the patient from the treatment. If a patient is removed, a debriefing with
the patient individually to provide calm, assertive feedback and a referral to new treatment is
helpful. In group treatment, a statement should be made to the remaining group members
about why the patient was withdrawn.
Do not eject a patient from treatment for using substances. To eject a patient from treat-
ment for using substances will not help the patient obtain needed skills to learn how to stop
using. Indeed, with any other psychiatric symptom (e.g., psychotic symptoms, depression),
one would not think of asking patients to leave treatment because they experience symptoms.
Using substances within the context of a substance use disorder is a psychiatric symptom and
needs high-quality help. The goal is to retain patients in treatment as long as possible to help
them achieve the skills they need to become abstinent. Ejecting a patient from treatment
does not cure substance abuse.

PROBLEM SITUATIONS AND EMERGENCIES

Patients with PTSD and substance abuse are, in general, a high-risk population. Due to both
substance use (which can impair judgment and lead to dangerous, at times illegal situations)
and PTSD (which can lead to suicidality and inability to cope), patients may be at risk for a
variety of very serious emergencies, including physical infections (HIV, sexually transmitted
diseases, hepatitis), housing eviction, job loss, domestic violence, suicide, child abuse situa-
tions, and inability to care for oneself. Examples of emergency situations include those in
which a patient:
50 Conducting the Treatment

 Is seriously threatening to kill her- or himself (with “seriously” meaning immediate

danger, such as within the next day or two; and high intent, such as 6 on a 0–10 scale).
 Breaks into the clinic after hours (e.g., to steal money).
 Overdoses and pages you.
 Is being battered by a partner.
 Harasses another group member.
 Threatens to physically hurt someone (e.g., a child).
 Is being evicted from housing and has nowhere to go.

When such situations arise, they may be life-or-death and will require careful interven-
tion. Although it is beyond the scope of this book to describe emergency procedures for such
high-risk patients in detail, and specific solutions will depend on the treatment context and
particular patient, a few brief guidelines can be noted. For more detailed guidelines on psy-
chiatric emergencies, see, for example, Hyman and Tesar (1994).

Plan in advance how you will handle a serious suicide emergency. Solutions may include
calling the local police to have them go to the patient’s home (e.g., if the patient has called in
by telephone), or having the patient escorted to a local emergency room. Know where you
can send patients who become suicidal, including patients who do not have insurance. The
same applies for patients who are suddenly homeless and need emergency housing; find out
how to send such patients to a shelter.
If you are evaluating a patient for life-threatening behavior, remember to ask very spe-
cific questions: “How likely are you to kill yourself within 24 hours, on a scale of 0–10, where
10 means a definite yes?”, “Can you promise to me right now that you will not hurt your child
before the police arrive?”, “How much have you had to drink?”
Finally, get the patient to a level of care sufficient for safety. This may be an immediate
emergency session with you or another of the patient’s treaters, a hospital emergency room,
or an inpatient unit. If possible, involve a safe family member, friend, or AA sponsor to escort
the patient. Note that obtaining the phone numbers of such safe others from patients at the
start of treatment can be very helpful should an emergency arise. If you ask the patient to go
to a local emergency room, agree on a time by which the patient will get there and call you (or
have a doctor call you) to confirm that the patient arrived; if there is no phone call by the
agreed-upon time, call back the patient and, if no response, the police.
“When in doubt, seek others out.” This may include talking to a supervisor, contacting the
patient’s other treaters, sending the patient to the local emergency room, contacting an attorney,
or calling the police. Do not attempt to contain a dangerous situation alone, as this can escalate
the situation, may not work, and can present liability issues. Always take the stance of what your
actions would look like to a jury of your peers after the worst has happened (e.g., the patient
committed suicide or killed a child). It is always better to overreact than to underreact in serious
emergency situations—that is, to implement too many safety checks rather than too few.
Be clear with patients about limits to confidentiality. Clinicians and treatment centers
operate within standard professional confidentiality procedures, but many clinicians and pa-
tients do not realize that patient records can be subpoenaed if a patient is involved in a court
case. Damaging information about substance abuse or other illegal behavior might be re-
vealed to the court even when the clinician and patient do not want it to be.
Conducting the Treatment 51

Know and inform patients of situations where you must report them to authorities. These
include “duty to warn” (you are legally obligated to warn anyone whom the patient has threat-
ened to harm physically); suspected child or elder abuse; or the need for involuntary commit-
ment due to serious suicide risk or inability to care for oneself. Consult an attorney if there is
any question on how to proceed in a specific case.
Develop safety procedures for staff. These may include placing the therapist chair near-
est the door so that the therapist can exit easily if a patient becomes threatening; making sure
sessions are held only when other staff members are in the same building and can help in an
emergency; keeping clinicians’ home phone numbers and addresses protected from patient
access; and informing clinicians of emergency numbers to call and clear procedures to follow.
Have staff members who work with substance abusers obtain hepatitis shots and learn
infection control procedures. Also, if possible, have patients obtain medical clearance before
beginning treatment, to avoid patients’ infecting each other and the staff.
Know and inform patients of what to do in case of a mental health or substance abuse
emergency. In the topic Introduction to Treatment/Case Management, these issues are ad-
dressed. Be explicit about your availability to be contacted, within what time frame you will
call the patient back, and what the patient should do if you are not available (e.g., go to the
nearest emergency room, contact a clinician who is covering for you, etc.). Also, know the cri-
teria and process for committing a patient who needs involuntary commitment to a mental
hospital.
Know and inform patients what will happen if they show up high or drunk. If a patient
shows up intoxicated to a session, do not attempt to conduct any therapeutic intervention
with the patient except for planning how to get the person home safely. The patient can be
asked to stay and sit in view of a staff member until no longer high, or to sit in an emergency
room waiting area for this purpose. With the patient’s permission, a friend or family member
can be called to pick up the patient. A cab can be called to take the patient home. If the pa-
tient has overdosed, send the patient to an emergency room for evaluation. Never let an in-
toxicated patient drive home; you may need to take the patient’s car keys away until the pa-
tient is sober enough to drive.
If the patient attempts to discuss issues other than the plan to return home safely, keep
firmly saying, “I would very much like to talk to you, but we cannot discuss anything right
now when you are intoxicated except how to get you home safely.” In doing so, you are send-
ing the message that showing up high prevents useful dialogue. However, setting such a limit
requires empathic skill so as not to communicate rejection. You may want to say, for example,
“Everything will be okay; we’ll find a safe way for you to get home.” Or “We can’t talk now,
but I’d be happy to talk to you later when you’re no longer high.” Finally, some follow-up is
usually needed, such as calling the patient’s primary treater to inform that person of the inci-
dent and, the next time the patient comes to the clinic, reiterating the agreement not to come
to the clinic when intoxicated (as per the Treatment Agreement).
Seek consultation if you’re feeling very angry, or upset, or have other intense feelings
about a patient. These are signs of a treatment process in need of review. Seek out supervi-
sion or collegial consultation for yourself, and offer the patient the opportunity for consulta-
tion with an outside clinician, to prevent a situation from escalating.
Stay calm. In an emergency, remember the precept that “emotion breeds emotion.” If
you are calm, this will calm the patient; if you are agitated, this will agitate the patient.
52 Conducting the Treatment

CHECKLIST BEFORE BEGINNING THE TREATMENT

Essential
¨ Make copies of the quotation and handouts for each topic (see treatment topics). Sta-
pling these together tends to work well.
¨ Make copies of “Materials for All Sessions” (see the next section of this chapter).
¨ Prepare a Resource Book for case management (see the topic Introduction to
Treatment/Case Management).

Suggested
Read the key background readings marked in the References list with an asterisk.
¨
Attend at least one AA meeting.
¨
¨ Try to have available in the area other therapeutic materials that patients can read (lists
of AA meetings, pamphlets on HIV risk, etc.). You may also want to put up motivational post-
ers. For free posters, pamphlets, and other materials on substance abuse, call:
( National Clearinghouse for Alcohol and Drug Information at 800-729-6686.
( Center for Substance Abuse Treatment Hotline at 800-662-HELP [4357].
( National Institute on Drug Abuse (NIDA) Info-Fax Service at 888-NIH-NIDA [644-
6432] (a free, 24-hour line for faxed information on treatment, substance abuse
trends, and drug effects).
( See also the list of toll-free numbers for AA and other resources in Handout 1 of the
topic Community Resources (subheadings “Substance Abuse” and “Trauma”).
¨ Rehearse the “Tough Cases” listed in each topic with a colleague or supervisor.
¨ Try applying each of the treatment topics to your own life to explore how difficult they
are.
If you plan to obtain patient background information with self-report measures, it is
¨
suggested that the patient do them on site with a clinician available in case the patient has
negative reactions to the assessment. Although negative reactions are rare, they are possible,
particularly with trauma measures.
¨ Organize any “extras” your treatment program is able to offer (e.g., child care, parking,
pamphlets to read, opportunities to watch educational videos related to treatment, books to
borrow).

MATERIALS FOR ALL SESSIONS

To Post on the Bulletin Board before Treatment Begins

Several materials were designed to be posted on the wall (or a bulletin board) for patients’ use
throughout treatment. If you prefer not to post them, have them available in a folder for the
patient to use. You can use all the materials provided, or select those that you believe will be
most helpful to your patients.
Conducting the Treatment 53

1. Check-In and Check-Out. This reminds patients of check-in and check-out questions
to answer (one copy of Handout 1 in this chapter).
2. Safe Coping Skills. This is a resource for patients to draw upon during the session (one
copy of Handout 2 in the topic Safety).
3. Core Concepts of Treatment. This summarizes the key points throughout the treat-
ment (one copy of Handout 2 in this chapter).
4. List of Treatment Topics. This allows the patient and/or therapist to choose the order
of topics, and helps keep track of those completed (one copy of Handout 3 in this
chapter).

To Use in Sessions
Pages to be copied for use in all sessions are as follows.

5. Session Format. The therapist can look at this during a session as a reminder of the
session format (one copy of the Therapist Sheet in this chapter).
6. Safe Coping Sheet. Have this available at all sessions, to use during a session or for pa-
tients’ commitment between sessions (one copy of Handout 4 in this chapter).
7. Commitment to Recovery. Have this available at all sessions, to use at the end of each
session (one copy of Handout 5 in this chapter).
8. End-of-Session Questionnaire. Have this available at all sessions, to use at the end of
each session (one copy of Handout 6 in this chapter).
9. Certificate of Achievement. This can be awarded at the end of treatment to honor pa-
tients’ attendance (one copy of Handout 7 in this chapter).
THERAPIST SHEET

Session Format

INTRODUCTION
1. Check-In

To find out how patients are doing. Patients report on five questions. Since the last session (a) “How are you feel-
ing?” (b) “What good coping have you done?” (c) “Any substance use or other unsafe behavior?” (d) “Did you com-
plete your commitment?” and (e) Community Resource update? (up to 5 minutes per patient).

2. The Quotation

To help emotionally engage patients in the session. A patient reads the quotation out loud. The therapist asks,
“What is the main point of the quotation?”, and links it to the session (2 minutes).

SESSION TOPIC
3. Relate the Topic to Patients’ Lives

To connect the topic meaningfully to patients’ experience. This is the heart of the session, using specific and current
examples from patients’ lives and offering intensive rehearsal of the material (30–40 minutes).

Protocol:
A. Ask patients to look through the handouts (up to 5 minutes).
B. Relate the material to current and specific problems in patients’ lives.

¬ Optional: The Safe Coping Sheet

CLOSING
4. Check-Out

To reinforce patients’ progress and give the therapist feedback. Patients answer three questions: (a) “Name one
thing you got out of today’s session (and any problems with the session)”; (b) “What is your new commitment?”;
and (c) What Community Resource will you call? (up to 5 minutes).

¬ Optional: End-of-Session Questionnaire

Reminder: The “Big Picture” Priorities Are To . . .

1. Eliminate substance use
2. Reduce PTSD symptoms
3. Increase safety (from HIV risk, domestic violence, self-harm, etc.)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

54
HANDOUT 1

Check-In and Check-Out

CHECK-IN
Since your last session . . .
1. How are you feeling?

2. What good coping have you done?

3. Any substance use or other unsafe behavior?

4. Did you complete your commitment?

5. Community resource update?

CHECK-OUT
1. Name one thing you got out of today’s session
(and any problems with the session).

2. What is your new commitment?

3. What community resource will you call?

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

55
HANDOUT 2

Core Concepts of Treatment

ê Stay safe

ê Respect yourself

ê Use coping—not substances—to escape the pain

ê Make the present and future better than the past

ê Learn to trust

ê Take good care of your body

ê Get help from safe people

ê To heal fully from PTSD, become substance-free

ê If one method doesn’t work, try something else

ê Never, never, never, never, never, never, never, never

give up!

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

56
HANDOUT 3

List of Treatment Topics

Completed (yes/no)
Introduction to Treatment/Case Management
Safety
PTSD: Taking Back Your Power
Detaching from Emotional Pain (Grounding)
When Substances Control You
Asking for Help
Taking Good Care of Yourself
Compassion
Red and Green Flags
Honesty
Recovery Thinking
Integrating the Split Self
Commitment
Creating Meaning
Community Resources
Setting Boundaries in Relationships
Discovery
Getting Others to Support Your Recovery
Coping with Triggers
Respecting Your Time
Healthy Relationships
Self-Nurturing
Healing from Anger
The Life Choices Game (Review)
Termination

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

57
HANDOUT 4

Safe Coping Sheet

Name: Date:

You can learn to cope safely, no matter what happens in your life.

Old Way New Way

Situation

« Your Coping «

Consequence

How safe is your old way of coping? How safe is your new way of coping?
Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

58
HANDOUT 5

Commitment to Recovery

A commitment is a promise—to yourself, to your recovery, and to your therapist.

If you cannot complete your commitment, or need to change it,
be sure to leave your therapist a message before your next session.

Name: Date:

Commitment for next session

I will do: By when:

Community Resource to call before next session

I will call: By when:

REMINDERS

• Your next session is scheduled for: Date Time

• Where will you put this sheet to remember it?: Wallet Refrigerator door Notebook
Other location:
(tear here) – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – (tear here)

THERAPIST COPY

Patient Initials: Today’s Date:

Commitment for next session

I will do: By when:

Community Resource to call before next session

I will call: By when:

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

59
HANDOUT 6

End-of-Session Questionnaire

To be completed anonymously; do not fill in your name.

Session Topic: Date:
Please be honest about your view of today’s session, so that the treatment can be made as helpful as possible.
Answer questions 1–6 below using the following scale:

0 1 2 3
Not at all A little Moderately A great deal

1. How helpful was today’s session for you, overall?

2. In today’s session, how helpful were:

a. The topic of the session?
b. The handout?
c. The quotation?
d. The therapist?

3. How much did today’s session help you with your:

a. PTSD?
b. Substance abuse?

4. How much do you think you’ll use what you learned in today’s session in your life?

5. Do you have any other comments or suggestions about today’s session? Please be honest about both posi-
tive and negative reactions.
Positive reactions:

Negative reactions:

6. How could this treatment be more helpful to you?

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

60
 HANDOUT 7

Certificate of Achievement

61
 FURTHER INFORMATION ABOUT SEEKING SAFETY

For more on Seeking Safety, please go to the website www.seekingsafety.org. It

provides updates on new research, journal articles that can be downloaded, infor-
mation on training therapists, and resources for conducting research on the treat-
ment.

62
TREATMENT TOPICS


COMBINATION

Introduction to Treatment/
Case Management

SUMMARY

This topic has two parts: (1) introduction to the treatment and getting to know the patient;
and (2) case management. For group therapy, it can be conducted in individual format prior to
the start of the group.

ORIENTATION

The first session is probably more crucial than any other in setting the tone of the treatment
toward safety and support, and in orienting patients to the coping skills philosophy. First im-
pressions count! Patients with substance abuse are notorious for high dropout rates from
treatment (Crits-Christoph & Siqueland, 1996), and patients with PTSD typically have diffi-
culty trusting people (Herman, 1992). Coming to a first session may feel vulnerable and anxi-
ety-provoking. Today’s topic is designed to help patients feel rewarded for their effort by pro-
viding materials attentive to their concerns (e.g., information about the treatment), concrete
benefits (e.g., case management referrals), and an atmosphere of emotional validation by the
therapist.
At the start of treatment, it is helpful for the therapist to convey the optimistic yet realis-
tic projection that all patients can get better if they work at treatment. Patients with PTSD
and substance abuse may be prone to taking a passive or hopeless stance, letting others (or
substances) control them. Building a strong alliance with the therapist and the treatment can
help them ally with the healthier parts of themselves and increase their motivation to actively
heal their lives.
Case management is a major focus for several reasons. First, our research found that
many patients had received little or no professional care prior to entering treatment
(Najavits et al., 1999a, 1998e). One woman, for example, had been using alcohol to get to

65
66 Treatment Topics

sleep every night for over 10 years and had never had a psychopharmacology evaluation to
obtain more appropriate sleep medication. In the month prior to entering our program,
42% of the 50 women surveyed had had no professional treatment (Najavits et al., 1999a).
Dramatic improvements in patients’ lives can thus sometimes be achieved simply by
helping patients to obtain ancillary services, such as job counseling, housing referrals, med-
ications, and entitlement benefits (e.g., Medicaid). Second, because this treatment is short-
term and achievement of case management goals may take a lot of repeated work, it is
necessary to begin aftercare planning from the start. It is very common to see patients re-
lapse just after this treatment ends if other services are not already in place. Emotionally,
they are likely to feel abandoned if the treatment ends abruptly without a smooth transition
to other supports. Third, this treatment was designed to be used in conjunction with as
many other services as possible to increase the likelihood of patients’ success in fighting
the very difficult dual disorders of PTSD and substance abuse (Drake & Noordsy, 1994).
Moreover, when problems are beyond the therapist’s expertise (e.g., domestic violence, job
counseling, psychopharmacology), the patient needs to be steered toward people trained to
work on those issues. Finally, this treatment is designed to help patients get on the right
track in their recovery from both disorders, but it is rare to see a patient fully recover from
both in a few months. Realistically, this treatment can give patients new skills, inspire them
to stay in treatment, and achieve significant reductions in their symptoms (Najavits et al.,
1998e); however, patients with very severe problems whose lives have been wrecked by
their disorders may need to continue in a variety of treatments for a long time to achieve
lasting gains.
Three case management issues are literally of life-or-death urgency: domestic violence,
HIV risk, and suicidal/homicidal intent. It is strongly suggested that the therapist carefully
assess patients’ danger in these domains and refer the patient for any necessary additional
help (as per this topic’s Therapist Sheet B). If the patient is resistant, additional individual
sessions (for group therapy patients) and/or referral to additional treaters may be needed. See
also the section in Chapter 2 on “Problem Situations and Emergencies.”
In working on case management, note that the term “community resources” is suggested
when talking with the patient. The term “case management” implies that the patient is simply
a “case” to be “managed.” The term “community resources” has the more upbeat tone of “op-
portunities out in the world.” Thus, in the check-in and check-out for each session, the term
“community resources” is used. However, because “case management” is so common in treat-
ment settings, it is used here to avoid confusion.
In the initial sessions, you will also begin to hear each patient’s story: What led to coming
here? What daily life struggles does this person go through? What successes and strengths
exist amid the pathology? How does the patient relate? Your own reactions will also begin:
How difficult is treatment likely to be? How do you respond to the patient’s style in areas
such as ability to articulate feelings, ability to “hear” you, and overall appeal?
Note that this topic has a large amount of material. It also requires more preparation than
most other topics, especially if you are doing this treatment for the first time. Indeed, it is
best to split the session into two if at all possible (introduction to treatment and getting to
know the patient as one session, and case management as another).
Introduction to Treatment/Case Management 67

Countertransference Issues
It may feel difficult to focus on the patient amid so many tasks and handouts in the session.
However, most therapists feel comfortable after trying it once or twice. With regard to case
management, therapists may feel overwhelmed or burdened by it; see this topic’s Therapists
Sheets A through D for in-depth guidance on this.

Acknowledgment
The study on completing therapy homework mentioned in Handout 3, How to Get the Most
from This Treatment, is by Burns and Auerbach (1992).

PREPARING FOR THE SESSION

♦ If possible, have the patient read the handouts prior to the session. Either asking the
patient to arrive a half hour ahead of time, or mailing them before the first appointment, is a
way to do this.
♦ Add a description of your background as the therapist to the end of Handout 1, About
the Seeking Safety Treatment. It is placed at the end so that you can make it whatever length
you choose or can omit it altogether if you prefer.
♦ For completing Handout 2, Practical Information about Your Treatment, have a phone
book available to identify the nearest emergency room and a local hotline for patients.
♦ Prepare a Resource Book for case management (see Therapist Sheet A).

SESSION FORMAT

Note that in this introductory session there is no check-in. However, it is suggested that the
standard check-out be done.

1. Quotation (briefly). See page 87. Link the quotation to the session—for example, “It’s
wonderful that you’ve come in for treatment. As the quotation suggests, it is always possible
to create the life you want.”
2. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Note that each handout is its own subtopic. See “Session Content” (below)
and Chapter 2 for how to choose from the large number of handouts, depending on
patients’ needs and your time frame. Cover them in multiple sessions if you have
the time.
Introduction to Treatment
Handout 1: About the Seeking Safety Treatment
Handout 2: Practical Information about Your Treatment
68 Treatment Topics

Handout 3: How to Get the Most from This Treatment

Handout 4: Seeking Safety Treatment Agreement
Case Management
Therapist Sheet A: Making It Happen: Case Management Strategies
Therapist Sheet B: Therapist Assessment of Patient’s Case Management Needs
Therapist Sheet C: Case Management Goal Sheet
Therapist Sheet D: Therapist Checklist for Case Management
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
3. Check-out (briefly). See Chapter 2.

SESSION CONTENT

As noted earlier, this topic is really two separate ones: (1) introduction to treatment and get-
ting to know the patient; and (2) case management. If at all possible, conducting them as sep-
arate sessions is advisable, particularly for patients with serious case management needs.
If you are limited to just one session, a useful balance is about 10 minutes for introducing
the treatment, about 15 minutes for getting to know the patient, and about 35 minutes for
case management.

Handouts 1, 2, 3, and 4: Introduction to Treatment

Goals
¨Introduce the treatment (Handout 1).
¨ Provide “nuts-and-bolts” information about the treatment and emergency procedures
(Handout 2).
¨ Explore ways to help the patient get the most from the treatment (Handout 3).
¨ Review treatment rules (Handout 4).
¨ Inform the patient about any “extras” your treatment program offers (e.g., child care,
parking, pamphlets to read, opportunity to watch educational videos related to treatment;
books to borrow).

Ways to Relate the Material to Patients’ Lives

ê Review of handouts. Briefly introduce the session agenda—for example, “Our goals
today are to discuss the treatment, to get to know each other a little, and to help you locate
resources outside this treatment that may be helpful.” Then give the patient the handouts.
Ideally, this will be done prior to the session; if not, allow the patient 5–10 minutes to look
the sheets over, taking the materials home to read in more detail later. Fill in the informa-
tion and emergency procedures in Handout 2, Practical Information about Your Treatment.
Ask the patient to sign two copies of it and also of Handout 4, Seeking Safety Treatment
Agreement (one copy of each for the patient to keep and one for you). Draw the patient
Introduction to Treatment/Case Management 69

into a discussion about the upcoming treatment, responding to questions and comments
the patient may have.
ê Self-exploration. Encourage patients to identify their strengths and weaknesses when
reviewing Handout 3, How to Get the Most from This Treatment. They can put a check next
to the ones they already do and circle those that may be difficult. If you have time, you may
want to help process ways to overcome the difficult ones (although there may not be time or
inclination to address them fully at this point). For example, if a patient has difficulty showing
up for treatment, discuss methods to overcome this, such as having a phone session if the pa-
tient is unable to get to the session, or establishing a person who can bring the patient to
treatment.
ê Discussion
• “What would you like to get out of this treatment?”
• “Do you have any concerns about the treatment?”
• “How do you think you can make the most of this treatment?”
• “Is there anything I can do to help you feel safe in the treatment?”
• “If you wanted to drop out of treatment, do you think you could let me know?”
• “Do you feel that you can be honest with me about your substance use?”
• “Some people find it hard to come in after they’ve used substances; do you think
you’ll be able to keep coming back no matter what?”
• “Do you tend to dissociate (‘lose time’ or ‘space out’) during treatment? If so, are
there any strategies you have found helpful that you would want me to say to you at
those times?”
• “Are there any specific topics you would like us to cover during the treatment?”

Suggestions
✦ Commend the patient for courage in coming to this new treatment, and help the pa-
tient feel validated and respected for reaching out for help.
✦ Do not summarize the material for the patient. The goal is to get the patient to do most
of the talking while you guide the session to cover the material. Also, don’t feel you have to
review each point; rather, seek to identify key areas relevant to the particular patient.
✦ When filling out Handout 2, Practical Information about Your Treatment, you may
need to modify it based on your treatment setting (e.g., emergency procedures and your role).
However, it is strongly recommended that you be available for the patient to reach in an
emergency outside of sessions, especially if no other treater is available. In the pilot test of
this treatment, patients reported that this availability was very important to them, although
they rarely used it. If you have any concerns about how to manage patients’ excessive calling
outside of sessions, an article by Gunderson (1996) may be helpful.
✦ In advance, decide your policy about being called outside of sessions. Note that Hand-
out 2, Practical Information about Your Treatment, requires a plan for whom the patient
should call in the event of an impulse to use substances or self-harm, as well as for severe psy-
chiatric emergencies. You may want to think out ahead of time whether you want to be avail-
able for calls on these issues, particularly if a patient has no one else to call and feels she or he
would not call a hotline. It is suggested that the therapist be available for contact by page or
70 Treatment Topics

phone outside of sessions, but that such availability be carefully contained and explained to
the patient. Moreover, a goal of treatment would be to help such a patient establish a network
of others to call.

Tough Cases
∗ “I refuse to do urine testing—it triggers trauma memories.”
∗ “I need to call you a lot between sessions.”
∗ “Have you ever done drugs?”
∗ “The last time I got clean, my PTSD got worse. I can’t handle that.”

Getting to Know the Patient

Goal
¨ Provide an opportunity for the patient to tell you more about her- or himself.

Ways to Relate the Material to Patients’ Lives

ê Discussion
• “Is there anything you would like me to know about you?”
• “What is most important to you right now?”
• “What is hardest for you these days? What is going well these days?”
• “Is there anyone (such as your child or spouse) whose life would improve if you got
better?”
• “Do you have any favorite activities, such as hobbies or sports?”
• “Do you have any life goals that you would like to make happen (e.g., career, a
move)?”
• “What do you think your life would be like if you could cope without substances?”
• “Do you have any favorite ‘thing’ that symbolizes hope for you, such as a photo-
graph? Favorite book or song? Quotation?”
• “Is there anything you want to know about me?”
• “Is there anything you would like me to know about what you’ve been through in
the past?” (Note: You may first want to inquire whether the patient feels ready to talk
about this and whether any dangers are likely to occur, such as relapsing on sub-
stances or becoming overwhelmed or suicidal. See Chapter 2 for a discussion of this
issue.)

Suggestions
✦ Follow the patient’s lead and focus mostly on validation and listening. The goal is to
try to learn everything you can about the patient, within the context of completing the session
tasks.
Introduction to Treatment/Case Management 71

✦ If the patient becomes upset, empathize with the emotional pain and then redirect the
conversation to a neutral, present topic. Provide a rationale so that the patient will not feel
invalidated (i.e., will not conclude that intense feelings are bad or wrong or that you cannot
tolerate them). For example, you might say, “I would like to hear about your experiences, but
I’m concerned that we’re not far enough into treatment to do that safely.”
✦ Try not to offer information about yourself unless the patient specifically asks ques-
tions. This keeps the focus on the patient’s needs.

Therapist Sheets A, B, C, and D: Case Management

Goals
¨ Evaluate case management needs and, with the patient, set immediate goals to be ac-
complished in the next week (Therapist Sheets A, B, and C).
¨ Return to case management goals throughout the treatment (Therapist Sheet D).

Ways to Relate the Material to Patients’ Lives

ê Conduct a case management interview. Therapist Sheets A through D provide exten-
sive materials for this purpose. The steps are as follows:
1. Making It Happen: Case Management Strategies (Therapist Sheet A) provides
background about case management.
2. Assess areas of concern, using the Therapist Assessment of Patient’s Case Manage-
ment Needs (Therapist Sheet B).
3. For each case management goal that is not already met, fill out a separate Case
Management Goal Sheet (Therapist Sheet C). A filled-out example is provided.
4. With the patient’s input, identify at least one specific case management goal to pur-
sue before the next session, and provide specific written referrals and deadlines.
5. Process emotional and practical obstacles that might interfere with completion of
the case management goals.
6. In future sessions, refer to the Therapist Checklist for Case Management (Therapist
Sheet D) to assist patients who are unable to follow through on case management
goals.
ê Discussion
• “Do you have any concerns about following through on these referrals?”
• “How do you feel about calling these referrals?”
• “How can you remember to do these?”
• “Can you leave me a voice mail message to let me know you completed this?”
• “Are there any practical problems that might get in the way of completing this (e.g.,
transportation, child care)?”
72 Treatment Topics

Suggestions
✦See Therapist Sheets A through D for detailed suggestions.
✦Use the term “community resources” when talking with patients. It is more under-
standable to them and more positive in tone than “case management.” Note that the Commit-
ment to Recovery (Handout 5 in Chapter 2) and the Check-In and Check-Out for all sessions
(Handout 1 in Chapter 2) all use the term “community resources.”

Tough Cases
∗ “I just can’t get myself to do this, even though I know I should.”
∗ “I have no phone, no babysitter, and no money—how can I get there?”
∗ “I feel totally overwhelmed.”
∗ “I’ve always had bad experiences with doctors; I don’t trust them any more.”
∗ “Sure, I’ll do it!” (yet the patient comes back every week without it done).
THERAPIST SHEET A Introduction to Treatment/Case Management

Making It Happen: Case Management Strategies

PRACTICAL ISSUES
The general theme in case management is “The more the better!” Getting into additional treatments will help the
patient’s recovery now and will also serve as aftercare when this treatment ends.

 Develop a Resource Book, with a section for each of the case management needs listed in Therapist Sheet
B (Therapist Assessment of Patient’s Case Management Needs). The simplest way is to have a binder, with tabbed
sections for “Housing,” “Job Training,” “Domestic Violence,” “Therapists,” and so on. Cast a wide net: Call the toll-
free numbers listed in Handout 1 of the topic Community Resources; explore the Internet; use the Yellow Pages and,
if available in your location, the Human Service Yellow Pages; ask colleagues; identify state and federal agencies and
hotlines; talk to a social worker in your area who knows community options; keep professional “junk mail” sent to
you (e.g., fliers, catalogues). In addition, keep a list of all therapists you refer to and what insurance they accept, as
well as a listing of detox facilities (both public and private) and sober housing. There are an enormous number of re-
sources available, although unfortunately there is as yet no systematic way to locate them. Once you have created
your Resource Book, it will be invaluable and save a lot of time and effort later.
 Thoroughly assess the patient’s needs, using Therapist Sheet B (Therapist Assessment of Patient’s Case
Management Needs) as an interview. Ask as many questions as needed to determine whether the case management
goal has already been met or needs further work. For example, for housing you might ask, “Do you have any prob-
lems with housing?”, “Is there anything unsafe about your current housing?”, or “Do you live with anyone who
abuses substances?” Note that there may be situations where the patient feels the goal is met, but you do not (e.g.,
the patient feels it’s okay to live with a person who abuses substances, but you do not). In this case, fill out the sheet
from your perspective, but note on it that the patient differs.
 Be sure to find out patients’ insurance coverage, as this will have a major impact on where you can refer
them.
 Prioritize. For patients with an enormous number of needs, address the most important, life-endangering
ones first. Think of Maslow’s (1970) hierarchy of needs, in which food and shelter come before social relationships.
 Give the patient a written list of specific referrals (name and phone number to call) for each area of un-
met need, using your Resource Book. The simplest way is to list this information on the Commitment to Recovery
handout (see Handout 5, Chapter 2), which the patient will take home. If a need comes up for which you do not yet
have a resource, tell the patient you will locate one by the next session.
 Give the patient several options from which to choose, without overwhelming the patient. Typically,
two referrals for any case management goal will be a good start.
 Work with the patient by providing a reason for the case management goal—for example, “Getting an
individual therapist can help improve your chances of recovery by providing more support.”
 Set deadlines. If a patient can only do one goal at a time, that’s okay, but each goal needs a deadline to
which the patient can agree. Without deadlines, many patients will come back week after week without accomplish-
ing their goals. It is human nature to procrastinate! Whenever possible, make the deadline “by the next session.”
 Identify practical obstacles. Some patients can’t get a ride to go to a referral, do not have a phone, or
have no babysitter. It is extremely important to find solutions for these in any way possible—for example, “Could you
call from a neighbor’s phone?”, “Could you get a pager?”, “Could you get Medicare to give you transportation?”
The bottom line: Do whatever it takes to solve the problem, within professional boundaries.
 Break complex goals into small steps. For example, if the patient has not had any medical exams for
years, start by having the patient get a general physical exam, then later a dental exam, a vision exam, and so on.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

73
THERAPIST SHEET A (page 2 of 3) Introduction to Treatment/Case Management

 Use Therapist Sheet D (Therapist Checklist for Case Management) whenever a patient has been unable to
complete the case management goal since the last session.
 In addition to your guidance, offer your Resource Book directly to the patient to look through before or
after the session, if desired.
 Be sure to follow up on the patient’s progress with each goal at each session until all case manage-
ment needs are met. At every session, case management is part of the check-in and check-out (where it is called
“community resources”). In many cases you will need to continue to help the patient resolve emotional obstacles to
such goals throughout the treatment.
 Schedule additional case management sessions later in treatment if needed. This may occur for pa-
tients who have a great number of needs or who have difficulty completing case management goals.

EMOTIONAL ISSUES
In addition to providing a list of referrals, most patients will need your help in overcoming emotional obstacles to pur-
suing services.
 Find out what goals the patient most wants to pursue and focus on those. The only exception would
be a situation of extreme emergency, in which you may need to set your own agenda to protect the patient. For ex-
ample, if a patient is in serious danger of suicide, you may need to obtain an involuntary commitment for inpatient
care.
 Convey that any movement forward is progress, even in small steps. Do not give up!
 Empower patients by taking a consumer view. Patients can “shop around” until they find treatments
that feel genuinely beneficial. Encourage them to try resources without feeling obligated to stay with them. Pushing
patients to stay in a treatment they find unhelpful rarely works and can make them feel coerced and unheard. This is
particularly true for patients with PTSD and substance abuse, for whom control is often a major theme. See the topic
Community Resources for more on the consumer view of treatment.
 Observe the patient’s actual behavior—ability to follow through on goals—as information to gauge
your interventions. What might seem easy to you or to other patients may not be to this patient.
 Keep in mind that a patient may become overwhelmed or feel like a failure if case management goals
are not realistic and concrete. Build success experiences that reinforce the patient’s efforts.
 Be sensitive to cultural, racial, and systems issues that may play a role for some patients. They may fear
entering treatment systems that are unfamiliar to them, or may have had negative experiences in previous treatment
systems.
 Have a sense of urgency and concern in getting the patient to move forward on case management goals.
It may take a lot of work to get into needed treatments. Each week should have new goals and strategies until the
patient is safely into all needed treatments.
 When trying to solve a tough referral problem, ask yourself, “If it were my close relative who needed
help, how would I locate a resource?”

THERAPIST ISSUES
 View yourself as the primary case manager for each patient, even if the patient has other treaters. The
reason for this is that many treaters do not have time, training, or inclination to work with the patient on case man-
agement goals, and more often than not the patient receives inadequate services. Even if a patient has a formal case
manager, be sure to be in close contact and follow the patient’s progress carefully, adding assistance as needed.
 Some therapists were trained to conduct treatment in which the therapist stays neutral and actions
are “up to the patient.” The case management approach is quite different: It assumes that patients may need ad-
(cont.)

74
THERAPIST SHEET A (page 3 of 3) Introduction to Treatment/Case Management

ditional care and will need a lot of assistance from the therapist to make it happen. Patients with severe histories may
never have learned how to obtain help and often feel passive in the face of adversity. Thus the philosophy is to strive
for all reasonable case management unless there is a legitimate reason not to (e.g., a patient cannot start
psychopharmacology due to being pregnant).
 Be sure not to ask the patient to do things that you do not understand or know yourself. Navigating
systems such as the welfare system, hospital bureaucracies, and government agencies can require enormous skill and
effort. Locating subsidized housing or obtaining entitlement benefits such as Medicare may land the patient in an
endless series of phone calls; the patient may become frustrated and give up. If patients could negotiate such sys-
tems themselves they likely would have already found the help they need. If you do not know the answer to a partic-
ular question, make phone calls with the patient in the session to model how the process works, as well as to obtain
the specific answer needed. Or tell the patient you will find the information by the next session (e.g., by consulting
colleagues). If needed, refer the patient to a social worker skilled in case management. You will be modeling re-
sourcefulness and integrity by not giving up, by drawing on local and national resources, and by using every means
available to help patients get assistance. The worst thing is to suggest that patients seek help, but without giving
them specific names and numbers to call—this communicates a confusing, unhelpful message (“Do as I say, not as I
do”).
 Successful case management requires the therapist to be persistent, creative, and attuned to pa-
tients’ needs. It may help to imagine that you are in the role of a parent and that the patient needs supportive guid-
ance that is neither too “pushy” nor too “passive.” Many patients never had someone help them when they were
growing up, and greatly need effective guidance.

75
THERAPIST SHEET B Introduction to Treatment/Case Management

Therapist Assessment of Patient’s Case Management Needs

Patient: Therapist: Date:

Town (or catchment area) patient lives in: Insurance:

Note: At the end of this form is a section, “Patient Case Management Needs,” which patients can fill out prior to the
session to identify their key areas of need. However, it is still important for the therapist to assess each goal directly,
as patients may not be aware of some needs.

(1) Housing

Goal Stable and safe living situation.

Notes Unhealthy living situations include short-term shelter, living with a person who abuses substances,
unsafe neighborhood, domestic violence situation.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(2) Individual Psychotherapy

Goal Treatment that patient finds helpful.

Notes Try to get every patient into individual psychotherapy. Inquire if patient has any preferences (e.g.,
gender? theoretical orientation?).

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(3) Psychiatric Medication

Goal Treatment that patient finds helpful for psychiatric symptoms (e.g., depression, sleep problems)
and/or substance abuse (e.g., naltrexone for alcohol cravings).

Notes If patient has never had a psychopharmacology evaluation, it is strongly recommended that this
occur, unless patient has serious objections; even then, evaluation and information is helpful before
deciding.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

76
THERAPIST SHEET B (page 2 of 6) Introduction to Treatment/Case Management

(4) HIV Testing/Counseling

Goal A test as soon as possible, unless completed in the past 6 months and no high-risk behaviors since
then. For a patient at risk for HIV who is unwilling to get testing and counseling, it is strongly
suggested that the therapist hold an individual session with the patient to explore and encourage
these.

Notes See the topic Community Resources for a list of national resources on HIV/AIDS.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(5) Job/Volunteer Work/School

Goal At least 10 hours/week scheduled productive time.

Notes If patient is totally unable to do the above, have patient hand in a weekly schedule with
constructive activities out of the house (e.g., library, gym). See the topic Respecting Your Time for
more on this.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(6) Self-Help Groups/Group Therapy

Goal As many groups as patient is willing to attend.

Notes Elicit patient’s preferences and consider a wide range of options (e.g., dual-diagnosis groups, women’s
groups, veterans’ groups). For self-help groups (e.g., AA), give patient a list of local groups, strongly
encourage them, and mention that they are free. However, do not insist on self-help groups or convey
negative judgment if patient does not want to attend. If patient participates in self-help groups,
encourage seeking a sponsor. See the topic When Substances Control You for more on this.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(7) Day Treatment

Goal As needed, and based on patient’s level of impairment, ability to attend a day program, and schedule.

Notes Locate specialty day program if possible (e.g., substance abuse or PTSD day program). If patient is
able to function (job, school, or volunteer activity), do not refer to day treatment, as it is generally
better to have the patient keep working; however, if patient is working part-time, some programs
allow partial attendance.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(cont.)

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THERAPIST SHEET B (page 3 of 6) Introduction to Treatment/Case Management

(8) Detox/Inpatient Care

Goal To obtain appropriate level of care.

Notes Detox. Necessary if patient’s use is so severe that it represents serious danger (e.g., likelihood of
suicide; substance use is causing severe health problems; or withdrawal from substance requires
medical supervision, such as for painkillers or severe daily alcohol use). If patient is not in acute
danger, but simply cannot get off substances, detox may or may not be helpful; many patients are
able to stay off substances only during the detox, but then return to their usual living environment
and go right back to substance use. For such patients, helping set up adequate outpatient supports
is usually preferable. Inquiring about patient’s history (e.g., number of past detoxes and their
impact) can be helpful for making a decision.

Psychiatric Inpatient Care. This is typically recommended if patient is a serious suicide or homicide
risk (not simply ideation, but immediate plan, intent, and inability to contract for safety),1 or
patient’s psychiatric symptoms are so severe that functioning is impaired (e.g., psychotic symptoms
prevent a mother from caring for her child). Under some circumstances, the patient may need to be
involuntarily committed; seek supervision and legal advice on this topic.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(9) Parenting Skills/Resources for Children

Goal If patient has any children, inquire about: (a) parenting skills training; and (b) referrals to help the
children obtain treatment, health insurance, and other needs.

Notes You may also need to gently inquire to assess whether patient’s children are currently being abused
or neglected. If they are, you are required by law to report that to your local protective service
agency. The same applies for elder abuse/neglect.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(10) Medical Care

Goals Annual exams for (1) general health, (2) vision, (3) dentistry, (4) gynecology (for women); and (5)
adequate birth control/prevention of sexually transmitted diseases.

Notes Other medical care may be needed if patient has a particular illness.

Status • If all five goals already met, check here o and describe___________________________________
• If any of the five goals not met, or other medical issues need attention, check here o and fill
out Case Management Goal Sheet (Therapist Sheet C) for each.

1For homicide risk (or any other intent to physically harm another person), the therapist must follow “duty to warn” legal standards, which usually
involve an immediate warning to the specific person the patient plans to assault. Be sure to seek supervision and legal advice, and be knowledge-
able in advance about how to manage such a situation.
(cont.)

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THERAPIST SHEET B (page 4 of 6) Introduction to Treatment/Case Management

(11) Financial Assistance (e.g., food stamps, Medicaid)

Goal Health insurance, and adequate finances for daily needs.

Notes It is crucial to help the patient obtain health insurance and entitlement benefits, if needed (e.g.,
food stamps, Medicaid). The patient may need help filling out the forms. If a great deal of help is
needed, you may want to refer to a social worker or other professional skilled in this area; the
patient may be unable to manage it alone, as the bureaucracy of these programs can be
overwhelming. If the patient is a parent, be sure to check whether the children are eligible too.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(12) Leisure Time

Goal At least 2 hours/day in safe leisure activities.

Notes Leisure includes socializing with safe people, hobbies, sports, outings, movies, etc. Some patients
are so overwhelmed with responsibility that they do not find time for themselves. Adequate leisure
is necessary for maintaining a healthy lifestyle. See the topic Self-Nurturing for more on this.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(13) Domestic Violence/Abusive Relationships

Goal Freedom from domestic violence and abusive relationships.

Notes Remember that it may be extremely difficult to get the patient to leave a situation of domestic
violence. Be sure to consult a supervisor and/or a domestic violence hotline (see the topic
Community Resources).

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(14) Impulses to Harm Self or Others (e.g., suicide, homicide)

Goal Absence of such impulses; or if such impulses are present, a clear and specific safety plan is in
place.

Notes Many patients have thoughts of harming self or others; however, to determine if the patient is
actually at serious risk of action, and how to manage this, see Chapter 2 (“Problem Situations and
Emergencies”). For a Safety Plan, see the topic Red and Green Flags, and for a Safety Contract to
prevent harm to self or others, see the topic Healing from Anger.

Status • If goal already met, check here o and describe___________________________________

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(cont.)

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THERAPIST SHEET B (page 5 of 6) Introduction to Treatment/Case Management

(15) Alternative Treatments (e.g., acupuncture, meditation)

Goal Patient is informed of alternative treatments that may be beneficial.

Notes It is recommended that patients be informed that some people in early recovery benefit from
acupuncture, meditation, and other nonstandard treatments. Try to identify local referrals for such
resources.

Status • If goal already met, check here o

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(16) Self-Help Books and Materials

Goal Patient is offered 1–2 suggestions for self-help books (and/or other materials such as audiotapes, or
Internet sites that offer education and support).

Notes All patients should be encouraged to use self-help materials outside of sessions as much as possible.
For patients who do not like to read, alternative modes (e.g., audiotapes) are suggested. Self-help
can address PTSD, substance abuse, or any other life problems (e.g., study skills, parenting skills,
relationship skills, leisure activities, and medical problems).

Status • If goal already met, check here o

• If goal not met, check here o and fill out Case Management Goal Sheet (Therapist Sheet C).

(17) Additional Goal: ________________________________

Goal

Notes

Note: Some therapists like to have patients fill out the form on the next page before conducting the assessment
above.

(cont.)

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THERAPIST SHEET B (page 6 of 6) Introduction to Treatment/Case Management

PATIENT CASE MANAGEMENT NEEDS

Do you need help with any of the following?

(1) Housing Yes / Maybe / No

(2) Individual Psychotherapy Yes / Maybe / No

(3) Psychiatric Medication Yes / Maybe / No

(4) HIV Testing/Counseling Yes / Maybe / No

(5) Job/Volunteer Work/School Yes / Maybe / No

(6) Self-Help Groups/Group Therapy Yes / Maybe / No

(7) Day Treatment Yes / Maybe / No

(8) Detox/Inpatient Care Yes / Maybe / No

(9) Parenting Skills/Resources for Children Yes / Maybe / No

(10) Medical Care Yes / Maybe / No

(11) Financial Assistance (e.g., food stamps, Medicaid) Yes / Maybe / No

(12) Leisure Time Yes / Maybe / No

(13) Domestic Violence/Abusive Relationships Yes / Maybe / No

(14) Impulses to Harm Self or Others (e.g., suicide, homicide) Yes / Maybe / No

(15) Alternative Treatments (e.g., acupuncture, meditation) Yes / Maybe / No

(16) Self-Help Books and Materials Yes / Maybe / No

(17) Additional Goal: _________________________________________________ Yes / Maybe / No

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THERAPIST SHEET C Introduction to Treatment/Case Management

Case Management Goal Sheet

Patient: Therapist: Today’s date:

Case management goal:

Describe current situation:

List referrals given to patient, date given, and deadline (if any) for each:

Describe patient’s motivation to work on this goal:

Emotional obstacles that may hinder completion (and strategies implemented to help patient overcome these):

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

82
THERAPIST SHEET C (page 2 of 2) Introduction to Treatment/Case Management

Therapist to do:

Follow-up (date and update):

Follow-up (date and update):

Follow-up (date and update):

Check off when goal fully met: Date:

Note: Add blank pages as needed for more follow-up entries if goal not yet met.

83
EXAMPLE OF THERAPIST SHEET C Introduction to Treatment/Case Management

Case Management Goal Sheet

Patient: Helen D. Therapist: Deborah Today’s Date: 5/28/98

Case management goal:

Housing

Describe current situation:

Patient living with husband who abuses cocaine. Other than that, no housing
issues (living in stable apartment).

List referrals given to patient, date given, and deadline (if any) for each:
1. 5/23: Gave patient Al-Anon meeting list to get support. She said she
would attend at least one meeting by 6/1.
2. Gave patient instructions to:
a. Ask husband not to use cocaine around her.
b. Ask husband to hide cocaine in locked box so she can’t get to it.
She said she’d do these before next session on 6/1.

Describe patient’s motivation to work on this goal:

Patient wants to find way to decrease being triggered by husband, but
doesn’t know how. Says husband wants to help her; no domestic violence
between them.

Emotional obstacles that may hinder completion (and strategies implemented to help patient overcome these):

1. Patient a little afraid of groups, so not sure if Al-Anon will be

good for her, but willing to try.
2. Unsure if husband will follow through on her requests. I told patient
that if he doesn’t follow through, we could do joint meeting with husband
to discuss it, or can refer them to a family therapist.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

84
EXAMPLE OF THERAPIST SHEET C (page 2 of 2) Introduction to Treatment/Case Management

Therapist to do:

If I need to refer patient to family therapist, need to find one with

sliding scale (patient has no insurance).

Follow-up (date and update):

6/1:
(1) Patient did not get to Al-Anon because was home sick, but says will go
to a meeting by 6/10.
(2) Patient says she told husband both (a) and (b) (see “Gave patient
instructions . . ., ” above), and that he said he doesn’t understand why
he needs to do these things. Patient feeling hopeless about changing
husband’s behavior, but willing to try joint meeting and says thinks
husband would be willing to come in. Set up meeting for 6/10.

Follow-up (date and update):

6/10:
(1) Patient went to Al-Anon, and willing to keep going once a month.
(2) Had joint meeting with patient and husband; signed agreement that they
would both follow through on (a) and (b), and that patient would help by
buying lock box for husband.

Follow-up (date and update):

6/15: Patient says goal is met; husband now following through on (a) and
(b). However, they also said they’d like referral to family therapist; gave
them two names to try (Dr. Westen at Massachusetts General Hospital and
Dr. Cramer at McLean Hospital).

Check off when goal fully met: ü Date: 6/15

85
THERAPIST SHEET D Introduction to Treatment/Case Management

Therapist Checklist for Case Management

If a patient is not following through on a case management goal after your first deadline, have you tried to do the
following:

¨ Ask the patient to make a phone call to that referral before, during, or after your session, and provided a
phone to do it?
¨ Role-play what the patient will say when the call is made?
¨ Give the patient a specific, immediate deadline (e.g., within 24 hours)?
¨ Ask the patient to leave brief daily updates on your voice mail, with the idea that you will not call back but
just want to hear how it’s going? For many patients, this is perceived as very caring and gives them some ex-
ternal motivation to complete their tasks.
¨ Call the patient’s other treaters (e.g., other therapist, AA sponsor) to discuss ways to coordinate having the
patient follow through? Note: Be sure to get the patient’s permission to contact other treaters at the start
of treatment. It is illegal to contact another treater unless you have a written release from the patient.
¨ Ask the patient to identify the practical obstacles getting in the way of following through? Evaluate each
possible obstacle below and help the patient problem-solve any that apply.
¨ Not clear where to go (or whom to call)?
¨ No transportation?
¨ No one to go with?
¨ Has no phone to receive calls?
¨ Is afraid someone will be upset (e.g., abusive partner)?
¨ No time to get it done due to schedule?
¨ No babysitter?
¨ Confirm that the patient wants to achieve the goal? If not, try setting a new goal that the patient does
want.
¨ Ask the patient to do a “walk-through” and imagine out loud everything that would be needed to achieve a
particular goal?
¨ Ask the patient to “try an experiment”? That is, if the patient feels a lack of faith that follow-through will
help, ask “How helpful do you think this will be?” (rated 0–10, 10 being “extremely helpful”); then the pa-
tient can try it and report back to you “how helpful it was” (rated 0–10). Even if it wasn’t helpful, you can
also ask, “How good do you feel that you got it done (0–10)?”
¨ Give the patient a written sheet on which the goal and the phone number to call and the deadline are all
written down, to make sure they are not forgotten? In addition, you can ask the patient to keep the written
sheet on the dashboard of the car or the refrigerator to make sure it is not forgotten.
¨ Set up a reward the patient can give him- or herself if the goal is achieved (e.g., going to the movies, buying
chocolate, taking a half day off from work or school)?
¨ Check up at each session to see whether the patient is accomplishing the goal?
¨ Consider having a supportive family member assist the patient with the goal (perhaps inviting the family
member into a session, with the patient’s permission)?
¨ Break down the task into smaller steps?
¨ Ask the patient to drive by a place ahead of time to know how to get there?
¨ Seek supervision or consultation with a colleague?
¨ Locate additional information that might help you work better with the patient on the goal (e.g., hotlines,
government agencies, professional books)?

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

86
 Quotation

“It’s never too late to be

what you might have been.”
—George Eliot
(19th-century British writer)

From Seeking Safety by Lisa M. Najavits (2002).

87
HANDOUT 1 Introduction to Treatment/Case Management

About the Seeking Safety Treatment

WHAT IS THE SEEKING SAFETY TREATMENT?

This treatment is designed for people with substance abuse and trauma. “Trauma” means that a person has suffered
a severe life event, such as physical or sexual abuse, a car accident, or a hurricane. Many men and most women who
abuse substances have experienced a trauma during their lifetime. Some people develop posttraumatic stress disor-
der (PTSD) as a result of their trauma; you will learn more about this during treatment.
The treatment consists of 25 psychotherapy topics. It is an “integrated” treatment, meaning that both trauma
and substance abuse issues are worked on at the same time to promote the most successful recovery possible. It was
developed at Harvard Medical School and McLean Hospital beginning in 1993, with funding by the National Institute
on Drug Abuse.

WHY IS IT CALLED SEEKING SAFETY?

The #1 goal of the treatment is to help you become safe. “Safety” includes the ability to:

• Manage trauma symptoms (such as flashbacks, nightmares, and negative feelings).

• Cope with life without the use of substances.
• Take good care of yourself (such as getting regular medical exams and eating well).
• Find safe people who can be supportive to you.
• Free yourself from domestic violence or other current abusive relationships.
• Prevent self-destructive acts (such as cutting, suicidal impulses, and unsafe sex).
• Find ways to feel good about yourself and to enjoy life.

You may want to start thinking about what safety means to you.

FINDING SELF-RESPECT
Many people who have PTSD and substance abuse—especially if these have gone on for a long time—find it hard to
like themselves. You may feel that you have never really gotten to know yourself, or that you have lost yourself some-
where along the way. This treatment seeks to help you understand yourself, to develop a new identity as someone
who can cope successfully with life, and to respect who you are.

WHAT WILL BE COVERED IN THE TREATMENT?

Each topic will focus on a specific strategy to help you cope with trauma and substance abuse. Examples of topics are
Honesty; Asking for Help; Setting Boundaries in Relationships; Taking Good Care of Yourself; Compassion; Recovery
Thinking; Creating Meaning; Self-Nurturing; Respecting Your Time; Getting Others to Support Your Recovery; and
Community Resources.
The treatment is evenly divided among behavioral, cognitive, and interpersonal topics. “Behavioral” refers to your
actions; “cognitive” refers to your thinking; and “interpersonal” refers to your relationships. Because of the focus on
thinking and actions, the treatment is called “cognitive-behavioral.” This type of psychotherapy was originally developed
by Dr. Aaron Beck at the University of Pennsylvania. Previous research has shown that cognitive-behavioral treatments
can be helpful for a variety of psychological problems, including depression, anxiety, and substance abuse.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

88
HANDOUT 1 (page 2 of 3) Introduction to Treatment/Case Management

WHAT IS THE FORMAT OF THE SESSIONS?

Each treatment session is structured to make the most of the time available.
1. Check-in. At the start of each session, you will be asked five questions: “How are you feeling?”, “What good
coping have you done?”, “Any substance use or other unsafe behavior?”, “Did you complete your commitment?”
and “Community resource update?” (Some of these terms may be unfamiliar to you, but they will become clear.)
2. Handout. You will be given a written sheet that summarizes the main points of the topic.
3. Discussion/practice. Most of the session will be spent discussing the session topic. For example, we will discuss
how the topic relates to your life, and ways in which to apply the concept to current problems you have. Also, several top-
ics have exercises in which you will have the opportunity to practice a new strategy, such as role plays, or an in-session
practice exercise. Your participation will always be voluntary, so you can just watch if you prefer that.
4. Check-out. At the end of the session, you will be asked to describe your views of the session. Also, you will
be asked to name one action you can commit to before the next session. This is to help you move forward in your life
as quickly as possible. It will always be up to you to decide what you want to commit to, but the therapist can help
you think of options. Examples might include trying to ask someone in your life for help; calling up a hotline if you
feel in distress; writing about your feelings; getting an HIV test; or doing something fun every day for a week.

WHAT IF I MISS A SESSION?

If you miss a session, you can call to have the session material mailed to you. Or you can pick it up at the next session
(or in advance if you know you’ll be away). The goal is to help you get the most from this treatment! Please try, how-
ever, to be here for every session.

WILL I BE TERMINATED FROM TREATMENT FOR USING A SUBSTANCE?

No. The goal is to help you attain abstinence; however, the approach is to try to help you learn from mistakes and un-
derstand better what motivates the choices you make. You will not be terminated from treatment for using sub-
stances. You would only be prevented from returning to treatment if you present a serious danger to staff or pa-
tients (e.g., assault, selling drugs).

WILL I GET A CHANCE TO TALK ABOUT MY TRAUMA?

Yes, but the aim will be to talk about the impact of your trauma on your current life. Sometimes people want to talk
a lot about the past, but then are unable to manage overwhelming feelings and memories that come up. Our goal is
to help you establish safety first and to learn strategies to cope with intense negative feelings. Once you have mas-
tered these, you can—and should—move on to talking in depth about the past. These guidelines are particularly true
if you are in a group treatment, because details about past traumas (and, similarly, “war stories” about substance
use) can be too upsetting to other patients. If you are in group treatment, it is strongly recommended that you par-
ticipate in individual therapy at the same time so that you will have a place to talk about the past if you want to.

WILL I HAVE URINE/BREATHALYZER TESTING?

You may be asked to agree to urine and/or breathalyzer testing as part of this treatment. This is the best way for the
therapist to know what is truly going on. Unfortunately, part of the problem with substance abuse is that it can lead
to lying, even among people who are generally trustworthy. Years of experience in substance abuse treatment sug-
gest that urine testing promotes the best possible care of patients. And many patients say that they feel more able to
give up substances when they know they’ll be tested. Some patients with trauma histories may have particular con-
cerns about urine testing (e.g., that it will “trigger” them into painful memories of abuse, or will feel demeaning).
(cont.)

89
HANDOUT 1 (page 3 of 3) Introduction to Treatment/Case Management

However, a study of this treatment found that virtually all patients were able to do just fine with urine testing once
they tried it, and as long as the results were kept confidential.

WHAT IF I DON’T LIKE PARTS OF THE TREATMENT?

The best thing to do is to tell your therapist. Be honest about your comments—it can help to get your needs met, and
also to improve the treatment program. Also, at the end of every session, you may be asked to fill out a brief ques-
tionnaire about the session. The more comments you make, the more the treatment can be made helpful to you and
to other patients in the future! All of your comments will be kept confidential. If you have any concerns about the
therapist, the first step is to tell the therapist directly; you can also talk to his or her supervisor, if there is one.

WHO DEVELOPED THE TREATMENT?

The treatment was developed by Lisa Najavits, PhD. She is Professor of Psychiatry, Boston University School of Medi-
cine; Lecturer, Harvard Medical School; clinical psychologist at VA Boston Healthcare System; and clinical associate,
McLean Hospital. She is author of A Woman’s Addiction Workbook (New Harbinger Press, 2002), as well as over
140 professional publications. She has received various awards, including the 1997 Chaim and Bela Danieli Young
Professional Award of the International Society for Traumatic Stress Studies; the 1998 Early Career Contribution
Award of the Society for Psychotherapy Research; the 2004 Emerging Leadership Award of the American Psychologi-
cal Association’s Committee on Women; and the 2009 Betty Ford Award of the Association for Medical Education
and Research in Substance Abuse. She served as president of the Society of Addiction Psychology of the American
Psychological Association; and is an advisory board member of Psychotherapy Research, the Journal of Gambling
Studies, and Addiction Research and Theory. Dr. Najavits has received a variety of National Institutes of Health and
other research grants. She is a fellow of the American Psychological Association, board certified in behavioral ther-
apy, a licensed psychologist in Massachusetts, a psychotherapy supervisor, and she conducts a psychotherapy prac-
tice. She received her PhD in clinical psychology from Vanderbilt University (Nashville, TN) and her bachelor’s degree
with honors from Columbia University (New York, NY). Her major clinical interests address vulnerable populations, in-
cluding homeless, women, veterans, and community-based care; she specializes in trauma/substance abuse, develop-
ment of new psychotherapies, and evaluation and outcome research. If you have comments about this treatment,
you can contact her program by phone (617-299-1610) or email (info@seekingsafety.org).

WHAT HAS RESEARCH SHOWN SO FAR ABOUT THIS TREATMENT?

This is the first treatment for PTSD and substance abuse that has undergone scientific testing. Based on a sample of
17 patients who participated in a study on the treatment, results showed significant improvements in substance use,
trauma-related symptoms, suicide risk, suicidal thoughts, social adjustment, family functioning, problem solving, de-
pression, thoughts about substance use, and knowledge related to the treatment. Positive results have also been
found in three other studies thus far: a study of women in prison, a study of inner-city women, and a study of men.
The treatment and the initial research on it are summarized in the following articles:
Najavits, L. M., Weiss, R. D., & Liese, B. S. (1996). Group cognitive-behavioral therapy for women with PTSD and substance use
disorder. Journal of Substance Abuse Treatment, 13, 13–22.
Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and posttraumatic stress disorder in women:
A research review. American Journal on Addictions, 6(4), 273–283.
Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. (1998). “Seeking Safety”: Outcome of a new cognitive-behavioral psychotherapy
for women with posttraumatic stress disorder and substance dependence. Journal of Traumatic Stress, 11, 437–456.

WHO IS THE THERAPIST?

[If you choose to, fill in information about yourself as the therapist here after whiting out this sentence, and con-
tinue onto another page as needed.]

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HANDOUT 2 Introduction to Treatment/Case Management

Practical Information about Your Treatment

Therapist’s name:
À Schedule of sessions:
H Location of sessions:
( If you need to reach the therapist for nonemergency reasons, please call the following number and the
therapist will return your call within hours:
( If you cannot attend a session, please be sure to leave a message at:

EMERGENCY PROCEDURES

It is extremely important to reach out for help in an emergency!

h What is an emergency? It is any situation in which you feel you are in serious danger of killing yourself or
harming anyone else (e.g., children); or any other experience of extreme symptoms for which you need immediate
psychiatric help (severe hallucinations, “mental breakdown,” etc.).
% Name and phone number of primary person to contact in a psychiatric emergency:

% If you need to reach the therapist for this treatment in an emergency, call:

% If you cannot reach anyone, go to your nearest hospital emergency room, which is:

% Other emergency procedures:

OTHER IMPORTANT SITUATIONS IN WHICH TO CALL FOR HELP

å If you feel in danger of using a substance, please call:
« AA sponsor:
« Other person(s):
« Hotline:
' If you feel in danger of self-harm (e.g., cutting, burning), please call:

« Hotline:
« Other person(s):
ð Please rehearse ahead of time with the person you will call: (1) what you will say; (2) what the other per-
son will say. Be sure to let the person know in advance how to be the best help to you.

I agree that I need to stay safe, and I agree to all of the above safety procedures.

Patient signature Therapist signature Date

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 3 Introduction to Treatment/Case Management

How to Get the Most from This Treatment

It is possible to recover from both PTSD and substance abuse, and this treatment is designed to help you do that.
However, this treatment cannot work without you. Therefore:

« Notice your strengths. Keep actively recognizing your strengths, talents, and abilities. At each session you
will be asked to tell at least one example of something you did well (good coping) since the previous session.
No one gets anywhere by putting oneself down.
« Be honest. Lies and secrecy often accompany PTSD and substance abuse, but honesty is the path to recov-
ery. In your treatment, be honest about everything: your substance use, your true feelings (both negative
and positive), and your reactions to the therapist.
« Safety above all. The highest priority is staying safe. In fact, for both trauma and substance abuse, there
are several phases of healing. Right now you are in the first stage, establishing safety: getting off all sub-
stances, staying alive and not hurting yourself, locating a network of supportive people, learning to cope
with day-to-day problems.
« Show up, no matter what. Sometimes you may not want to come to treatment. You may have used a sub-
stance and feel ashamed. You may be so depressed that you don’t want to get out of bed. Come to treat-
ment anyway. Keep reaching out for the help that is available to you. You can talk about your mixed feelings
in the session.
« Stay focused on your own goals. Do not compare yourself to other people. You are fighting your own
battle. Whether others are doing better or worse does not matter.
« Participate. The more you put into something, the more you will get out of it. Work your very hardest—
100%. Listen, learn, speak up, read the materials, and try the new strategies being taught. These efforts will
pay off!
« Complete commitments between sessions. You will be asked to make a commitment between each ses-
sion, to move forward in your recovery. It is up to you what you select, but once you make a commitment, it
is important to keep it. Research shows that patients who complete assignments outside of sessions improve
three times as much as patients who do not.
« Free yourself from substance use. Substances block your feelings and prevent the emotional work needed
to recover; they also block your general growth and emotional development. While you may have mixed feel-
ings about giving up substances (a natural reaction at first), keep talking about it in treatment, and keep aim-
ing for freedom from all substances. You will feel more powerful, stronger, and better about yourself. Even if
you cannot or do not want to give up substances, come to treatment anyway to obtain help with other prob-
lems in your life that you want to work on.
« Know that you may feel worse before you feel better. As you stop using substances, you will notice
many changes. Some may be wonderful (e.g., increased energy), while others may be difficult (e.g., more
depression, physical problems) Hang in there, and these symptoms will go down eventually. “The only way
out is through.”

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

92
HANDOUT 4 Introduction to Treatment/Case Management

Seeking Safety Treatment Agreement

✦ The goal of this treatment is safety above all!

✦ I will try my very hardest to recover, including reading session materials, completing commitments between
sessions, and reaching out for all help available to me.
✦ I am always welcome back, even if I relapse.
✦ The more I put into treatment, the more I’ll get out of it.
✦ I understand that I may feel worse before I feel better, but that I should stick with treatment no matter what.
✦ Everything said in treatment will be kept strictly confidential. I am aware, however, that there are certain le-
gal conditions where the therapist is obligated to release records: (1) if I am in serious danger of harming my-
self or others; (2) if child or elder abuse becomes known; or (3) if a court subpoenas the therapist’s records.
✦ I will strive to be totally honest with the therapist about my substance use, my safety (including self-harm,
suicidal impulses, and danger to others), and any negative reactions I have to the treatment or the therapist.
✦ I will be on time for sessions, and will leave a message if I need to cancel.
✦ If I arrive to a session intoxicated or high, the session will not be held. I will be escorted to a safe place (e.g.,
emergency room) until I can return home, or will be sent home with a friend or in a taxi.
✦ In an emergency, I will follow the written emergency instructions I have been given.
✦ Buying, selling, or using substances with another patient, or alone anywhere in or near this treatment office
is a serious danger, and may lead to termination from this treatment.
✦ Urinalysis and/or breathalyzer testing o will o will not be conducted as part of this treatment. If conducted,
it will be conducted as follows:

FOR GROUP TREATMENT ONLY

✦ I will not discuss details of trauma or substance use, to avoid upsetting other patients.
✦ I will strive to create an atmosphere of mutual respect (e.g., no interrupting others, no physical contact be-
tween group members).
✦ Contact with group members outside of sessions is discouraged unless it is reviewed with the therapist in ad-
vance, to protect patients’ boundaries.
✦ To help everyone feel safe, it is essential that nothing a patient says in session is ever repeated to anyone out-
side of the group.

The therapist, in return, agrees to conduct the highest-quality treatment possible,

with respect and care, to help promote your recovery.

Patient signature Therapist signature Date

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

93
COMBINATION

Safety

SUMMARY

Safety is described as the first stage of healing from both PTSD and substance abuse, and the
foremost guiding principle throughout this treatment. A list of over 80 Safe Coping Skills is
provided, and patients explore what safety means to them.

ORIENTATION

“I would like to learn the difference between feeling safe and unsafe. I know the difference
in my head but not in my heart. I’m always scared.”

Descriptions of both PTSD recovery (Herman, 1992) and substance abuse recovery
(Kaufman, 1989; Kaufman & Reoux, 1988) are remarkably similar in identifying the first stage
of treatment as the establishment of safety. Later stages are remembrance and mourning and
reconnection (to use Herman’s terms). For PTSD, these stages were identified as early as 1889
in Pierre Janet’s classic description of treatment for “hysteria”; Janet called the stages “stabili-
zation,” “exploration of traumatic memories,” and “personality reintegration” (van der Hart,
Brown, & van der Kolk, 1989, cited in Herman, 1992). Throughout this century, they have
been observed in various traumatized populations, including combat veterans (Scurfield,
1985), patients with complicated PTSD (Brown & Fromm, 1986), and patients with multiple
personality disorder (Chu, 1992; Putnam, 1989).
In substance abuse treatment, stage models are also widely used (Najavits & Weiss,
1994a) and parallel those in PTSD treatment. The idea that the patient must be stabilized and
attain abstinence before more in-depth “character reorganization” occurs has long been un-
derstood by professionals (Brown, 1985; Carroll et al., 1991; Kaufman, 1989; Kaufman &
Reoux, 1988) and represented by the sequence of the twelve steps in AA (Nace, 1988). The
centrality of mourning as a later phase in substance abuse treatment is summarized by Daley
(1993): “A key issue in . . . long-term recovery is working through grief. Patients who give up

94
Safety 95

alcohol or drugs . . . have also surrendered their main strategy for coping with problems,
stress, or emotional pain. They may experience the loss as a void” (pp. 29–30).
The stages described below for both PTSD and substance abuse are drawn largely from
Herman (1992) for PTSD, and Kaufman and Reoux (Kaufman, 1989; Kaufman & Reoux,
1988) for substance abuse. Safety is highlighted because it is the entire focus of this treat-
ment. In addition to the patient’s therapeutic tasks, a corresponding description of the thera-
pist’s role at each stage is provided.
After the concept of safety is introduced to patients (see Handout 1), an extensive list of
Safe Coping Skills (Handout 2) is provided to concretize how safety can be attained in day-to-
day life. It is hoped that patients can begin to internalize the extraordinary importance of
safety as the preeminent goal above all else, and can utilize the treatment sessions ahead to
implement it in action.

The Patient’s Stages

1. Safety. This is the foundation for all therapeutic work. The goals are to achieve ab-
stinence from substances, eliminate self-harm, acquire trustworthy relationships, gain
control over overwhelming symptoms, attain healthy self-care, and remove oneself from
dangerous situations (e.g., domestic abuse, unsafe sex).

2. Mourning. After achieving safety, the patient needs to delve into the past in detail and
face the extreme feelings of pain and mourning that result. This stage is marked by explora-
tion, insight, and grieving deep levels of hurt. The patient tells the story of what happened,
and in doing so transforms it from one of “shame and humiliation” into one of “dignity and
virtue” (Mollica, 1988, cited in Herman, 1992). The patient faces how trauma and substance
abuse were damaging and alienated the patient from her- or himself.
3. Reconnection. After working through mourning, the patient is emotionally able to re-
connect with joy and productive activity in the world. While never forgetting that past
trauma and substance abuse occurred, the patient can live a more fulfilling life in the present,
including stable relationships, a career, altruistic activities (which often relate directly to
trauma or substance abuse, such as volunteer work with rape victims or becoming an AA
sponsor), and a capacity to develop meaningful life goals. The patient essentially completes
the task of creating a new identity to replace the old identities of “victim” and “substance
abuser.”

The Therapist’s Stages

1. Safety. The therapist empowers the patient to regain control; helps the patient iden-
tify cues of who, what, and where are safe; teaches coping skills that may never have been
learned in childhood; assesses the extent and impact of substance abuse and develops a
plan for abstinence; closely monitors the patient’s current substance use and craving; and
provides psychoeducation about the diagnoses of PTSD and substance abuse. The thera-
pist is active and directive, but always tries to give the patient control rather than control-
96 Treatment Topics

ling the patient. The therapist seeks to understand the patient’s self-destructive behavior
as “symbolic or literal reenactments of the initial abuse” (Herman, 1992, p. 166), and to
understand the substance abuse as a disorder that holds the patient hostage.
Equally important is what the therapist does not do during this stage: offer dynamic in-
terpretations; confront defenses; focus the patient on examining the relationship between
patient and therapist; seek insight or personality change; or encourage the patient to con-
front an abuser or family members who deny the trauma.

2. Mourning. The therapist is “witness and ally” (Herman, 1992, p. 175), and guides the
patient to face the devastation inflicted by trauma and substance abuse. Treatment tech-
niques include eliciting a detailed description of the patient’s life history (connected to emo-
tional reexperiencing), insight, personality change, and exploration of underlying issues.
Therapeutic interventions that were proscribed in the safety phase (e.g., dynamic interpreta-
tions) are now useful. The patient is monitored throughout to make sure that she or he can
cope safely with the intense emotions that arise.
3. Reconnection. The therapist supports the patient’s efforts to create a new life, which
may include processing of many trial-and-error attempts at new roles and activities, explora-
tion of goals, and evaluation of possible confrontation of the abuser.

Countertransference Issues

Therapists may tend toward two extremes with regard to safety. Some therapists are ex-
tremely warm and supportive of patients and ally with their vulnerability (particularly around
their trauma history), but do not adequately “push” them to master urgent safety skills. They
may be very kind, but appear to shy away from actively rehearsing safety skills (e.g., “What
would you do if you felt like using cocaine tonight?”), or from giving constructive feedback
and direct advice that might spur the patient to greater mastery of safety (e.g., “I really be-
lieve it is dangerous for you to take a job as a stripper”). At the other extreme, some therapists
launch too quickly into in-depth emotional work rather than first assessing the patient’s grasp
of the basics of safety and teaching new safety skills (Chu, 1988; Keane, 1995). If patients are
ill equipped to cope with imminent dangers such as the intense emotions of drug and trauma
triggers, they may spiral downward.

Acknowledgments

The idea of describing therapist stages that are comparable to those of patients was suggested
by Howard Shaffer, PhD, and Joni Vanderbilt, MA. The “signs of recovery” in Handout 1 are
based in part on Harvey (1990). Some of the Safe Coping Skills (Handout 2) are from Marlatt
and Gordon (1985) (e.g., “Setbacks are not failures” and “Create ‘positive addictions’”); some
are related to AA (e.g., “Work the material” and “Go to a meeting”); “No feeling is final” is
from Rilke (1996); and many are drawn from the general lexicon of cognitive-behavioral and
relapse prevention models (e.g., Beck et al., 1985). The quotation for this topic was cited in
Marlatt and Gordon (1985, p. 15).
Safety 97

PREPARING FOR THE SESSION

♦ To understand the three stages of PTSD recovery, Herman’s (1992) Chapters 8, 9, and
10 provide an eloquent, beautiful summary. For substance abuse, the Kaufman (1989) and
Kaufman and Reoux (1988) articles may also be helpful.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 100. Link the quotation to the session—for example, “As
the quotation suggests, it is definitely possible to overcome suffering. Today we’ll focus on
safety as a way to do that.”
3. Relate the topic to patients’ lives: (in-depth, most of session).
a. Ask patients to look through the first two handouts, which can be used separately or
together. Cover them in multiple sessions if you have the time. See “Session Con-
tent” (below) and Chapter 2.
Handout 1: Safety Is the Most Important Priority Right Now!
Handout 2: Safe Coping Skills
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT

Handout 1: Safety Is the Most Important Priority Right Now!

Goals
¨ Convey the central goal of this treatment: safe coping, no matter what happens in life.
¨ Discuss safety as the first stage of recovery.
¨ Help patients explore what safety means to them.

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Help patients explore ways in which they are currently safe and un-
safe. Guide them to prioritize safety as their major task right now. Reinforce current safe cop-
ing (e.g., the “What Is Safety to You?” section of Handout 1).
ê Discussion
• “Do these stages make sense to you? Why or why not?”
• “Why do you think safety has to happen first?”
• “What does safety mean to you? For example, moving to a safer neighborhood?
Leaving a destructive relationship? Being able to sleep at night?”
98 Treatment Topics

• “Why is safety the first step for both PTSD and substance abuse?”
• “Are there any other ‘signs of recovery’ that you think are important?”

Suggestions
✦ Be sure patients understand the idea of safety. The treatment is designed to convey
one idea above all: Stay safe, no matter what happens. Help patients understand this message.
✦ Stay flexible when discussing stages. As with all stage models, the stages aren’t always
separate. Patients may find themselves moving back and forth between stages at times.

Handout 2: Safe Coping Skills

Goals
¨ Explore the list of Safe Coping Skills.
¨ Encourage patients to return to the list of Safe Coping Skills throughout the treat-
ment.

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to go through the list of Safe Coping Skills, checking off
(ü) the ones they already do and putting a star («) next to the ones they want to learn.
ê Question–answer format. This format can be useful because patients likely already
know many of the safe coping skills. After looking through the handout, you could ask pa-
tients to turn it over and then ask them to describe, for each skill that you name, either (1)
what it means; (2) how the skill could be useful to them; or (3) an example of when they used
it recently. Also, you could present hypothetical situations and ask how they might stay safe
using the coping skills: For example, “What if you have a flashback and feel like drinking?
How might you cope safely with that?”
ê Replay the scene. Ask patients to think of a time in the past week when they did not
cope successfully, focusing particularly on substance use or other high-risk behaviors. Then
have them “replay” it by describing how they could cope more safely next time, using the
Safe Coping Skills list as a guide. If you want, you can introduce the “replay” as follows:
“Imagine that you are a movie director, and you can ‘replay’ the scene to have a better end-
ing—how could you cope safely this time?” Optional: You may want to use the Safe Coping
Sheet (Handout 4 in Chapter 2), which is designed specifically for this purpose.
ê Discussion
• “When you want to use a substance, what safe coping skills could you use?”
• “Could you apply the skills to anything difficult coming up for you this week?”
• “Are there any safe coping skills you like that are not on the list?”
• “What would it feel like if you could cope safely every time life throws you a ‘curve
ball’ (difficult event)?”
• “Is there any situation that cannot be coped with safely?”
• “Where can you keep the list so you can use it whenever you need it?”
Safety 99

Suggestions
✦ This handout conveys the essence of the entire treatment program: Stay safe, no mat-
ter what. Nothing has to lead to substance use or any other self-destructive behavior. No mat-
ter what events patients face in life, they can learn to cope safely with them. Once again, be
sure patients understand this core concept.
✦ It can be helpful to convey a sense of urgency. Now is the time for patients to start cop-
ing safely; this is more important than anything else in their lives (because without safety,
they cannot recover); and they need to practice it over and over until it becomes habitual. You
may also want to convey that safe coping is what some people learn while growing up, and
that there are good reasons why patients may not have learned it (neglectful parents, over-
whelming trauma, etc.).
✦ Ask patients to carry the list with them. When they feel overwhelmed, they can pull
out the list and see if anything might help.
✦ Many of the skills are taught in more detail in later sessions, but are described briefly
in the list.

Tough Cases
∗ “I don’t want to stay safe; I want to die.”
∗ “I am safe; that’s not a problem for me.”
∗ “I need to mourn my trauma now, not wait until later.”
∗ “Some of these safe coping skills contradict each other—one says to ‘Pretend you like
yourself,’ and another is ‘Honesty.’ Which is it—lying or honesty?”
∗ “These are fine, but when I get triggered, it’s so fast that I don’t even have time to
think about what I’m doing.”
 Quotation

“Although the world is full

of suffering, it is full also
of the overcoming of it.”
—Helen Keller
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

100
HANDOUT 1 Safety

Safety Is the Most Important Priority Right Now!

This entire treatment revolves around one central idea: You need to stay safe. The good news is that you can learn to
cope safely, no matter what negative life events come your way. Nothing has to make you use substances or engage
in any other high-risk behavior.

EXAMPLES
Life situation. You lose your job; your mother criticizes you; you wake up depressed; someone offers you co-
caine; your dog dies; you dissociate; your partner gives you a hard time; you have no money; you find out you have a
tumor; you have a flashback; you can’t sleep.
Your coping. This is everything! No matter what happens in your life, you can cope safely.

Unsafe Coping versus Safe Coping

Use substances versus Ask for help
Hurt yourself (e.g., cutting, burning) versus Take good care of your body
Let someone harm you versus Set a boundary in a relationship
Act on impulse versus Rethink the situation

The goal of this treatment is to help you become more aware of how you are coping and to teach you how to cope
more safely. That’s it!

STAGES OF HEALING FROM PTSD AND SUBSTANCE ABUSE

For both PTSD and substance abuse, safety is the first stage in healing, according to a great deal of research and clin-
ical wisdom. The stages are as follows:

1. Safety. This is the phase you are in now. The goals are to free yourself from substance abuse, stay alive,
build healthy relationships, gain control over your feelings, learn to cope with day-to-day problems, protect your-
self from destructive people and situations, not hurt yourself or others, increase your functioning, and attain sta-
bility.

2. Mourning. Once you are more safe, you may need to grieve about the past—about what your trauma and
substance abuse did to you. You may need to cry deeply to get over the losses and pain you experienced: loss of in-
nocence, loss of trust, loss of time.
3. Reconnection. After letting yourself experience mourning, you will find yourself more willing and able to re-
connect with the world in joyful ways: thriving, enjoying life, able to work and relate well to others. You will get to
this stage if you can establish safety now!

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

101
HANDOUT 1 (page 2 of 3) Safety

It is important to know that you can heal from PTSD and substance abuse; many people do. It does not mean that
you forget about the past. Rather, it means that it no longer holds such destructive power over your life. (Note that
some people use the term “recovery”; others do not like to use it for PTSD, substance abuse, or both. Whatever
wording you prefer is okay.)

SIGNS OF RECOVERY
“Recovery” means that you . . .

∗ Can talk about the trauma without feeling either very upset or numb.
∗ Can function well in daily life (such as holding a job).
∗ Are safe (e.g., not suicidal or abusing substances).
∗ Are able to be in healthy relationships without feeling completely vulnerable or isolated.
∗ Are able to take pleasure in life.
∗ Take good care of your body (e.g., eating, sleeping, exercising).
∗ Can rely on yourself and others.
∗ Can control your most overwhelming symptoms.
∗ Believe that you deserve to take good care of yourself.
∗ Have confidence that you can protect yourself.

WHAT IS SAFETY TO YOU?

Describe what safety means to you. Write out who you feel safe with, what activities you feel safe doing, and where
you feel safe. You might also want to describe in detail a safe place that helps you feel calm and connected, such as
a room, the beach, your therapist’s office, or another place that brings you back to a feeling of inner peace. You can
add drawings, quotations, or anything else that you like, to better express what safety is for you. Continue on the
back of this page if you need more space.

102
HANDOUT 2 Safety

Safe Coping Skills

Ask for help Reach out to someone safe

Inspire yourself Carry something positive (e.g., poem), or negative (e.g., photo of friend who overdosed)

Leave a bad scene When things go wrong, get out

Persist Never, never, never, never, never, never, never, never give up

Honesty Secrets and lying are at the core of PTSD and substance abuse; honesty heals them

Cry Let yourself cry; it will not last forever

Choose self-respect Choose whatever will make you like yourself tomorrow

Take good care of your body Healthy eating, exercise, safe sex

List your options In any situation, you have choices

Create meaning Remind yourself what you are living for: your children? love? truth? justice? God?

Do the best you can with what you have Make the most of available opportunities

Set a boundary Say “no” to protect yourself

Compassion Listen to yourself with respect and care

When in doubt, do what’s hardest The most difficult path is invariably the right one

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

103
HANDOUT 2 (page 2 of 6) Safety

Talk yourself through it Self-talk helps in difficult times

Imagine Create a mental picture that helps you to feel different (e.g., remember a safe place)

Notice the choice point In slow motion, notice the exact moment when you chose a substance

Pace yourself If overwhelmed, go slower; if stagnant, go faster

Stay safe Do whatever you need to do to put your safety above all

Seek understanding, not blame Listen to your behavior; blaming prevents growth

If one way doesn’t work, try another As if in a maze, turn a corner and try a new path

Link PTSD and substance abuse Recognize substances as an attempt to self-medicate

Alone is better than a bad relationship If only treaters are safe for now, that’s okay

Create a new story You are the author of your life: be the hero who overcomes adversity

Avoid avoidable suffering Prevent bad situations in advance

Ask others Ask others if your belief is accurate

Get organized You’ll feel more in control with “to-do” lists and a clean house

Watch for danger signs Face a problem before it becomes huge; notice red flags

Healing above all Focus on what matters

(cont.)

104
HANDOUT 2 (page 3 of 6) Safety

Try something, anything A good plan today is better than a perfect one tomorrow

Discovery Find out whether your assumption is true, rather than staying “in your head”

Attend treatment AA, self-help, therapy, medications, groups—anything that keeps you going

Create a buffer Put something between you and danger (e.g., time, distance)

Say what you really think You’ll feel closer to others (but only do this with safe people)

Listen to your needs No more neglect—really hear what you need

Move toward your opposite For example, if you are too dependent, try being more independent

Replay the scene Review a negative event: What can you do differently next time?

Notice the cost What is the price of substance abuse in your life?

Structure your day A productive schedule keeps you on track and connected to the world

Set an action plan Be specific, set a deadline, and let others know about it

Protect yourself Put up a shield against destructive people, bad environments, and substances

Soothing talk Talk to yourself very gently (as if to a friend or small child)

Think of the consequences Really see the impact for tomorrow, next week, next year

Trust the process Just keep moving forward; the only way out is through

(cont.)

105
HANDOUT 2 (page 4 of 6) Safety

Work the material The more you practice and participate, the quicker the healing

Integrate the split self Accept all sides of yourself; they are there for a reason

Expect growth to feel uncomfortable If it feels awkward or difficult, you’re doing it right

Replace destructive activities Eat candy instead of getting high

Pretend you like yourself See how different the day feels

Focus on now Do what you can to make today better; don’t get overwhelmed by the past or future

Praise yourself Notice what you did right; this is the most powerful method of growth

Observe repeating patterns Try to notice and understand your reenactments

Self-nurture Do something that you enjoy (e.g., take a walk, see a movie)

Practice delay If you can’t totally prevent a self-destructive act, at least delay it as long as possible

Let go of destructive relationships If it can’t be fixed, detach

Take responsibility Take an active, not a passive approach

Set a deadline Make it happen by setting a date

Make a commitment Promise yourself to do what’s right to help your recovery

Rethink Think in a way that helps you feel better

(cont.)

106
HANDOUT 2 (page 5 of 6) Safety

Detach from emotional pain (grounding) Distract, walk away, change the channel

Learn from experience Seek wisdom that can help you next time

Solve the problem Don’t take it personally when things go wrong—try just to seek a solution

Use kinder language Make your language less harsh

Examine the evidence Evaluate both sides of the picture

Plan it out Take the time to think ahead—it’s the opposite of impulsivity

Identify the belief Examples: shoulds, deprivation reasoning

Reward yourself Find a healthy way to celebrate anything you do right

Create new “tapes” Literally! Take a tape recorder and record a new way of thinking to play back

Find rules to live by Remember a phrase that works for you (e.g., “Stay real”)

Setbacks are not failures A setback is just a setback, nothing more

Tolerate the feeling “No feeling is final”; just get through it safely

Actions first, and feelings will follow Don’t wait until you feel motivated; just start now

Create positive addictions Examples: sports, hobbies, AA . . .

When in doubt, don’t If you suspect danger, stay away

(cont.)

107
HANDOUT 2 (page 6 of 6) Safety

Fight the trigger Take an active approach to protect yourself

Notice the source Before you accept criticism or advice, notice who’s telling it to you

Make a decision If you’re stuck, try choosing the best solution you can right now; don’t wait

Do the right thing Do what you know will help you, even if you don’t feel like it

Go to a meeting Feet first; just get there and let the rest happen

Protect your body from HIV This is truly a life-or-death issue

Prioritize healing Make healing your most urgent and important goal, above all else

Reach for community resources Lean on them! They can be a source of great support

Get others to support your recovery Tell people what you need

Notice what you can control List the aspects of your life you do control (e.g., job, friends . . . )

Acknowledgments: The “signs of recovery” in Handout 1 are based in part on Harvey (1990). Some of the safe coping skills in Handout 2 are from
Marlatt and Gordon (1985) (e.g., “Setbacks are not failures” and “Create positive addictions”); some are related to AA (e.g., “Work the material”
and “Go to a meeting”); “No feeling is final” is from Rilke (1996); and many are drawn from professional books and articles on cognitive-
behavioral therapy and relapse prevention. Ask your therapist for guidance if you would like to locate any of these sources.

108
 Safety

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Go through the list of Safe Coping Skills, checking off (ü) the ones you already do, and putting a
star («) next to the ones you want to learn.
ª Option 2: Start keeping a “journal of successes” (times that you coped safely, obstacles overcome, successes
in resisting substance use, coping skills that you used).
ª Option 3: Create an “inspiration book” or “inspiration box” to inspire you to stay safe (including photographs
of people you love, songs, poems, quotations, news clippings, etc.).
ª Option 4: Fold the list of Safe Coping Skills in half down the middle. Read the names of the skills on the left
side and try to remember what each one means. Give yourself 1 point for each correct answer.
ª Option 5: Write a paragraph on what “safety” means to you.
ª Option 6: Try using one new skill this week from the list of Safe Coping Skills and write how it went.
ª Option 7: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation I got laid off from work. I got laid off from work.
« Your Coping « I feel like I can’t cope— Say to myself, “If I stay
this is the last straw. I safe, I can try to cope with
don’t know what to do. I this.” I can:
have money problems already,
• Call my brother to talk
and this will put me under.
about it.
I got high.
• Talk to my counselor about
how to get a new job.
• Go to an AA meeting and be
around people.
Consequence Felt out of control, felt Able to stay safe without
like a failure. getting high; felt okay.
Even though I’m still out of
a job, I feel proud of
having not buckled under the
stress.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

109
COGNITIVE

PTSD: Taking Back Your Power

SUMMARY

Four handouts are offered to help patients understand PTSD: (1) What Is PTSD?; (2) The
Link between PTSD and Substance Abuse; (3) Using Compassion to Take Back Your Power;
and (4) Long-Term PTSD Problems. In each of these, the goal is to provide information as
well as a compassionate understanding of the disorder (the key to “taking back your power”).
They can be used alone or in combination, depending on patients’ needs and available time.

ORIENTATION

“For so long I didn’t know what was going on. So many diagnoses. I never felt I fit those
categories, but this feels right.”

“I’m amazed—finding out about PTSD has given me a motivation for finally getting clean.
I used to be able to stop drugging for a little while, but then, since I didn’t know what was
going on with me, I would just go back to drugs. Now that I know that I suffer from PTSD,
it’s given me a good reason not to use. All I ever needed was a good reason.”

Patients will enter the treatment with various levels of knowledge about PTSD, with some ig-
norant of what the letters “PTSD” even stand for and others highly knowledgeable about the
disorder. In addition to conveying new information, an implicit function of the discussion is to
empathize with patients’ experience of PTSD, and, in group treatment, to establish a bond
with other survivors as all sharing a traumatic past. Naming symptoms of the disorder fights
the inclination to deny or minimize their experience. The impulse to disavow trauma is not
just as a personal issue, but historically also a societal one (Herman, 1992), and one that pa-
tients may have encountered in family, friends, or authorities who ignored the trauma or pun-
ished them for talking about it.

110
PTSD: Taking Back Your Power 111

For many patients, understanding their substance abuse in light of their PTSD may be
one of the most crucial steps in their recovery. Many patients have said that even after years
in AA or other treatments, it was only when they were guided to directly connect the rela-
tionship between the two disorders that they finally understood a more benign view of their
substance abuse. Substance abuse, like trauma, can be rife with self-blame, societal blame,
and countertransference (e.g., “low life,” “lazy,” and “stupid”; Imhof et al., 1983).
PTSD and substance abuse are, by definition, disorders of powerlessness. In PTSD, a
terrible event occurred that the patient neither chose nor wanted. In substance abuse, the pa-
tient has lost control over intake of substances. In today’s topic, the goal is to help patients
begin to regain their sense of power by efforts such as:

 Naming the symptoms of PTSD and understanding that they are a “normal reaction to
abnormal events.”
 Understanding that substance abuse makes sense in light of PTSD.
 Exploring strengths that may have arisen from adversity.
 Encouraging them to view their symptoms with the highest compassion.
 Helping them see that they are not alone (i.e., the dual diagnosis of PTSD and sub-
stance abuse is very common).

Notice that this topic is labeled “cognitive.” Although the term “cognitive” is never for-
mally used, the material is designed to help patients acquire a new understanding of their
problems. Thus, when discussing PTSD and substance abuse, the emphasis is on helping pa-
tients understand that they are not crazy or weak for having such symptoms; rather, the symp-
toms make sense in relation to their terrible life experiences. This does not mean “excusing”
the substance abuse (indeed, a primary goal of the treatment is to eliminate all substance
use). It also does not mean that their symptoms are positive or desirable—no one wants to be
burdened with these disorders. Rather, it is the simple message that symptoms can be seen as
methods of survival that were needed to manage overwhelming feelings. By ascribing this
meaning to their suffering, it is hoped that they can move on to acquire healthier coping strat-
egies now. Each symptom can thus be interpreted with compassion rather than self-blame:
for example, PTSD dissociation can be viewed as the mind’s natural response when it is se-
verely overwhelmed, rather than as “crazy.” Through this shift in understanding, the power of
the cognitive model can be experienced—not in a dry, intellectual sense, but felt deeply.
Such rethinking can move patients to a more motivated stance from which to tackle their
problems, rather than the discouragement that can sometimes accompany just a listing of
symptoms. You are giving them a tool—compassion—that gives them power. Keep the tone
empathic, but optimistic.

Countertransference Issues
The issue of countertransference in PTSD is a major topic. Herman (1992), for example, has
described how therapists may unwittingly reenact the roles inherent in trauma: those of by-
stander (watching a patient being harmed and not intervening, such as allowing a patient in
112 Treatment Topics

group therapy to be scapegoated), victim (allowing the patient to intimidate the therapist), or
perpetrator (becoming angry and abusive toward the patient). Alternately, therapists some-
times feel so identified with patients’ pain that they become excessively “easy”—trying to
make up for their suffering by simply praising them, unable to hold them accountable to the
work necessary in recovery (see Chapter 2 on this point). Vicarious traumatization, in which
the therapist feels traumatized by hearing so much painful material, is also a concern
(Pearlman & Saakvitne, 1995).

Acknowledgments
This topic draws heavily on Herman (1992). Handouts 1 and 2, What Is PTSD? and The Link
between PTSD and Substance Abuse, draw from a multitude of sources: the American Psy-
chiatric Association (1994); Brown et al. (1995); Kessler et al. (1995); Najavits et al. (1998c);
Ouimette, Brown, and Najavits (1998); and Triffleman (1998). Handout 4, Long-Term PTSD
Problems, is drawn in part from Herman (1992) and from Elliott and Briere (1990).

PREPARING FOR THE SESSION

♦ If PTSD treatment is new to you, read some key books on the topic (e.g., Herman,
1992; Janoff-Bulman, 1992) and seek supervision.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 117. Link the quotation to the session—for example, “As
the quotation suggests, it is not your fault that you suffered terrible experiences. But, there is
a lot you can do to make your life better now.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Note that each handout is its own subtopic. See “Session Content” (below)
and Chapter 2 for how to choose from this large number of handouts, depending
on patients’ needs and your time frame. Cover them in multiple sessions if you
have the time.
Handout 1: What Is PTSD?
Handout 2: The Link between PTSD and Substance Abuse
Handout 3: Using Compassion to Take Back Your Power
Handout 4: Long-Term PTSD Problems (see clinical warning about this handout
in “Session Content”)
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
4. Check-out (briefly). See Chapter 2.
PTSD: Taking Back Your Power 113

SESSION CONTENT

This topic has many handouts, which cannot all be covered in one session. It was designed
to allow the therapist maximal flexibility on one of the essential topics of the treatment—
PTSD—for which patients may vary in their needs. It is suggested that patients be given
all the handouts; then, during the session, select subtopics on which to focus (based on
patients’ preference or your knowledge of them). See the section “Relate the Topic to
Patients’ Lives” in Chapter 2 for suggestions on deciding which handouts to cover. Patients
can read the rest of the handouts on their own, or you may want to come back to them at
future sessions.

Handout 1: What is PTSD?

Goal
¨ Define PTSD.

Ways to Relate the Material to Patients’ Lives

ê Question–answer format. Ask the patients questions to see what they do and do not
know. It is one of the best ways to introduce the topic, and can be done before having them
look at the handout. It is particularly useful in group treatment as a way to engage the group.
For example, you can ask, “Does anyone know what PTSD is?”, “Does anyone know what the
letters ‘PTSD’ stand for?”, “What are the main symptoms of PTSD?”
ê Discussion
• “What PTSD symptoms most bother you?”
• “What does it mean to say that PTSD is a ‘normal reaction to abnormal events’ ”?
• “What coping strategies work best for your PTSD?”

Suggestions
✦ Skip this handout for patients who are already highly knowledgeable about PTSD.
✦ Make sure patients understand the connection between their trauma and PTSD symp-
toms. Some patients have interpreted PTSD to mean “feeling stressed out.” Indeed, through-
out the treatment, you may want to use the term “trauma” or “childhood abuse” if you find
that more helpful or clear for patients. This can also be done for patients who do not meet full
criteria for PTSD, but have a trauma history.
✦ Consider asking patients to share, briefly, what their trauma was. If a patient
chooses not to, do not require it, but some patients like to disclose a little about their back-
ground. In group treatment, this can help patients feel more connected to each other.
However, it also requires careful monitoring to make sure patients do not trigger each
other. If triggering appears to be happening, the therapist can reestablish safety in the
group by redirecting the patient. The therapist can explain that such material is very im-
114 Treatment Topics

portant, but may upset others in the group, and thus needs to be discussed primarily in
one’s individual therapy. See also the section “Treatment Guidelines” in Chapter 2 for sug-
gestions on discussion of trauma.
✦ In addition to education about PTSD, the goal is to help patients feel validated. This
includes ideas such as “The trauma is not your fault” and “Your symptoms are not ‘crazy,’ ” as
well as generally conveying respect for patients’ symptoms in light of their experience.
✦ Allow patients to decide what was traumatic for them. Some patients may feel that
their race or ethnic identity as a minority is traumatic; others may feel that a divorce was trau-
matic. While you may want to mention the technical definition of “trauma” (which involves
the threat, witnessing, or experience of actual physical harm), this is less important than hon-
oring patients’ experiences. Conversely, if a patient went through an event that meets the def-
inition of “trauma” but does not feel upset by it, do not insist that it must be painful; indeed,
remember that most trauma does not result in PTSD (Kessler et al., 1995).

Handout 2: The Link between PTSD and Substance Abuse

Goal
¨ Explore the relationship between PTSD and substance abuse.

Ways to Relate the Material to Patients’ Lives

ê Review key points. Ask patients to summarize the main points of the handout—for ex-
ample, “What do you think the handout is trying to convey?”
ê Discussion
• “How are PTSD and substance abuse related for you?”
• “Was using substances a way for you to cope with your PTSD?”
• “How does it feel to see the connection between the two disorders?”
• “Can linking your PTSD and substance abuse help your recovery?”

Suggestions
✦It is less important for patients to learn facts about PTSD and substance abuse than to
relate the material to their own experience. Thus, keep the discussion personal and focused
on patterns that patients notice in themselves.
✦ See the topic When Substances Control You for additional handouts and issues re-
lated to the link between PTSD and substance abuse.

Handout 3: Using Compassion to Take Back Your Power

Goal
¨ Help patients “take back their power” by viewing PTSD and substance abuse with
compassion.
PTSD: Taking Back Your Power 115

Ways to Relate the Material to Patients’ Lives

ê Rehearsal. Ask a patient to identify a specific situation in which compassion might
help; then have the patient practice it out loud. For example, ask, “The last time you were an-
gry with yourself for having PTSD problems, how might you have talked to yourself in a com-
passionate way?”
ê Discussion
• “How might compassion for your PTSD and substance abuse help your recovery?”
• “How does self-blame for your PTSD or substance abuse drag you down?”
• “Can you think of any ways that the PTSD and substance abuse symptoms were
ways of coping for you? Do you think you can learn to cope safely now, without sub-
stances?”

Suggestions
✦ Whenever possible, have patients rehearse how compassion sounds out loud, rather
than talking about it abstractly.
✦ Note that PTSD and substance abuse symptoms should not be interpreted as “posi-
tive” in the present. For example, one therapist said to a patient, “That’s great that you
dissociate—it gives you time to yourself!” In fact, no one wants to have these symptoms. The
compassionate view is that the symptoms served a functional role—helping the patient
survive—but that the goal now is to find ways to cope safely to reduce both PTSD and
substance abuse. Some therapists have difficulty coming up with ways that patients can rein-
terpret symptoms with compassion, and inadvertently give a confusing message that their
symptoms are “just fine.” Try to think out your responses ahead of time.
✦ Be aware that compassion may feel impossible at this point, or may stir up negative
feelings. If a patient cannot be compassionate, you can try to help, but you don’t need to force
it. Perhaps just emphasize that it gets easier over time if one keeps working at it.
✦ The basic idea is that when patients are kind to themselves, they will have more moti-
vation and energy to take care of themselves. Recovery is hard work, and one way to make it
happen is to keep encouraging oneself by being very understanding. It may help to draw an
analogy with teaching children: “If you were teaching children to take care of themselves,
would you be kind or yell at them?”

Handout 4: Long-Term PTSD Problems

Goal
¨ Help patients understand the long-term impact of severe trauma.

Clinical Warning
In testing this treatment, it was found that while most patients benefited from reading Hand-
out 4, occasionally someone became upset when reading it (triggered to use substances, de-
moralized at seeing so many problems). Give patients a choice of whether or not to read it,
116 Treatment Topics

and if anyone becomes upset, stop the reading, validate feelings, and redirect to safe topics.
This handout can be easily omitted if necessary.

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to check off the problems they have.
ê Discussion
• “How does it feel to understand these problems as part of your PTSD?”
• “Which PTSD problems do you most want to work on in this treatment?”
• “How are these problems understandable reactions to trauma?”

Suggestions
✦ This handout is particularly relevant for victims of chronic childhood abuse. The
symptoms described in the handout are related to the diagnosis of “DESNOS,” or “disorders
of extreme stress not otherwise specified.” This diagnosis has been suggested as more accu-
rate for victims of severe child abuse than the standard PTSD diagnosis in DSM-IV (Herman,
1992).
✦ Emphasize that these problems can get better. No matter how long-standing they may
be, all can be changed and improved.

Tough Cases
∗ “I’ll never recover from PTSD.”
∗ “I can’t talk to myself compassionately; I hate myself too much.”
∗ “Reading about PTSD makes me want to burn myself.”
∗ “Substances help me deal with my PTSD.”
∗ “How is compassion going to stop me from using crack?”
 Quotation

“You are not responsible for being

down, but you are responsible
for getting up.”
—Jesse Jackson
(20th-century American political leader)

From Seeking Safety by Lisa M. Najavits (2002).

117
HANDOUT 1 PTSD: Taking Back Your Power

What Is PTSD?

PTSD stands for “posttraumatic stress disorder”—a set of emotional problems that can occur after someone has
experienced a terrible, stressful life event.
PTSD means: “post traumatic stress disorder”
↓ ↓ ↓ ↓
“after” “trauma” “anxiety” “reaction”
« Do you have PTSD? Check off (ü) those below that are true for you.

1. You survived a trauma: an event outside of your control in which you experienced or witnessed a physical threat
(e.g., sexual abuse, physical abuse, war combat, seeing someone killed, surviving a hurricane, a car accident).
2. Your response to the trauma involved intense helplessness, fear, or horror (or, if you were a child at the time,
agitated or disorganized behavior).
3. After the trauma, you suffered each of the following problems for over a month:
ª INTRUSION: The trauma comes back into mind even when you don’t want it to, as in nightmares,
flashbacks, or images.
ª AVOIDANCE: Numbing, feeling detached, avoiding any reminders of the trauma.
ª AROUSAL: Feeling “hyped up” (e.g., easily startled, sleep problems, anger).
ª LOWER FUNCTIONING: Problems with relationships, work, or other major areas of life.
Note: You have PTSD if you checked off all of the items above.

TYPES OF PTSD
There are two types of PTSD. “Simple PTSD” is from a single incident (such as a car accident or a tornado), usually as
an adult. “Complex PTSD” is from repeated incidents such as domestic violence or ongoing childhood abuse. It has a
broader range of symptoms, including problems with self-harm, suicide, dissociation (“losing time”), relationships,
memory, sexuality, health, anger, shame, guilt, numbness, loss of faith and trust, and feeling damaged.

MORE ABOUT PTSD . . .

* Your PTSD symptoms are normal after what you have been through. You are not crazy, weak, or bad!
That is why PTSD has been called “a normal reaction to abnormal events.”
* PTSD is considered an anxiety disorder because it is marked by an overwhelming feeling of anxiety during
or after the trauma. It is a psychiatric illness, but it is definitely possible to heal from it.
* Rates of PTSD: 61% of men experience trauma during their lives, with 5% developing PTSD; for women,
51% experience trauma, and 10% develop PTSD. Why do some people develop PTSD after trauma and others don’t?
This is not fully known, but some risk factors include more severe, repeated, and/or early trauma; poverty; parents
who had PTSD; and life stress.
* Knowledge about PTSD is relatively recent. It was first studied in soldiers who experienced combat. Later,
it came to be understood in a wide variety of terrible life events (e.g., sexual and physical abuse, natural disasters).
PTSD was added to the official list of psychiatric disorders only in 1980. More is being learned all the time because it
is so important.
* It is possible to heal from severe trauma. Some famous people who have include Oprah Winfrey (TV per-
sonality), Melanie Griffith (actress), and Maya Angelou (writer).

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).
HANDOUT 2 PTSD: Taking Back Your Power

The Link between PTSD and Substance Abuse

PTSD and substance abuse are closely connected for many people, yet this link often goes unrecognized. Below is
some information that may be helpful to you.
u You are not alone! For people with substance abuse, PTSD is one of the most common dual diagnoses.
Among women in treatment for substance abuse, 30%–59% have current PTSD. Among men in substance abuse
treatment, 11%–38% have current PTSD.
u There are many reasons why people with PTSD abuse substances: to access feelings or memories, or
the opposite—to escape from feelings or memories; to get through the day; to compensate for the pain of PTSD; to
commit “slow suicide”; because they grew up with substance abuse in the family; because they don’t care about tak-
ing care of their bodies.
u People with PTSD and substance abuse tend to abuse the most dangerous substances: cocaine and
opiates.
u Gender differences: Women with PTSD and substance abuse typically experienced childhood physical and/
or sexual abuse; men with both disorders typically experienced crime victimization or war trauma.
u Two main themes of both disorders are secrecy and control. “Secrecy” means you may feel ashamed
and wish to keep your problems a secret (e.g., the traumas you experienced, the amount of your substance use).
“Control” refers to the idea that with trauma and substance abuse, you feel out of control. In PTSD, a terrible event
occurred that you neither chose nor wanted; in substance abuse, you have lost control over your ability to stop using.
Learning the skills of honesty and regaining control are thus important for healing.
u Each of the disorders makes the other more likely. If you have PTSD, you are at increased risk for sub-
stance abuse. If you have substance abuse, you are at increased risk for trauma. It is thus important to try to keep
yourself safe to prevent further trauma and substance abuse.
u The relationship between PTSD and substance abuse is complex. Using substances can either increase
or decrease the PTSD symptoms. Yet abstinence from substances can also either increase or decrease the PTSD symp-
toms. Try to notice the patterns that occur for you. Getting to know the relationship between the two disorders in
your life can help you cope better with the recovery process.
u Why do PTSD and substance abuse occur together? Four patterns are common:
1. PTSD can lead to substance abuse. To overcome the terrible symptoms of PTSD, you may use sub-
stances to “self-medicate”—to try to feel better. For example, you may have begun using alcohol to get to
sleep at night.
2. Substance abuse can lead to PTSD. If you abuse substances, you may be vulnerable to dangerous
traumatic situations because your “guard is down” or your self-esteem is low—for example, getting drunk at
a bar and going home with a stranger who assaults you.
3. PTSD and substance abuse may have both occurred together. Some people grew up in a home
where family members abused substances and also hurt each other.
4. PTSD and substance abuse can be connected in a “downward spiral.” PTSD can lead you to use sub-
stances; by using substances, you are at increased risk for more trauma; if more trauma happens, you may
use more substances to “cope” . . . and so on.
The “big picture” priorities in this treatment:
« Eliminate substance use « Learn to manage PTSD « Become safe
You can heal from both PTSD and substance abuse!

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

119
HANDOUT 3 PTSD: Taking Back Your Power

Using Compassion to Take Back Your Power

Having compassion for your PTSD and substance abuse is a way to “take back your power.” One of the
most troubling aspects of PTSD and substance abuse is that you feel powerless over them—they are controlling you
rather than you controlling them. “Compassion” means accepting and respecting yourself. The opposite of compas-
sion is harshness. Rather than blaming yourself, the goal is to understand and really listen to yourself at a deep level.
This can make it easier to heal from PTSD and substance abuse.
Compassion may feel very difficult to do. It is easier to “beat yourself up” and hate yourself, especially if you
grew up in a family where this is how you were treated. With PTSD and substance abuse, you may view yourself as
sick, damaged, weak, crazy, bad, or lazy. There may be people in your life who view you in those ways too. However,
it is helpful to understand your PTSD and substance abuse as attempts to survive and cope. It has been said that
“these symptoms simultaneously conceal and reveal their origins; they speak in disguised language of secrets too ter-
rible for words” (Herman, 1992, p. 96).
This does not mean that the PTSD and substance abuse should continue. Indeed, the major goal of this
treatment is to help you overcome PTSD and substance abuse by learning safe ways of coping. But it helps to under-
stand your PTSD and substance abuse as signs of distress. It is like having a fever when you are ill—it tells you that
you need to get help and take good care of yourself.

COMPASSION FOR YOUR PTSD

PTSD can be understood as an attempt by your mind and body to survive overwhelming trauma. PTSD
symptoms may have helped you to “tune out” the terrible trauma . . . protect yourself from further harm . . . feel
more in control of an uncontrollable situation . . . feel safer . . . adapt to your environment . . . get people to notice
your pain.

Examples of Viewing PTSD Symptoms with Compassion

Suicidal thinking
Harsh view: “I’m hopeless. What’s wrong with me? I should just get over it already.”
Compassionate view: “It’s my way to feel more in control, by choosing life or death. In therapy I can learn other
ways to feel control, but suicidal thoughts make sense after what I’ve lived through.”

Relationship problems
Harsh view: “I’m unlovable. I deserved what happened to me. I’m a bad person.”
Compassionate view: “I learned not to trust people, and that helped me survive. I can keep working on relation-
ship issues, but I need to be respectful of myself and why I have these problems.”
« Write a harsh versus compassionate view of your PTSD. (Continue on back for more space.)
Harsh view:

Compassionate view:

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

120
HANDOUT 3 (page 2 of 2) PTSD: Taking Back Your Power

COMPASSION FOR YOUR SUBSTANCE ABUSE

Substance abuse can be understood as a misguided attempt to cope with PTSD and other problems.
Using substances may have been a way to numb the pain . . . get to sleep . . . escape negative feelings . . . forget
about the past . . . get through the day . . . access feelings or memories that you know are there . . . try to feel
normal . . . show people how bad you feel because you can’t put it into words . . . compensate for your suffering
. . . give you some pleasure in life . . . feel in control . . . feel accepted by people . . . get rid of dissociation and
flashbacks.
Viewing your substance abuse with compassion does not mean “It’s okay to use, or “If I use, I can ex-
cuse myself because I was trying to numb the pain.” A major goal of this treatment is to eliminate all substance use.
If you truly view your substance abuse with compassion, you will strive to eliminate it completely because you will see
that, in the long run, it brings you only misery and dysfunction. Although it may sometimes work in the short run to
“self-medicate” problems, it never works in the long run.

Examples of Viewing Substance Abuse with Compassion

Can’t stop using substances

Harsh view: “I’m such a failure. Look what I turned into—I have no self-control; what a wreck.”
Compassionate view: “My substance abuse has been a way to try to deal with my overwhelming PTSD symp-
toms. I’ve been trying to numb the pain. I now need to learn other ways to cope. Substance abuse is a medical ill-
ness, and I need help with it.”

Lying about substance use

Harsh view: “I’m a no-good liar. I lie to my partner, my kids, my doctor. I hate my life.”
Compassionate view: “I need to stop lying so I can recover. But there are real reasons why I lie about my sub-
stance abuse: shame, guilt, feeling bad about myself. I need help working on these.”
« Write a harsh versus compassionate view of your substance abuse. (Continue on back for more space.)
Harsh view:

Compassionate view:

STRENGTHS FROM ADVERSITY

Another way to view PTSD and substance abuse with compassion is to recognize the strengths you may have devel-
oped—the “gifts from suffering.” Usually, the most profound growth occurs from overcoming difficult experiences.
PTSD and substance abuse may have given you the ability to survive under tough conditions . . . imagination and cre-
ativity . . . depth . . . spirituality . . . sensitivity to others . . . awareness of the extremes in life . . . the ability to persist
despite pain and setbacks . . . appreciation for animals, children, and people outside the mainstream . . . responsive-
ness to art and nature.
« Do you notice any personal strengths from your struggles with PTSD and substance abuse? (Continue on
back for more space.)

121
HANDOUT 4 PTSD: Taking Back Your Power

Long-Term PTSD Problems

This handout is provided for people who are already knowledgeable about PTSD and want additional information
about its long-term impact. It can be upsetting to read, so ask your therapist first, and do not read this if you feel too
vulnerable right now—you can wait until later in treatment. If you begin to read it and become upset, just stop.

In addition to the standard definition of PTSD described in Handout 1, there are other problems that may occur with
PTSD, especially for people who have suffered repeated childhood abuse (Herman, 1992). You may have some and
not others.

1. Your sense of self

• Helplessness, difficulty taking initiative
• Shame, guilt, self-blame
• Sense of being damaged
• Sense of being alien (e.g., not normal, less than human)
• Altered sense of age (feeling very old or very young)

2. Distorted views of the perpetrator

• Preoccupation with one’s relationship with the perpetrator
• Belief that the perpetrator continues to have all of the power
• “Stockholm syndrome”: idealizing the perpetrator, loving him or her, feeling grateful
• Sense of a supernatural or “fated” relationship with the perpetrator
• Acceptance of the perpetrator’s ideas and beliefs

3. Your sense of meaning

• Loss of faith
• Despair
• Feeling that you don’t have a future (such as not expecting to have a career, family, or children)

4. Your relationships
• Tendency to be revictimized (difficulty protecting yourself from harmful relationships)
• Isolation
• Difficulty having close relationships (distrust, conflicts, secrets)
• Tendency to view others as rescuers, victims, or perpetrators
• Tendency to repeat problematic relationship patterns (called “reenactment”)

5. Your physical well-being

• Sleep problems
• More than average health problems
• Eating problems
• Risk for HIV/AIDS
• Substance abuse
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 4 (page 2 of 2) PTSD: Taking Back Your Power

6. Managing your feelings and behaviors

• Suicidal thinking and attempts
• Difficulty tolerating depression and anxiety
• Explosive anger, difficulty expressing anger, or both
• Problems with sexuality (compulsive involvement, inhibited sexuality, confusion)
• Alternating between feeling numb (no feelings) and out of control (too much feeling)
• Use of destructive methods to cope with feelings (substance abuse, self-harm, destruction of property)

7. Your memory and perception

• Memory problems (no memory of traumatic events, or overwhelming memories)
• Dissociation (feeling “out of it,” “losing time”); feeling as though you are not real, or that you are out-
side your body
• Reliving experiences (flashbacks, nightmares, preoccupation with the event)

8. Other emotional disorders

• Depression
• Eating disorders
• Panic disorder and other anxiety disorders
• Personality disorder

Acknowledgments: Handouts 1, 2, and 4 draw from Herman (1992), Handout 1 draws from the American Psychiatric Association (1994) and
from various professional journal articles. Ask your therapist for guidance if you would like to locate any of these sources.

123
 PTSD: Taking Back Your Power

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Pretend that a TV station wants to interview you for a documentary, “People Who Survived PTSD
and Substance Abuse,” to help inspire others. The interviewer says, “Tell me what strengths have helped you
to survive.” What would you say?
ª Option 2: How can you “take back your power”? Identify at least one PTSD or substance abuse problem you
have and how you want to conquer it.
ª Option 3: Bring to the next session something that symbolizes hope to you (perhaps a photograph of some-
one important to you, a picture of a place you want to visit, or a poem).
ª Option 4: Reread the handouts from today’s session and underline the material that makes you feel most
motivated to work on your recovery.
ª Option 5: Write a dialogue in which you talk to yourself compassionately about your PTSD and/or substance
abuse problems.

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BEHAVIORAL

Detaching From Emotional Pain

(Grounding)

SUMMARY

A powerful strategy known as “grounding” is reviewed to help patients detach from emo-
tional 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.

ORIENTATION

“October is a terrifying month for me. That’s when a major trauma happened. Remem-
bering things makes me feel dirty. When I think about October, I want to die rather than
face what it brings me. So how will I handle October this year? Well, I hope to be able to
distract and keep myself in the present.”

Grounding can be also be called “centering,” “looking outward,” “distraction,” or “healthy de-
tachment.” It is particularly powerful because it can be applied to any situation where pa-
tients are caught in emotional pain (e.g., triggered), and can be done any time, anywhere, by
oneself, without anyone else noticing it. It can also be used by a supportive friend or partner
who can guide the patient in it when the need arises. It is very commonly used for PTSD, but
can be applied to substance abuse as well. Grounding is so basic and simple that it gives even
the most impaired patients a useful strategy. Even though the method is simple, however, it
must be practiced frequently to be maximally helpful.
It is important to note that grounding is not a relaxation exercise (e.g., as in Benson’s
[1975] The Relaxation Response). Some patients with PTSD actually become more anxious
when they are guided through conventional relaxation techniques (e.g., “Close your eyes, fo-
cus on your breathing”). For patients with PTSD, closing eyes can lead to dissociation; focus-

125
126 Treatment Topics

ing on breathing, and even the word “relax,” may be triggers that remind them of sexual
abuse. Grounding is a highly active strategy that works via distraction and connection to the
external world. Patients are asked to always keep their eyes open. You are teaching patients to
notice everything they can about the world in front of them and about the present, and by do-
ing so, to recognize that right now, in the present, they are safe.
In the context of today’s topic, it may be helpful to remind patients of the need to reduce
overwhelming feelings (any negative feelings over a 6 on a 0–10 scale). By moving from a
high to a middle or low range of negative feelings, they will be more able to cope successfully.
For example, one patient talked about getting extremely angry at a cousin for saying, “Just get
over the trauma already—stop feeling sorry for yourself.” With anger at a 9 on a 0–10 scale,
the patient was able to use grounding to reduce it to a 4, and thus left the room without start-
ing a huge fight. The patient was able to feel in control and see the cousin’s harshness as “his
problem,” and did not need to use drugs to cope with it. Thus one of the best ways of manag-
ing negative feelings is to recognize that one can pace and modulate them. If they rise too
high, one can decrease them to a more manageable level. Over time, patients’ ability to face
negative feelings can increase as they learn to feel more in control of them.
During the session, the therapist leads patients in an experiential exercise of grounding
to show its impact by direct experience rather than solely by talking about it. When such an
exercise is done correctly, most patients report it to be at least somewhat helpful.

Countertransference
As with all techniques, grounding can only work if the therapist truly believes that it works. If
you read the grounding script (Therapist Sheet A) without any conviction, patients will sense
the emptiness behind the words, and it will likely fall flat. If you are not sure whether the
method works, you will need to explore it more ahead of time (e.g., in supervision, by trying it
on other patients first, or by trying it yourself).

Acknowledgments
Grounding is a mainstay of the treatment of trauma patients at McLean Hospital, and many of
the techniques were learned during the author’s training there.

PREPARING FOR THE SESSION

♦ Recommended: Bring a tape recorder and blank tape to the session to create a 10-
minute cassette tape of the grounding exercise. This can be given to the patient for practice at
home.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 132. Link the quotation to the session—for exam-
Detaching From Emotional Pain (Grounding) 127

ple, “Today we’re going to learn a very powerful yet simple method of managing emotional
pain, called ‘grounding.’ As the quotation suggests, no matter how hard a time you’re having,
it’s important to keep perspective.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handout, Using Grounding to Detach from Emo-
tional Pain.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Teach grounding as a set of simple but powerful techniques to detach from emotional
pain.
¨ Conduct an in-session experiential exercise on grounding (and, if possible, record it as
an audiotape for patients to practice at home).
¨ Explore how grounding can be applied to patients’ day-to-day problems (drug crav-
ings, etc.)

Ways to Relate the Material to Patients’ Lives

ê Conduct an in-session grounding demonstration. This is highly recommended, as it is
the best way for patients to truly see how grounding works and to directly experience what
parts of it work for them. A complete script you can use to demonstrate grounding is provided
in this topic’s Therapist Sheet. Allow enough time to conduct the exercise and explore it af-
terward (at least 35 minutes).
ê Create an audiotape for patients to practice grounding at home. This can be done by ei-
ther recording the in-session grounding demonstration, or, for individual therapy, customizing
it for the patient. Asking the patient to share the tape with a safe significant other (e.g., spouse,
AA sponsor), who can assist with grounding in time of need, may also be very helpful.
ê Discussion
• “Which of the grounding techniques do you think may work best for you?”
• “When you had an unsafe behavior in the past week, do you think grounding might
have helped?”
• “Are there any grounding techniques that you would like to add to the list?”
• “Why is it important to detach from emotional pain?”
• “When might you use grounding in the next week? For example, how would you use
grounding if you had a craving to use a substance? A flashback? Rage? A panic at-
tack?”
ê Self-exploration. Ask patients to mark the handout: “Are there any strategies that ap-
peal to you? Put a check mark next to those.” “Are there any that you already do that work for
you? Put a star next to those.” Patients can ignore strategies that don’t appeal to them.
128 Treatment Topics

ê
“Question–answer” format. You can ask questions to see whether patients have
learned grounding enough to use it effectively on their own: “Can you name three ways of
grounding?,” “How long should grounding last?,” “Why do you keep your eyes open during
grounding?,” “What if there are people around; can you still do grounding?,” “Is grounding
the same as relaxation exercises?,” “How can you know if the grounding worked?,” “If
grounding doesn’t work when you try it, what might you do to get it to work?”

Suggestions
✦ Briefly introduce the in-session demonstration so that patients will not feel disturbed
or afraid (as most topics in this treatment do not have in-session exercises such as this). For
example, say, “Today we’re going to focus on a set of simple but powerful strategies to detach
from emotional pain. It is called ‘grounding’—has anyone heard of it? I’d like to lead a brief
10-minute demonstration of grounding and then talk about how it went for you. Does that
sound okay?”
✦ Relate grounding to patients’ problems outside of sessions. Rehearse and explore how
grounding can be used for specific situations (e.g., “How can you use grounding if you feel
like drinking?,” “How can you use grounding if you feel like hurting yourself?,” etc.).
✦ Occasionally a patient may become anxious during the in-session demonstration. This
may manifest as joking, laughing, or making fun of the exercise. In an individual session, you
may want to address it by asking the patient whether the exercise is anxiety-provoking, pro-
cessing such feelings, and then getting back to the topic. In a group session, it is suggested
that the therapist gently limit such behavior or else the mood of the exercise can deteriorate.
For example, you might say, “This exercise may create anxiety for some people. Please try to
stay with the exercise, and allow others to stay with it as well. But it’s okay to step outside the
room if you don’t want to do this. We’ll have you come back in once the exercise is over in a
few minutes.”
✦ Try not to let the discussion focus heavily on what does not work. Rather, after validat-
ing that a particular grounding strategy may not work for some people, guide patients to no-
tice methods they have not yet tried, and ways to make grounding more powerful. No patient
has tried all the strategies so there is always room for new attempts even if grounding did not
work for a patient in this session (or in life thus far).
✦ Encourage patients to use any term for grounding that they prefer. For example, to
combat veteran air pilots, “grounding” can mean a crashed airplane; thus a term such as “cen-
tering” is more helpful.
✦ You may want to try having the patients access a negative feeling before starting the
grounding exercise. This can make it a more powerful exercise. See the topic Coping with
Triggers, which describes this in detail. Note, however, that this should only be done in indi-
vidual therapy rather than groups (where it could be too triggering for patients).
✦ Create a cassette tape of grounding. Record a cassette of grounding for the patient to
play at home. The grounding script (Therapist Sheet) can be used, or the therapist can cus-
tomize it to patients’ preferences. The tape can be created in the session with the therapist
and/or patient recording grounding statements. Later, the patient can also have safe family
and friends add grounding statements to the tape. Note: If making a cassette tape in a group
Detaching From Emotional Pain (Grounding) 129

session, no names should be included, for confidentiality reasons. Copy the tape and give one
to each patient at the next session.

Tough Cases
∗ “I can do grounding if you lead it, but not by myself.”
∗ “But I thought it’s important to face my feelings—not detach from them.”
∗ “By ‘detaching from pain,’ do you mean dissociation?”
∗ “Yes, it works, but I never remember to do it.”
∗ “This stuff is hokey.”
THERAPIST SHEET Detaching from Emotional Pain (Grounding)

Script for a 10-Minute In-Session Grounding Demonstration

Ask patients to rate their level of negative feelings before the exercise. “Before starting this exercise, no-
tice how you are feeling right now. If you were to rate your negative feelings on a 0–10 scale, with 10 being the
worst, how bad do you feel right now? The reason to rate feelings is to see whether grounding helps to reduce the
negative feelings; we will rerate the feelings after the exercise.” Ask each patient to state a rating, and write these
ratings down. Guide patients to give you a number, rather than to describe their feelings.
Orient patients to grounding. “Many people with PTSD find grounding very helpful. In grounding, the goal is
to turn your attention to the outside world, to shift away from the inner world of negative feelings. You can detach
and distance from emotional pain. If you notice yourself focusing on negative feelings, try to let them go, like leaves
in a fall breeze. Turn away from them, focusing your attention even stronger on the outside world. You may want to
think of this as ‘changing the channel,’ just like a television, where you can change the channel to get a different
show. Keep your eyes open the entire time and look around the room as much as you like. Remember that you are al-
ways in control. And try not to judge anything—just notice what ‘is.’ I will give you grounding instructions for about
10 minutes. We will try three types of grounding: mental grounding, physical grounding, and soothing grounding.
You can see which types work best for you. I’ll also be asking a number of simple questions.” For individual therapy:
“Please answer the questions out loud.” For group therapy: “Please answer the questions silently to yourself.”
Mental grounding. “Start by reminding yourself that you are safe. You are here in therapy, today is
(e.g., Monday), and you are at the Hospital (or clinic, etc.). Now let’s try to imagine putting a buffer be-
tween you and all of your negative feelings. Imagine that your negative feelings are bundled up and put in a con-
tainer. Next, think of something you can put between you and that container of negative feelings. Perhaps it’s a wall,
a suit of armor, or a big open field in the country—anything that creates safe distance between you and your nega-
tive feelings. Good!
“Now let’s focus on the room. Look around the room. Name as many colors as you can. Good. Now name as
many objects as you can: How many chairs are there? Are there curtains? How many windows? Look out the win-
dow—what is the weather outside? Good. Are there paintings or posters? If so, choose one and describe it, not judg-
ing it, but just describing everything you can about it: colors, shapes, content. Excellent! What color is the carpet or
floor? How many doors are there? Are the lights fluorescent or yellow? What color is the paint on the walls? Do you
see any words printed anywhere in the room (on a poster or book jacket)? If so, read each letter backward (the rea-
son we read it backward is that you just want to notice the letters themselves—as if you’re seeing these letters for the
first time). Terrific!
“Next we’ll try naming some facts. Tell me the names of cities—as many cities as you can name. Wonderful!
Now try naming all the sports teams that you can remember. How about TV shows? Name as many as you can. Now
take the number 100; subtract 5 from that and notice the new number; subtract 5 again, and notice the new num-
ber. Don’t worry if you can’t get the math—just let it go.”
Physical grounding. “Now we’re going to try physical grounding methods. Please keep following along with
me. Notice your feet on the floor. They are literally grounded, connected to the floor. Wiggle your toes inside your
shoes. Dig your heels gently into the floor to ground yourself even more. Good. Now, touch your chair: Tell me any-
thing you can about it—what material is it made of? Now touch the table (or desk): What is it made of? Is it colder or
warmer than the chair? Good. Now, find any object that’s near you—perhaps a pen, or your keys, or something here
on the desk. Pick it up and hold it, and say everything you can about it: What it’s made of, how heavy it is, whether
it’s cold or warm, what colors it is. Now clench your fists; notice the tension in your hands as you do that. Now re-
lease your fists. Good. Now press your palms together, with elbows to the side; press as tightly as you can. Focus all
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

130
THERAPIST SHEET (page 2 of 2) Detaching from Emotional Pain (Grounding)

of your attention on your palms. Now let go. Excellent! Now grab onto your chair as tightly as you can; then after a
few moments, now let it go. Finally, roll your head around in a circle a few times. Excellent.”
Soothing grounding. “Now let’s move on and try soothing grounding. Let’s start with favorites. Think of your
favorite color: What color is it? Good. Think of your favorite animal: What animal is it? Think of your favorite TV
show: What TV show is it? Excellent. Now, think of your favorite season of the year: What season is it? Now think of
your favorite time of day. What time of day is it? Think of a favorite person—it may be someone you know, or it could
be a famous person. Picture that person. Good! If you want to, think of a favorite, upbeat song, and try to remem-
ber the tune and the words.” Give patients at least a minute or so to do this.
“Now, try to think of a safe place. Still keeping your eyes open, think of a place that is very safe, soothing, and
calming for you: Maybe the beach, the mountains, a walk in the city, a favorite room, or a park? If you can’t think of
a safe place, that’s okay too—just let yourself notice this room, since we’re safe here. Good. Now, try to notice every-
thing you can about your safe place. Notice everything you love about it—the colors, the textures, the shapes; and
the safety and calm of the place. Good. You have done a terrific job.” Keep going until at least 10 minutes have been
completed.
Ask patients to rerate negative feelings after the exercise. “Now rerate your negative feelings on a 0–10
scale (10 being the most negative).” Check whether patients’ ratings have changed from their initial ratings.

EXPLORE PATIENTS’ REACTIONS TO THE GROUNDING DEMONSTRATION

Before-and-after ratings. Ask patients to notice whether their ratings changed from before to after the exer-
cise. In group therapy, you may want to summarize patients’ ratings—for example, “Most of you went down at least
a point or two. A few people went down by 4 points,” and so on.
Explore patients’ views about grounding. For example, ask, “What did you like and dislike about the
grounding? What type of grounding works best for you? How did you feel after the exercise? Were you able to focus
your attention during the exercise? Were any of the parts of the exercise a problem for you? Were any parts espe-
cially helpful for you?” Try to praise patients for any successes they had with it (e.g., “That’s good that you were able
to focus on it”). If patients are negative about it, accept this, and try to process it (see below).
Discuss how grounding can help with specific situations. For example, how can it be used when having a
drug craving? When wanting to hurt oneself or others? When feeling angry? When upset? Try to work through spe-
cific examples that patients confront from day to day.
Process negative reactions. The “check” for whether the grounding has worked is the emotion rating that is
built into the experiential exercise. Occasionally a patient’s rating does not improve. If this happens, be sure to pro-
cess it, such as by asking what the patient thinks might help make it more effective next time and by looking through
the handout for ideas. Often success is a matter of practicing longer, selecting the grounding methods that appeal to
that particular patient, or trying the advanced grounding techniques in the handout (see the section “What If
Grounding Does Not Work?”). See also the “Suggestions” in the “Session Content” for today’s topic.

131
 Quotation

“No feeling is final.”

—Rainer Maria Rilke
(20th-century German poet)

From Seeking Safety by Lisa M. Najavits (2002).

132
HANDOUT Detaching from Emotional Pain (Grounding)

Using Grounding to Detach from Emotional Pain

WHAT IS GROUNDING?

Grounding is a set of simple strategies to detach from emotional pain (e.g., 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 feeling either too much (overwhelming emotions
and memories) or too little (numbing and dissociation). In grounding, you attain a balance between the two: con-
scious of reality and able to tolerate it. Remember that pain is a feeling; it is not who you are. When you get caught
up in it, it feels like you are your pain, and that is all that exists. But it is only one part of your experience—the others
are just hidden and can be found again through grounding.

Guidelines
u Grounding can be done any time, any place, anywhere, and no one has to know.
u Use grounding when you are faced with a trigger, enraged, dissociating, having a substance craving,
or whenever your emotional pain goes above 6 (on a 0-10 scale). Grounding puts healthy distance between
you and these negative feelings.
u Keep your eyes open, scan the room, and turn the light on to stay in touch with the present.
u Rate your mood before and after grounding, to test whether it worked. Before grounding, rate your
level of emotional pain (0–10, where 10 means “extreme pain”). Then rerate it afterward. Has it gone down?
u No talking about negative feelings or journal writing—you want to distract away from negative feel-
ings, not get in touch with them.
u Stay neutral—avoid judgments of “good” and “bad.” For example, instead of “The walls are blue; I dislike
blue because it reminds me of depression,” simply say “The walls are blue” and move on.
u Focus on the present, not the past or future.
u 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 than relax-
ation training for PTSD.

WAYS OF GROUNDING
Three major ways of grounding are described below—mental, physical, and soothing. “Mental” means focusing your
mind; “physical” means focusing on your senses (e.g., touch, hearing); and “soothing” means talking to yourself in a
very kind way. You may find that one type works better for you, or all types may be helpful.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

133
HANDOUT (page 2 of 3) Detaching from Emotional Pain (Grounding)

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 col-
ors.”
— Play a “categories” game with yourself. Try to think of “types of dogs,” “jazz musicians,” “states that be-
gin with ‘A’ ,” “cars,” “TV shows,” “writers,” “sports,” “songs,” or “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; then 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 backward 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.

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, a ring, a 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.
* Clench and release your fists.
* Walk slowly, noticing each footstep, saying “left” or “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 in-
hale (e.g., a favorite color, or a soothing word such as “safe” or “easy”).

Soothing Grounding
ª Say kind statements, as if you were talking to a small child—for example, “You are a good person going
through a hard time. You’ll get through this.”
ª Think of favorites. Think of your favorite color, animal, season, food, time of day, TV show.
(cont.)

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HANDOUT (page 3 of 3) Detaching from Emotional Pain (Grounding)

ª Picture people you care about (e.g., your children), and look at photographs of them.
ª Remember the words to an inspiring song, quotation, or poem that makes you feel better (e.g., the
AA Serenity Prayer).
ª 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.
ª Say a coping statement: “I can handle this,” “This feeling will pass.”
ª Plan a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath.
ª Think of things you are looking forward to in the next week—perhaps time with a friend, going to a
movie, or going on a hike.

WHAT IF GROUNDING DOES NOT WORK?

Grounding does work! But, like any other skill, you need to practice to make it as powerful as possible. Below are
suggestions to help make it work for you.
« 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 which methods you like best—physical, mental, or soothing grounding methods, or some
combination.
« 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 a substance craving just starts or when you
have just started having a flashback. Start before anger gets out of control.
« Make up an index card on which you list your best grounding methods and how long to use them.
« Have others assist you in grounding. Teach friends or family about grounding, so that they can help
guide you with it if you become overwhelmed.
« Prepare in advance. Locate places at home, in your car, and at work where you have materials and remind-
ers for grounding.
« Create a cassette tape of a grounding message that you can play when needed. Consider asking your
therapist or someone close to you to record it if you want to hear someone else’s voice.
« Think about why grounding works. Why might it be that by focusing on the external world, you become
more aware of an inner peacefulness? Notice the methods that work for you—why might those be more powerful
for you than other methods?
« Don’t give up!

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 Detaching from Emotional Pain (Grounding)

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Practice grounding for 10 minutes or more, rating your feelings before and after (just as we did in
the session).

ª Option 2: Reread the handout, circling the methods that you most want to try.

ª Option 3: Find something to carry with you that helps you feel grounded (e.g., a small, beautiful rock; a pic-
ture of someone you love; an AA chip you earned). Keep it in a place that you can access at any time, such
as in your pocket or wallet, or on your key chain.

ª Option 4: Fill out the Safe Coping Sheet.

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation Having a flashback. Having a flashback.

« Your Coping « I got stuck in it; it was I can try to cope with a
awful. I tried to drown my flashback by doing grounding.
feelings in three gin-and- These are the ways that I
tonics. think would work for me:
1. Run my hands under cool
water.
2. Try to remember every
major Red Sox player from
the 1970s.
3. Turn on some music—loud,
to drown out the flashback.
Consequence I just feel like I have no The intensity goes down—not
control over my feelings. I completely away, but down
can’t stop myself from enough so that I don’t feel
drinking when I get like I have to drink.
overwhelmed.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

136
COGNITIVE

When Substances Control You

SUMMARY

This topic offers eight handouts on substance abuse that can be combined or used separately:
(1) What Is Substance Abuse? (2) How Substance Abuse Prevents Healing from PTSD; (3)
Choose a Way to Give Up Substances; (4) Climbing Mount Recovery (an imaginative exercise
to prepare realistically for giving up substances); (5) Mixed Feelings; (6) Self-Understanding
of Substance Use; (7) Self-Help Groups; and (8) Substance Abuse and PTSD: Common Ques-
tions.

ORIENTATION

“Drinking takes care of the young side of me that needs soothing.”

“I might as well shoot up because I don’t matter anyway.”

“A couple of beers makes me feel more normal.”

Substance abuse is the central focus of this treatment, beyond all other goals, because it end-
lessly keeps patients “down”—stuck in PTSD symptoms (they do not learn to manage and
face feelings); sliding down the socioeconomic scale (substance abuse is financially ruinous,
and destroys relationships and job functioning); and generally alienating patients both from
themselves and from normal lives. One of the most brilliant aspects of AA and other self-help
groups is their one simple message, repeated over and over in many different ways: Give up
substances, and you will regain your life. In this treatment the message is the same, but in ad-
dition, is addressed in relation to PTSD. Recovery from substance abuse is notoriously diffi-
cult, but in the presence of PTSD is even harder. Would any of us really want to give up
something that took away nightmares, overwhelming sadness and anger, and bad memories?
One of the reasons PTSD and substance abuse co-occur so frequently is that substance abuse

137
138 Treatment Topics

does “solve” some aspects of PTSD in the short term. Indeed, Khantzian (1998) has noted
that many patients with chronic PTSD who abuse substances appear more “together,” less
decompensated, and less crazy-seeming than patients with chronic PTSD who do not abuse
substances. Clearly, however, substances can also have a negative impact on PTSD—increas-
ing paranoia, causing sleeplessness, intensifying negative feelings, and (in the long term) spi-
raling patients downward into severe dysfunctionality.
When patients have had the two disorders for years, giving up substances is one of the
hardest tasks imaginable, and they may have little self-esteem, will, or hope left with which
to undertake it. One of the key principles in this uphill effort to “climb Mount Recovery”
is distinguishing the long-term versus short-term impact of substances. No matter how much
substances make something better in the short term, they always make things worse in the
long term. They decrease physical, emotional, and spiritual health. (Indeed, one of the best
definitions of mental illness in general is the triumph of short-term over long-term solu-
tions.) By making the link between PTSD and substance abuse as “self-medication,” pa-
tients can recognize that their wish to use substances is understandable, but does not work
in a lasting way. Another key message is “No matter what happens, you can cope safely
without substances.” Literally nothing (divorce, depression, diagnosis of HIV, dissociation,
sleep problems, job loss, or any other life event) has to lead to substance use. Breaking the
“logical” link between stressful life events and substance use will, it is hoped, spur patients
to master safe ways of coping. Thus the list of Safe Coping Skills (Handout 2 in the topic
Safety) is so long: Patients need to be reminded that there are innumerable ways to cope
without using substances.
To the same end, today’s topic offers a variety of strategies for eliminating substance use.
The patient and therapist can select one or more handouts, and then come back to others at
the next session or any time later in treatment when they may be relevant. Thus, if you have
patients who do not recognize that they have a problem with substances, you might spend a
whole session on Handout 1 (What Is Substance Abuse?) guiding patients to self-evaluate
honestly whether they have a substance abuse problem, using the DSM-IV criteria. To ex-
plore specific substance use incidents, you could use Handout 6, Self-Understanding of Sub-
stance Use, which offers a number of ways to “search one’s soul” for why one has chosen to
use a substance at a particular time (emphasizing that it is always a choice, not an accident).
For those who are afraid to give up substances (pretty much all patients!), Handouts 4 and 5,
Climbing Mount Recovery and Mixed Feelings, can help validate the realistic difficulties and
emotions along the way.
Another important issue relevant to substance use is the notion of harm reduction. This
innovation in substance abuse treatment (Harm Reduction Coalition, 1998) arose out of
awareness that some patients are simply not ready to buy into a “cold turkey” (total absti-
nence) model in which they must renounce all substance use forever. Rather, the “warm tur-
key” (Miller & Page, 1991) method of harm reduction means that all decreases in substance
use are praised and reinforced (e.g., using substances twice a week rather than five times a
week; using one substance rather than two). Over time, patients may feel more in control of
their ability to overcome substance use and may choose to become fully abstinent. In Seeking
Safety the ultimate goal is abstinence, as it is believed that full healing from PTSD requires a
lengthy period of abstinence to work through trauma issues. But for patients who are unable
When Substances Control You 139

to agree to abstinence currently, a harm reduction approach can move them toward absti-
nence in the long run. The hope is that this will keep more patients in treatment (rather than
feeling ashamed or guilty if they use), and will gradually enable them to move forward in
their recovery. However, it is crucial to note that the therapist cannot simply allow patients to
“choose” substance use. The therapist needs to convey serious concern at patients’ use, ex-
plore why they are using, have an explicit contract about how much use is agreed upon (see
Handout 3), and seek to keep reducing substance use throughout the treatment. One of the
most common mistakes therapists have made in doing this treatment (particularly for thera-
pists who are new to the substance abuse field) is to convey that it is okay to choose substance
use. The therapist must navigate a difficult balancing act: recognizing that patients with sub-
stance abuse cannot be forced or bullied into abstinence; yet also recognizing that such pa-
tients cannot make a rational choice to use unlimited substances. Substances are so addictive
and dangerous for this population that some effort must be made to curtail their use. It may
help to have an image of the patient as a small child who wants to play with matches: As a par-
ent, one would stop the child because such play would be unsafe, yet would do it in a way
that was kind and nurturing. This balance—between the extremes of being overly harsh and
overly lenient—is the goal.
The same principle applies to twelve-step self-help groups, such as AA. All patients
should be strongly encouraged to try them. However, patients who do not choose to attend
must be fully respected in that decision. As DuWors (1992) has said, “The good news is that
AA does work. The bad news is that it does not necessarily work for all problems for all peo-
ple” (p. 131). Some patients with PTSD report obtaining great solace from such groups, while
others feel misunderstood. For example, patients may meet AA members who oppose all
mental health treatment and medications (despite the formal policy of AA, which supports
treatment for psychiatric conditions). Or patients may hear a message that they should not at-
tribute their substance abuse to past traumas. For some women patients with PTSD, groups
comprised largely of men may also evoke negative feelings. One patient said, “The AA atti-
tude is ‘You don’t drink because you were molested as a child; you drink because you’re an al-
coholic.’ ” Other patients may have such poor social skills and lack of basic trust in people
that they cannot utilize groups of any kind until later in their emotional development. It is
crucial that the therapist not convey judgment, shame, or blame for a patient’s decision on
whether to attend such groups. Some patients get much better through such groups, and oth-
ers get better without them (Mark & Luborsky, 1992). There are always other treatment op-
tions if a patient needs additional help, such as more individual therapy, other group thera-
pies, other self-help groups, or day treatment.

Countertransference Issues
Substance abuse is known to evoke enormous countertransference in therapists, including
power struggles, boredom, cynicism, indifference, blaming, withdrawal, burnout, and intense
and unstable feelings about patients (Imhof, 1991; Imhof et al., 1983; Najavits et al., 1995).
Indeed, in studying therapists’ emotional responses to patients with substance abuse, we
found that therapists became more negative over time despite extensive training in substance
abuse (Najavits et al., 1995). Substance abuse is one of the most difficult disorders to treat;
140 Treatment Topics

dropout rates from treatment are high, even with therapists’ most heroic efforts; and sub-
stances are simply far more compelling than therapy for many patients. Although it is too
large a topic to summarize here, several articles summarize the role of the therapist in treat-
ing patients with substance abuse, in addition to those cited above (Najavits et al., 2000;
Najavits & Weiss, 1994b).

Acknowledgments

In Handout 1, What Is Substance Abuse?, the definitions of substance use disorders are de-
rived from the DSM-IV (American Psychiatric Association, 1994) and Rinaldi, Steindler,
Wilford, and Goodwin (1988). In Handout 3, Choose a Way to Give Up Substances, the ways
to give up substances are drawn from Miller and Page (1991), and the mention of research on
controlled drinking is based on McCrady and Langenbucher (1996). In Handout 4, Climbing
Mount Recovery, the title and illustration are from Sobell and Sobell (1993) (copyright 1993
by The Guilford Press; reprinted with permission), and “Three Main Thoughts That Lead to
Substance Abuse” are from DuWors (1992). Some parts of Handout 7, Self-Help Groups,
were written by Roger D. Weiss. The study of women with PTSD and substance abuse re-
ferred to in Handout 8, Substance Abuse and PTSD: Common Questions, is described by
Brady, Dansky, Back, Foa, and Carroll (2000).

PREPARING FOR THE SESSION

♦ Essential:

1. For Handout 3, Choose a Way to Give Up Substances, works by Miller and Page
(1991) and Miller and Rollnick (1991) are enormously helpful, particularly if you
have doubts about the options proposed.
2. For Handout 7, Self-Help Groups, obtain listings of local AA and other self-help
groups to give to patients. Call the local AA Central Service or the AA national toll-
free number (800-637-6237).
3. If substance abuse treatment is new to you, read some key books on the topic (Beck
et al., 1993; Marlatt & Gordon, 1985; Miller & Rollnick, 1991) and seek supervision.

♦ Recommended:

1. For Handout 3, Choose a Way to Give Up Substances, obtain an informational sheet

on each major drug (e.g., alcohol, cocaine, heroin, marijuana) that describes how it
destroys the body. You can order these from NIDA InfoFax (888-NIH-NIDA, or
888-644-6432).
2. For Handout 7, Self-Help Groups, attend a twelve-step meeting if you never have
done so before. This can provide direct knowledge with which to help patients un-
derstand the value of such groups and how they work.
When Substances Control You 141

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 150. Link the quotation to the session—for example,
“Today we’ll be talking about substance abuse. As the quotation suggests, the goal is not to
blame yourself for using but to understand it so that you can heal from it.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Note that each handout is its own subtopic. See “Session Content” (below)
and Chapter 2 for how to choose from the very large number of handouts, depend-
ing on patients’ needs and your time frame. Cover them in multiple sessions if you
have the time.
Handout 1: What Is Substance Abuse?
Handout 2: How Substance Abuse Prevents Healing from PTSD
Handout 3: Choose a Way to Give Up Substances
Handout 4: Climbing Mount Recovery
Handout 5: Mixed Feelings
Handout 6: Self-Understanding of Substance Use
Handout 7: Self-Help Groups
Handout 8: Substance Abuse and PTSD: Common Questions
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT

This topic has more handouts than any other, and they cannot all be covered in one session. It
was designed to allow the therapist maximal flexibility on one of the essential topics of the
treatment—substance abuse—for which patients may vary in their needs. Allow patients to
select one or more handouts, or choose based on your knowledge of them. You may also want
to come back to some handouts later in treatment. See Chapter 2 for suggestions on deciding
which handouts to cover.

Handout 1: What Is Substance Abuse?

Goal
¨ Help patients honestly evaluate whether they have a substance use disorder.

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to check off the items that apply to them.
142 Treatment Topics

ê Discussion
Questions to determine whether to use this handout include:
• “Are you aware that you have a substance abuse (or dependence) problem?”
• “Do you, or does anyone in your life, have any doubt about your substance abuse
problem?”
• “Would it help for us to go over the definition of substance abuse, or should we
move on?”
Questions when using this handout include:
• “How do you notice substances controlling your life these days?”
• “What areas of your life are currently affected by your substance use? (Relation-
ships? Work? Physical health? Leisure time? Your development as a person?)”
• “What do you think your life would be like if you gave up substances?”

Suggestions
✦ Some patients need a review of substance use disorder criteria. These include those
who (1) are in denial about the impact of their substance use, despite clear evidence of a seri-
ous problem; (2) have minimal symptoms and the diagnosis is unclear; (3) get mixed messages
from treaters (e.g., some treaters tell them they have a problem, others say they don’t); (4) are
in danger of progressing from substance abuse to dependence and you want them to learn
what may be “up ahead”; and (5) want to understand substance abuse better. If in doubt, hav-
ing patients read it as part of their commitment is always an option.
✦ In group therapy, steer clear of “war stories.” It can trigger patients to hear details
about substance use, just as details of PTSD can be triggering. Redirect patients who do this.
Keep the focus on how to give up substances rather than on experiences from the past.
✦ Note that the review of DSM-IV criteria is optional here. This is in contrast to the
topic PTSD: Taking Back Your Power, where criteria for that disorder are provided for all pa-
tients (for reasons described in the “Orientation” to that topic). Originally the substance use
disorder criteria were reviewed with all patients as well, but in testing this treatment it was
found that many patients were aware that they had a problem with substances, and reviewing
the actual criteria did not provide much new learning.
✦ Be accurate in diagnosing substance use disorders. If a patient uses a substance but it
does not have significant negative impact, this does not meet the definition of a disorder.

Handout 2: How Substance Abuse Prevents Healing from PTSD

Goal
¨ Raise patients’ awareness of how substance abuse prevents healing from PTSD.

Ways to Relate the Material to Patients’ Lives

êReview key points. Ask the patient to summarize main points in the handout, and then
use this as a point of departure to work on the skill—for example, “What do you think the
handout is trying to convey?”
When Substances Control You 143

ê Discussion
• “Can you see ways that your substance use is interfering with your healing from
PTSD?”
• “How would it feel if you could learn to manage your PTSD without substances?”
• “Do you have any recent examples of using a substance to manage your PTSD?”

Suggestions
✦ Be aware that there are many reasons patients use substances, not just PTSD. These
include biological vulnerability to substance abuse, learned habit, external triggers (such as
running into one’s drug dealer), and growing up with family members who used. It is not nec-
essary, and not true, to relate every substance use incident to PTSD. The goal is for patients
to recognize, overall, the link between the two disorders to the extent that it feels true to
them.
✦ Remember that substances can have a positive impact on PTSD symptoms. There is
no simple model that all substance abuse leads to worse PTSD symptoms. Indeed, as dis-
cussed in the “Orientation” to this topic, one of the reasons substance abuse is so common
among patients with PTSD is that it does work to reduce some PTSD symptoms—it can
numb intense negative feelings, help patients sleep at night, make them feel more social,
help them access feelings, and decrease anxiety. It can also have a negative impact on
PTSD symptoms—such as increasing paranoia or sleeplessness. A key to working with pa-
tients who describe a positive impact of substances on their PTSD symptoms is to validate
that this may well be the case, but that the important question is whether this is true in the
long run. The positive impact is invariably short-term—a few minutes to several hours—
but in the long term (the next day, the next week), patients’ PTSD symptoms are not im-
proved. In addition, the substance use per se can decrease self-esteem and functioning.
Guiding patients to keep questioning the long-term impact helps them recognize that they
need to give up substances.

Handout 3: Choose a Way to Give Up Substances

Goal
¨ Identify an immediate plan to relinquish substance use that is realistic and acceptable
to the patient. Three choices are offered: “Quit all at once,” “Try an experiment,” or “Cut
down gradually.”

Ways to Relate the Material to Patients’ Lives

ê Create a written plan. The last section of the handout provides this opportunity.
ê Discussion
• “Which plan is most appealing to you? Which plan do you think is best for you?”
• “Which plans have you tried before? Have any worked or not worked for you be-
fore?”
• “How can you make sure to stick to the plan that you’ve selected?”
144 Treatment Topics

Suggestions

✦ Do not judge or blame patients who are not ready to commit to total abstinence. Re-
member the saying “A good plan today is better than a perfect plan tomorrow.” There are
many good reasons patients with PTSD may feel unable to give up all substances immedi-
ately: the realistic fear that PTSD symptoms may become overwhelming; suicidal hopeless-
ness; deep-level assumptions about being “bad” or not deserving to take good care of them-
selves; extremely low self-esteem. For clinicians whose training is primarily in substance
abuse, particularly twelve-step models, it may feel difficult or even “enabling” to ally with a
plan other than abstinence. It may help to remember that dual-diagnosis patients are differ-
ent from patients with substance abuse only, and that chronic PTSD is different even from
other dual diagnoses (e.g., depression, which typically improves with abstinence). Also, you
may come to see that many patients with PTSD will appear highly compliant if you insist on
abstinence—they may agree to it—but then never do it. For patients with PTSD who were
victimized in childhood, being forced or coerced to do anything can feel like a repetition of
their abuse. Strive to elicit their honest appraisal of what they can do now, and reinforce any
positive steps toward abstinence.
✦ Develop a clear plan to decrease substance use; patients cannot make a legitimate
“choice” to keep using substances as they have been. For clinicians whose training is primarily
in mental health, there may be an underestimation of the need for an immediate, clear plan to
reduce substance use. Telling patients it is “their choice” to keep abusing substances without a
major attempt to reduce it may be a dangerous message. While you cannot force a patient into
abstinence and need to use all possible motivational and supportive interventions to help a pa-
tient decrease substance use, it is also essential to convey concepts such as the following: (1)
Substance abuse is self-destructive, particularly in the context of PTSD; (2) you are worried
about them if they keep using as they have been; (3) as a clinician, you cannot agree with their
continuing the same level of substance use, given what you see it doing to them; (4) severe sub-
stance abuse can literally kill them. This “good parent” approach opens the door to selecting one
of the ways on the handout for immediate curtailment of substance use. Note that this does not
mean confronting the patients in the stereotyped way sometimes associated with substance
abuse treatment (e.g., breaking down patients’ denial by forcing your opinion on them). But it
does mean being very aware that substance abuse can destroy them and that you need to work
with them in highly effective yet empathic ways—just as you would with patients who have dan-
gerous impulses to cut themselves, abuse their children, kill themselves, or set fires. Finally, be
sure to understand why controlled drinking and moderation management are not considered
acceptable plans for patients at this point (see the handout).
✦ Patients may be unsure whether they need to give up substance use. This occurs quite
frequently. Patients may say that their problem is not as severe as others’, or that they are in con-
trol of it. This attitude may reflect ambivalence, or a fear of what will happen when substances
are relinquished (e.g., will the PTSD worsen?). Several interventions may be helpful here: edu-
cation about the course of recovery (particularly that it gets easier over time); trying to help pa-
tients make a connection between the use of substances and problems in their lives; and rein-
forcing the motivation to reduce any substance use (with the idea that over time, they’ll be able
to seek full abstinence). Equally important are what not to do: giving an ultimatum such as tell-
ing patients they cannot attend this treatment if they use substances, or that they must attend
When Substances Control You 145

AA; telling them they’re “in denial” (which simply adds a pejorative label to their experience); or
trying to force a premature commitment to abstinence (which may lead to a failure experience).
✦ Whichever of the three ways is selected, make sure that the plan is in writing, that it’s
specific, and that the patient is willing to try it. Also, process potential obstacles to following
through on it.
✦ Remember to reaffirm the plan throughout the treatment. Once a plan to decrease
substance use has been established, it is essential for the therapist to remember what plan
was agreed upon, and then to evaluate, throughout the entire treatment, whether the patient
is able to stick to it. If not, try renegotiating the plan to fit the patient more realistically (e.g.,
the patient may have promised more than is possible), or think of ways to make it happen.
Also, if the patient has agreed to “try an experiment” or “cut down gradually,” the therapist
will need to follow up by deciding with the patient what happens next (e.g., continue the ex-
periment or cut down more on substance use). Thus, you may want to fill out a new version of
Handout 3 with the patient each time the plan changes. In short, throughout therapy, there
should be in place, for each patient, a written and specific contract about substance use, with
the goal of either abstinence or continually decreasing use. If the patient does not have as a
goal any decrease in substance use, see the Suggestions above on ways to motivate the pa-
tient toward such a goal.
✦ Give patients information sheets on their substances of abuse to educate them about
how the substances damage the body. Patients have reported these sheets to be helpful to
them. (See “Preparing for the Session” for how to order these free materials.)

Handout 4: Climbing Mount Recovery

Goal
¨ Conduct an imaginative exercise, Climbing Mount Recovery, to help patients realisti-
cally prepare for giving up substances.

Ways to Relate the Material to Patients’ Lives

êDo a walk-through. Suggest situations and ask how they might be handled—for exam-
ple, “If someone offers you a substance, how would you handle it?” “If you get a major drug
craving, how would you handle it?” “If you have a slip, how would you handle it?”
ê Discussion
• “What do you think it will be like to give up substances? What will be hardest for
you?”
• “How can you prepare now for the difficulties of giving up substances?”
• “What can you do when you feel like using?”
• “If you have a slip1 (a single substance use incident), what can you do to keep it from
becoming a full-blown relapse?”
• “Do any of the ‘Three Main Thoughts That Lead to Substance Use’ sound familiar to
you?”
1The term “slip,” is problematic because it sounds like an accident rather than a choice to use a substance. How-
ever, as it is a standard term, it is included here.
146 Treatment Topics

Suggestions
✦ If a patient does not like using the Mount Recovery metaphor, let it go and just work
on the actual plan of exploring how to prepare realistically for giving up substances.
✦ In discussing Trail A of the Mount Recovery drawing, teach patients about the absti-
nence violation effect. The abstinence violation effect (Marlatt & Gordon, 1985) is a well-
known phenomenon in substance abuse recovery. When patients slip (have a single substance
use incident), they tend to believe “It’s all over; I’ve already blown it so I might as well keep
going”—thus deteriorating into a full-blown relapse. Prepare for this by rehearsing how to
stop after a single slip and keep climbing up the mountain!
✦ Help patients recognize that giving up substances will feel bad. Sometimes they “feel
bad about feeling bad”— they think that something is wrong with them because it feels so
miserable to give up substances. It can be helpful to normalize the bad feelings and figure out
how to cope with them as best as possible (e.g., by using the Safe Coping Skills). You might
want to use the metaphor of “bad weather” or “bad times” on the trip up the mountain—no
one likes these, but there are ways to cope, such as finding shelter and staying calm.

Handout 5: Mixed Feelings

Goal
¨ Help patients recognize that it is normal to have mixed feelings about giving up sub-
stances, as long as their actions remain safe.

Ways to Relate the Material to Patients’ Lives

êSelf-exploration. Ask patients to identify both positive and negative feelings they have
about giving up substances. This is known as a “pro and con” list (Marlatt & Gordon, 1985).
ê Discussion
• “Do you have any mixed feelings about giving up substances (or PTSD symptoms)?”
• “Do you ever feel ‘bad’ (or ‘unmotivated,’ ‘lazy,’ ‘different,’ etc.) when you want to
keep using substances?”
• “How can you keep your actions safe, even though you may have mixed feelings?”

Suggestion
✦ See the “Suggestions” for Handout 4, Climbing Mount Recovery, which apply to this
topic as well. Also, see the topic Integrating the Split Self, which offers more about different
sides of the self.

Handout 6: Self-Understanding of Substance Use

Goal
¨ Help patients seek a compassionate understanding of substance use incidents, rather
than self-blame.
When Substances Control You 147

Ways to Relate the Material to Patients’ Lives

ê Replay the scene. Ask patients to identify the last time they had a substance abuse slip
and apply the handout to that incident. Ask them to go through the exercise “in slow mo-
tion”—noticing every detail of what they were thinking, feeling, and doing. Make sure to di-
rect the exploration toward self-understanding rather than self-blame.
ê Discussion
• “After using a substance, do you seek self-understanding, or do you blame yourself?”
• “Why would self-understanding rather than blame decrease substance use over
time?”
• “What is the cost of your substance abuse, both financially and emotionally?”
• “What is the meaning of substance use in your life right now? Why do you do it?”
• “Which of the ways listed could help you understand your substance abuse better?”

Suggestions
✦ Remember that understanding substance abuse is not permission to keep using. If it
feels as though patients (or you) are buying into a framework of excusing substance use, it
needs to be redirected to the message that substance abuse is never justified—there are al-
ways ways to cope safely with whatever life brings, without substances. However, if an inci-
dent does occur, keeping it from happening again requires honestly facing what it was about,
such as a suppressed need, unacknowledged feeling, or misdirected coping.
✦ See the topic Compassion for more on compassionate understanding versus self-
blame.

Handout 7: Self-Help Groups

Goal
ê Discuss the role of self-help groups and encourage patients to attend them.

Ways to Relate the Material to Patients’ Lives

ê Create a plan to attend at least one self-help meeting. Identify a specific meeting in
the patient’s area, using a listing of local self-help groups that you bring to the session.
ê Discussion
• “Have you ever been to a self-help group? Why or why not?”
• “Do you have any concerns about such groups?”
• “How can you get yourself to try out a meeting and learn more about them?”
• “If you don’t like one meeting, can you try another?”

Suggestions
✦ The handout is recommended for patients who have never tried self-help groups, or
who have tried it but do not currently go. If a patient attends actively, there is likely no reason
148 Treatment Topics

to work on it (although you could help the patient process how to get a sponsor, participate
more, etc.).
✦ Encourage patients to attend twelve-step groups. Also, be sure to provide a list of local
meetings; see “Preparing for the Session” for how to obtain such lists. Help patients explore
and process some negative reactions they may have about going to a self-help group, all the
while giving the message that despite any negative features, self-help groups can be ex-
tremely helpful on balance.
✦ The challenge for some therapists is to respect patients’ right to decide whether to at-
tend twelve-step groups. Encouraging patients to try them is fine; insisting on them, or judg-
ing patients for not attending, is not. Remember that some people with PTSD have legitimate
problems with self-help groups, for various reasons: social phobia or paranoia; some of the
twelve steps (e.g., “sharing your story publicly” and “surrendering to a Higher Power”; Satel
et al., 1993); or the presence of men (e.g., for women traumatized by men who were drunk or
high when they committed the abuse). They should never feel forced to attend such groups,
or ashamed or wrong if they choose not to attend them. They need information with which to
make an open-minded choice.
✦ For patients who are highly resistant to trying twelve-step groups, you may want to
try the strategy of discovery (see the topic Discovery).
✦ It is strongly recommended that all therapists attend a twelve-step group, to gain di-
rect knowledge of them and thus to be able to help patients more with this topic. Anyone can
sit in on a meeting, and you will not need to say why you are there. Try to attend a speaker
meeting if possible. Questions about self-help groups patients may raise include, “What are
twelve-step groups, and why are they called that?”, “Will going to AA contradict what is be-
ing learned in therapy?”, “What are open, closed, and speaker meetings?”, “What’s the differ-
ence among AA, Narcotics Anonymous (NA), Cocaine Anonymous (CA), Al-Anon, and
Alateen?”, “How often should I go to AA?”, “What is the spiritual component of AA?”, “How
can AA help?”, “What is SMART Recovery, and how is it different from AA?”, “What is the
AA sponsor’s role?”

Handout 8: Substance Abuse and PTSD: Common Questions

Goal
Help patients make sense of confusing messages they may hear about recovery from
¨
PTSD and substance abuse.

Ways to Relate the Material to Patients’ Lives

ê “Question–answer” format. Ask patients questions to see what they do and do not
know—for example, “Is it essential to get ‘clean’ from substances before working on PTSD?”,
“What is ‘self-medication’?”, “What are ways to deal with trauma memories early in substance
abuse treatment?”
ê Discussion
• “Are there any main questions you have about recovery from PTSD and substance
abuse?”
When Substances Control You 149

• “Do these questions and responses make sense to you?”

• “Is there anything in the handout that you find helpful? Harmful?”

Suggestions
✦ Patients can feel confused when they hear extreme or rigid messages. Unfortunately,
some treaters or treatment systems, in a genuine attempt to help patients, may convey rigid
messages that may serve to make patients less likely to give up substances (e.g., “You have to
get ‘clean’ before you work on the PTSD”). The more severely impaired patients are, the
more unlikely it is that they can benefit from rigid messages, especially if they feel that their
own point of view is being invalidated rather than explored and understood. It is helpful to
soften extreme positions by acknowledging that there is much we do not yet know, that peo-
ple recover in different ways, and that patients with this dual diagnosis are not all the same.
✦ Therapists may hold different views on recovery from PTSD and substance abuse than
those on the handout, and may take offense at messages that are different from what they be-
lieve. The handout was written to try to convey that much is still unknown, but that these are
common current views on treatment for this dual diagnosis.
✦ Patients with dissociative identity disorder may attribute substance use to an alter.
Dissociative identity disorder (also known as multiple personality disorder) is a serious men-
tal illness that is highly associated with PTSD (American Psychiatric Association, 1994). In
this disorder, the self has split into distinct parts (“alters”) that typically have different names,
ages, genders, and personalities. Such patients genuinely may have an alter that uses sub-
stances while the other alters are not aware of this or cannot control it. Patients with such an
extreme disorder clearly need expert professional help to move toward healthy integration of
the alters. In any treatment, however, the patient can be encouraged to allow the substance-
using alter to become present in treatment (e.g., “Can the side of you that uses speak to
me?”), and be made aware that substance use is dangerous and needs serious attention no
matter which alter is doing it.

Tough Cases
∗ “Using cocaine makes my PTSD better—I can’t give it up.”
∗ “I don’t want to give up substances. I’ll never recover from PTSD, so why bother?”
∗ “It’s my alter who drinks, and she’s not here now.”
∗ “I definitely think I can do controlled drinking.”
∗ “I’m trying to be patient with myself and not set an unreachable goal like ‘decreasing
substance use.’ ”
∗ “How long do I have to stay off substances?”
∗ “Have you ever been an addict? If not, what makes you think you can help me?”
∗ “Do I have to get clean before working on my PTSD?”
∗ “I don’t want to go to AA.”
 Quotation

“Not to laugh,
not to lament,
not to judge,
but to understand.”
—Baruch Spinoza
(17th-century Dutch philosopher)

From Seeking Safety by Lisa M. Najavits (2002).

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HANDOUT 1 When Substances Control You

What Is Substance Abuse?

The simplest definition of “substance abuse” is that a substance has control over your life. In the language of the
American Medical Association, it is the “compulsive use of a substance resulting in physical, psychological, or social
harm . . . and continued use despite that harm” (Rinaldi et al., 1988). The substance may become more important
than your relationships, your work, and all else.
Substance abuse is widely considered a medical illness. It is not due to being “bad,” “lazy,” or “just wanting to
have a good time.”
No one fully understands why some people become addicted and others don’t. It may be due to biology, terri-
ble life experiences, or some combination. Whatever the cause, it is essential to learn how to overcome the illness. It
can be done!
Some people are unsure whether they truly have a problem with substances, or they may hear conflicting opinions
from others. It may be helpful to ask yourself whether either of the following formal definitions seems true for you.

DO YOU HAVE A PROBLEM WITH SUBSTANCE ABUSE?

If you have a problem with substances, you have either substance abuse (a mild version of the disorder) or substance
dependence (a severe version of the disorder). In popular language, “substance abuse” is used to refer to any prob-
lem with substances.

Substance Abuse
« Check off (ü) any that are true for you, being really honest with yourself.
Substance use that results in failure to fulfill obligations (e.g., work, parenting).
Repeated substance use in situations that are physically dangerous (e.g., driving).
Repeated legal problems resulting from substance use (e.g., disorderly conduct).
Continued substance use despite repeated problems from it (e.g., arguments with people).

If any one above is true for you, you would be diagnosed with substance abuse.

Substance Dependence
« Check off (ü) any that are true for you, being really honest with yourself.
Q Your quantity of substance use has increased.
U You are unable to control your substance use.
I Your substance use inter feres with your responsibilities (e.g., home, work, parenting).
T Your time is heavily devoted to using the substance.
N You need more of the drug to obtain the same effect (“tolerance”).
O Other aspects of your life have been damaged by substance use (e.g., health, social life), but you
continue to use.
W Physical withdrawal symptoms occur if you stop using the substance. Also, you may take the substance
to try to manage your withdrawal symptoms.

If any three above are true for you, you would be diagnosed with substance dependence, which you can remember
by the acronym “QUIT NOW.”

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 2 When Substances Control You

How Substance Abuse Prevents Healing from PTSD

There is no doubt that you want to heal from PTSD. No one wants to live with the suffering of that disorder. But are
you aware of how your substance abuse is preventing you from healing from PTSD? The following list may help.

« Check off (ü) any that feel true for you.

ABUSING SUBSTANCES . . .
¨ Makes PTSD symptoms worse. Substances can make you feel more depressed, more suicidal, and less sta-
ble. Even if substance abuse appears to “solve” some PTSD symptoms for a short while (such as getting to sleep or
“numbing out” for a few hours), in the long run it never solves them.
¨ Prevents you from knowing yourself. With substances, you get lost. To heal from PTSD, you need to be-
come more and more aware of who you really are—without substances.
¨ Does not get your needs met. You may be using substances to feel loved, to accept yourself, to feel less
pain, or to feel nurtured. However, substances cannot give you these. You need to learn safe coping methods to grat-
ify these very important needs.
¨ Stalls your emotional development. Although you may be an adult in terms of your age, emotionally you
may have become “stuck” somewhere earlier in your development, due to PTSD, substance abuse, or both. If you
give up substances, you can keep growing emotionally.
¨ Isolates you. You cannot have good relationships when high. One of the main features of PTSD is isolation:
keeping secrets, having to lie about what happened, feeling alone. Substance abuse perpetuates that aloneness.
¨ Keeps you from coping with feelings. It can feel unbearable to face the feelings associated with PTSD,
and it may be tempting to use substances to “self-medicate” them. But true healing means learning to gain control
over your feelings through safe coping. Healing is possible if you can give up substances that are getting in the way.
¨Takes away your control. One of the most difficult aspects of PTSD is that you had no control over the
trauma. The very nature of substance abuse is that it also takes away your control—it runs your life. Take back your
power by giving up substances!
¨ Makes you hate yourself. You can’t feel good about yourself when you are being controlled by a sub-
stance. With PTSD, you may already dislike yourself; substance abuse just adds to that.
¨ Is a way of neglecting yourself. Using substances impairs your health, your mind, your relationships, your
self-worth, and your spirituality. If you suffered childhood neglect or abuse, substance abuse may be a repetition of
that pattern, except that now you are doing it to yourself.

Healing from PTSD requires all of your care and attention—substance abuse keeps you stuck.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 3 When Substances Control You

Choose a Way to Give Up Substances

→ Quit all at once. This is the abstinence model developed in AA; it’s also called quitting “cold turkey.” It
works well for some people. It may feel harder to start, but may be easier to stick to.
→ Try an experiment. Try this “warm turkey” rather than “cold turkey” method—give up substances just for a
week to see what it’s like. Then reevaluate it in therapy.
→ Cut down gradually. This is called harm reduction. Making progress, even slowly, is better than staying
where you’re at. If you’re using every day, you can start by using every other day. If you’re using cocaine and mari-
juana, you can give up cocaine but keep using marijuana. Eventually, you can give up substances completely once
you achieve these smaller successes.

A key question: “Do I have to give up substance use completely?” It is clear that people with PTSD and
substance abuse need to quit substances completely—at least for a while—to successfully heal from PTSD. Later, once
their PTSD recovery is complete, they can explore whether any use is safe for them or not. Many people find that
once they recover from PTSD, they no longer even want to use. In the substance abuse field, there is a lot of contro-
versy about whether people with a history of substance abuse can ever use safely. Some people believe that “moder-
ation management” or “controlled drinking” are possible, meaning that using may be okay as long as it is kept within
certain limits. However, this is not considered safe for anyone who has a history of severe substance use. At this
point, just know that you need to give up substances to heal from your PTSD.

« What plan can you commit to starting today? Choose one below, then fill in the “Notes.”
¨ (1) Quit all at once (the AA or “cold turkey” model).
¨ (2) Try an experiment (the “warm turkey” model). Please write down how long you’ll give up sub-
stances: week(s).
¨ (3) Cut down gradually (the “harm reduction” model). Write down on the back of this page exactly
what substance(s) you’ll cut down or give up. Also, write down how much and how often you’ll be using at
most (you can always use less, but not more!).

Notes:
(a) I also agree to throw out my (substances) and all related paraphernalia.

(b) I also agree to ask (people in my life) not to offer me substances or use around me.
Signed: Dated:
( If I cannot stick to my plan, I will leave a [phone message? note?] for my [thera-
pist? sponsor? partner? friend?] to let him or her know within hours.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 3 (page 2 of 2) When Substances Control You

SUGGESTIONS
 Get rid of substances in your environment to help your plan work. Throw out your stash of substances
and tell people in your life not to offer you any.
 You can combine “Try an experiment” and “Cut down gradually” if you need to. If you are extremely
afraid of reducing your use, you can try to give up a little just for a short time.
 Keep in mind that many people have strong opinions about how to give up substances. However, at
this point, no one truly knows what works best, for whom, and how. Any of the three methods above may work as
long as you keep at it. If you try one way and it doesn’t work, you can reevaluate it with your therapist and then try
another plan.

No matter what happens, you can cope safely without substances!

154
HANDOUT 4 When Substances Control You

Climbing Mount Recovery

RECOVERY FROM SUBSTANCE ABUSE IS LIKE CLIMBING A MOUNTAIN

« What do you notice about Trail A and Trail B?

Trail A is trial and error—mistakes along the way, but people eventually make it to the top.
Trail B is perfect—no problems, just a direct path to the top. Very few people do it this way!

The message: Either trail will get you there.

If you do not like to imagine mountain climbing, select another image that works for you: A trip to a foreign coun-
try? Running a marathon? Learning to drive a car? Or none at all?

PREPARING FOR YOUR TRIP

As with any other journey, you need to be prepared. Just as for climbing a mountain you need to take hiking boots,
food, a tent, and a flashlight, for your recovery trip you will need to do the following:

→ Tell everyone close to you where you’re heading and ask them to help you with it (e.g., not using sub-
stances around you, never offering you substances).
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 4 (page 2 of 2) When Substances Control You

→ Be prepared for “bad weather.” Some people find that as they stop using substances, their PTSD gets
worse for a while. Just like a storm, this does not last forever. It simply means that you need to face feelings that
have been hidden by substance abuse. Accept and honor those feelings. Strive to cope with them as best as you can
without using.
→ Take your list of Safe Coping Skills—they’re just as vital as food to survive on this mountain! It’s also best
to pack a list of reasons not to use substances, and a list of rewards for yourself for each day you don’t use. Keep all
of these in your wallet for easy access.
→ Be prepared for down times. On all adventures, there are times that are not fun. When you give up sub-
stances, you may feel miserable and deprived. Just keep climbing up the mountain—better times await you ahead.
The view from the top is incredible!
→ Take “maps.” Just like having maps and a tourist guide, you’ll need to learn everything you can about your
journey—from self-help groups, books, educational videos, and talking to people who have recovered.
→ Carry a phone so that you can reach out for help if you get stranded.
→ Set a starting date. How about today?
→ Don’t take guilt, self-hatred, blame—these weigh you down.
→ Remember that there is never a good reason to use. Even if you’re homeless, had a fight, and lost all of
your money in a single day—none of this means “It’s okay to use.” Using a substance will not get you a home, get
you out of a fight, or get your money back . . . but it will make you less able to cope with your problems.
→ Remember that as you reduce substance use, your PTSD may get worse; be prepared for this, seek
help, and remember that it won’t last forever.
→ Surround yourself with safety—safe people, safe places, safe things.
→ Never “test” yourself by seeing whether you can turn down a substance. Just as you should never
test your safety by walking down a dark alley at night, you should never test your recovery by walking into a sub-
stance abuse situation.
→ Know that cravings are normal. As long as you don’t actually use, you’re okay.
→ Fight “AVE” (the “abstinence violation effect”). This is a common pattern in recovery: If you use once,
you think you might as well keep using because you’ve already failed. No—don’t keep using! Just stop and pick your-
self up. Having 1 drink is better than having 10 drinks.
→ Remember the bottom line: To heal from PTSD, strive to be substance-free!
→ Memorize the “Three Main Thoughts That Lead to Substance Use” (see the box below). They are
like snakes in the grass—they will jump out and hurt you when you’re not looking.

THREE MAIN THOUGHTS THAT LEAD TO SUBSTANCE USE:

å “I’ll just have one” å
€ “I can handle this alone” €
Q “I don’t care” Q

« Is there anything else you need for your journey?

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HANDOUT 5 When Substances Control You

Mixed Feelings

« What do you think? Circle “true” or “false,” then see the answers at the bottom of the page.

1. It’s best to wait until you feel motivated to give up substances. True False

2. Most people have mixed feelings about giving up substances. True False
3. There’s something wrong with you if you still want to use substances. True False

4. People who recover are totally sure they want to give up substances. True False

 You may have mixed feelings about giving up substances. You may alternate between wanting to re-
cover from substance abuse and then not wanting to. Such mixed feelings are called “ambivalence.” This is a very
common stage in early recovery. Despite all the suffering you go through with substance abuse, it is familiar. Giving
up substances can feel like the loss of a close friend. Most people who give up substances frequently have mixed
feelings about it. If you talk to people who have succeeded in achieving long-term abstinence, they too felt mixed
about it when they were in early recovery.

 With PTSD, there may also be mixed feelings about getting better. PTSD can feel very familiar, and
can even become your identity. It can be scary to move forward and let go of it: “If I keep feeling pain, this shows
how bad the trauma was,” “If I get better, it’s like my abuser has won,” “I don’t have a right to get better when my
buddies died on the battlefield.” To let go of such suffering may feel as though it invalidates what happened to you.

 How can you cope with mixed feelings? You can have lots of mixed feelings; it is normal to have them.
But always remember that no matter what you feel, you need to focus your actions on safety. This means not using
substances, sticking with treatment, and talking about your mixed feelings openly. You don’t have to feel like giving
up substances or PTSD symptoms. Isn’t that a relief?

[Answers to questions: F, T, F, F]

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 6 When Substances Control You

Self-Understanding of Substance Use

If you use a substance, the key is to understand why. No shame, no blame, no guilt, no “beating yourself up”—these
all prevent you from understanding yourself.
Note, however, that understanding substance use does not mean excusing it. It does not mean that it was right
or okay to use. Substance use is never a safe way of coping for someone who is in recovery from PTSD and sub-
stance abuse. Thus, “seek explanations but not excuses.”
Here are some ways to seek understanding about your substance use.

NOTICE THE CHOICE POINT

Every time you use, you make a decision to do so. “Own” the decision—notice what you said to yourself to
justify it. If you listen closely, every time you use a substance, you’ll hear a need that’s being neglected: a need for
pleasure, connection, relaxation, love, celebration, symptom relief. Some examples: “When my friend passed the
joint, I felt like I wanted to be part of things,” or “I saw the liquor store and said, ‘I’m stressed and just want one
drink.’ ” These are all legitimate needs that deserve attention, but not with substances. Also, it may be helpful not to
talk about your substance use as “slips” or “backsliding”—these make it sound as though they were accidents. Using
a substance is never an accident; it is always a choice. Owning the choice can help you understand yourself and your
needs.
Explore your unconscious. There may be times when you use and you truly do not know how it hap-
pened. Particularly for people who dissociate (which is common in PTSD), you may find yourself sitting at a bar
with a drink in hand, not knowing how you got there. The best strategy for this is to explore what unconscious
part of yourself led you to use. This is sometimes called the “Jekyll–Hyde personality” or the “split self”—there are
feelings that you are having trouble letting yourself feel, and they sneak up and surprise you. For example, you
may be having urges to use but denying them (“I shouldn’t feel this way, so I won’t let myself think about it”); or
you may be angry but not fully aware of it (“I don’t have a right to be angry”). Just know that every time you
use and are not conscious of it, you can become more conscious with effort. Here too, listen for unmet needs
that require attention.

REPLAY THE SCENE IN SLOW MOTION

As if you are watching a movie in slow motion, describe everything that led up to using, trying to un-
derstand what motivated you to use and being really honest with yourself:

Who were you with?

Where were you?
What happened that day?
What were you feeling and thinking?
What time was it?
What coping did you attempt?
What was the dialogue you went through, either with yourself or others?
Now try to figure out a better way to cope next time—replay the movie in slow motion, but this time with
a better ending. Again, no shame or blame—just identify how you can treat yourself better next time. Look at the
Safe Coping Skills list to identify better solutions.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 6 (page 2 of 2) When Substances Control You

For example, if you used because . . .

You felt upset . . . then talk to someone.
You can’t sleep at night . . . then talk to a doctor who specializes in sleep problems.
Your sister just died and you miss her . . . then let yourself cry and mourn the loss.

EXPLORE THE MEANING OF YOUR SUBSTANCE USE

For people with PTSD, substance use can have many meanings. Substance use can be a way of getting to
sleep, numbing the pain, giving you control, helping you feel accepted by people, committing slow suicide, getting
back at an abuser, crying out for help, showing others how much pain you feel, blotting out memories, accessing
memories . . . or many other meanings. Each time you use, try to understand the meaning.

NOTICE THE COST

Just as there’s “no free lunch,” there is no free substance use. Both emotionally and financially, substance
use has a cost. Using may feel good for a few minutes or hours, but you’ll pay the cost later. Think about the inter-
personal costs (who is it hurting?); the financial costs (is this a good use of your money?); and the emotional costs
(how will it make you feel about yourself?).

NOTICE HOW YOU RELATE TO YOURSELF AFTER USING

Many people with PTSD “beat themselves up” after using. They attack, reject, shame, and yell at them-
selves. This prevents growth because you’re not able to hear, with an open heart and open mind, your needs and
motivations for using. Another destructive pattern is perfectionism: If you use once, you harshly view it as failure and
so keep on using, turning 1 drink into 10. Notice the voice in your head after you use: Is it the voice of someone who
is kind and caring? Or harsh and judgmental? (And does the voice remind you of anyone who treated you harshly
when you were growing up?)

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HANDOUT 7 When Substances Control You

Self-Help Groups

Some people love self-help groups, some don’t. Such groups include Alcoholics Anonymous (AA), Narcotics Anony-
mous (NA), Cocaine Anonymous (CA), SMART Recovery, Dual Diagnosis, Rational Recovery, Secular Organization for
Sobriety (SOS), Gamblers Anonymous (GA), Sexaholics Anonymous (SA), Emotions Anonymous, Al-Anon, Alateen,
Parents Anonymous, and Co-Dependents Anonymous.

* If you’ve never tried self-help groups, you owe it to yourself to check them out.
* A group may help. Anything to support your recovery is worth doing. A self-help group can give you a com-
munity of people who are struggling as you are, education about substance abuse, hope for the future, and wisdom
from people who have recovered.

* If you’ve tried a group and don’t like it, try other groups to see if you can find one you like. The culture
of each group is different. There are also a lot of specialty groups: meetings for women, gays, combat veterans, be-
ginners, nonsmokers, and others. Meetings also have different formats, such as speaker meetings, step meetings,
and discussion meetings. Discover what works for you.

* If you don’t like the spirituality of twelve-step groups, try alternatives such as SMART Recovery, Ratio-
nal Recovery, or SOS. Many people who don’t like AA like these, because they take a rational rather than spiritual ap-
proach and do not view addiction as a lifelong disease.

* Set a weekly goal that’s realistic for you, and then stick to it. Better to promise yourself two meetings a
week and go, than to promise yourself seven and not go at all.

* Remember that self-help groups are designed to focus only on addiction, not PTSD. Use the groups
for what they can give, and don’t feel that you need to talk about your PTSD unless it is welcome there. Many people
don’t understand PTSD, so don’t be surprised by that.

* Sometimes you may hear people take an antimedication stand (“Using Prozac is just as bad as using co-
caine”) or an antitherapy stand (“All you need is AA”). This is not the official policy of self-help groups, and you can
ignore that advice.

* Some people with PTSD have difficulty with self-help groups because they can’t be around a lot of peo-
ple due to social fears or paranoia, because they get drawn into unhealthy relationships with people there, or for any
number of other reasons. If you’ve really tried to get involved in self-help and still don’t like it, that’s okay. No one
should make you feel bad or wrong for not going. It is a personal choice, and there are many paths for healing.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 8 When Substances Control You

Substance Abuse and PTSD: Common Questions

Because the link between substance abuse and PTSD has only recently been studied, you may hear many things
about this dual diagnosis. Below are some ideas to help sort out what you hear.

Question: Is it true that I have to get clean from substances before I can work on my PTSD?
Response: This is one of the most common messages. However, experts generally believe that the two disor-
ders can and should be treated at the same time. This is called integrated treatment and can prevent the “revolving
door” problem—you get clean, become overwhelmed by the PTSD, use substances again, and keep going around
and around.
You can work on both disorders at the same time, as long as the focus is on safety throughout your recovery.
Everyone can benefit from “current-focused treatment.” This means learning to cope with both PTSD and substance
abuse in the present (e.g., learning about the two disorders, practicing new skills to gain control over them, and be-
coming aware of how they impact each other). In addition, for some people “past-focused treatment” may also be
useful; this means talking in detail about your past (sometimes called “exposure therapy” or “mourning”). Note,
however, that such treatment is very upsetting; it is important to work with your therapist to assess whether you are
safe to do such work now, or should wait until later in your recovery. (See the next question below for more on this
issue.)
It is also important to emphasize that most experts agree that getting clean is necessary in the long term for full
healing from PTSD (see the topic PTSD: Taking Back Your Power for more on full healing). Using substances prevents
healing from PTSD.
You may be aware that some people—and usually well-meaning people—will tell you a very extreme message,
such as “You cannot work on PTSD until you have been abstinent for a certain number of months, such as 6 months
or a year.” Or they may say, “The only problem that really matters is your substance abuse—that’s the only thing you
need to focus on.” If you have been involved in treatment that deals only with PTSD but not substance abuse, you
may have heard the reverse message. Again, the key point is that working on both disorders at the same time is cur-
rently believed to be the best treatment for this dual diagnosis. Both your PTSD and your substance abuse matter,
and learning to cope safely with both right now is highly recommended.

Question: Is it helpful to talk about my painful trauma memories right away in treatment?
Response: For some people it may be helpful; for others it may not. This is a complex issue, and too little is
known about it at this point. However, “integrated treatment” (treating both PTSD and substance abuse at the same
time) does not mean that you have to delve into painful memories of the past while you are trying to get “clean.” For
some people this is too overwhelming, and clinical experience suggests that it may lead to relapsing on substances if
adequate coping skills are not in place. That is why the Seeking Safety treatment is designed to teach you coping
skills that can make it possible to talk about painful material later, when you may be more able to handle it.

(cont.)
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book for personal use only (see copyright page for details).

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HANDOUT 8 (page 2 of 2) When Substances Control You

Question: Do I have to go to AA or other self-help groups?

Response: Some people with PTSD and substance abuse find them extremely helpful; some dislike them; and
some are neutral. If you like them, that’s terrific. If you have tried them and do not like them, that is okay too—there
are many ways to get clean and sober, and you need to find the ways that work for you (e.g., psychotherapy, drug
counseling, medications). Sometimes people feel pressured to go to self-help groups, and this pressure can make
them feel bad about themselves (which does not help their PTSD!). It is entirely valid to have your own views on self-
help groups, particularly if you have given them a chance. If you have not tried them, it is important to give them a
chance. However, some people with severe social anxiety may first need to make progress in individual treatment,
such as psychotherapy, before trying them. In short, people heal in many different ways, and you need to respect
your own path and find what fits you as a person. The best bet is to shop around.

Question: I have problems other than just substance abuse and PTSD; is it okay to focus on those too?
Response: Not only is it okay, it is recommended. You are a person, not a label. People with substance abuse
and PTSD often have additional problems, such as other addictions (e.g., gambling, eating disorders) and other gen-
eral life problems (e.g., lack of a job, homelessness, medical problems, domestic violence). Working on whatever
problems are most important to you right now and most central to your survival is usually the best. Also, be aware
that you can apply the Seeking Safety treatment to any problems for which you find it helpful.

Question: I’ll feel better once I’m abstinent, right?

Response: You may or may not in the short term, but over the long term you will. Not enough is known at this
point about the typical pattern, but clinical experience suggests that some people feel worse before they feel better.
This is important to remember, because if you get clean and start to feel bad, you can know that it truly will go away
over time: Just hang in there, get support, and cope, cope, cope. Sometimes people talk about dual diagnoses as if
they are all the same, and they may tell you that you’ll feel better quickly with abstinence. But dual diagnoses are not
all the same. For example, people with substance abuse and depression sometimes find that as soon as they get
“clean,” their depression goes away. With PTSD, this is believed to be less likely.

Question: Is it true that substance abuse is “self-medication” of my PTSD?

Response: Many people report this. They experienced trauma, then became addicted to substances as a mis-
guided attempt to cope with the psychological pain of the trauma. However, other people had substance abuse first
and experienced trauma after that (sometimes due to the substance abuse, such as hanging out with unsafe people
or getting into danger when high). For others, they grew up in homes where both trauma and substance abuse were
always present. Regardless of which way the two disorders originally developed, once you have both, they often be-
come intertwined. This means that right now you need help with both.

Keep in mind that much more research is needed to turn these responses into facts. These are emerging
views based on what we know so far from research and clinical writings. However, it is important to keep conducting
research and learning from people who actually have PTSD and substance abuse to understand more about these
topics. Just as you need to keep learning, so too do the fields of substance abuse and mental health!

Acknowledgments: In Handout 1, the definitions of substance use disorders are derived from the American Psychiatric Association (1994). In
Handout 3, the ways to give up substances are drawn from Miller and Page (1991). In Handout 4, the title and illustration are from Sobell and
Sobell (1993) (copyright 1993 by The Guilford Press; reprinted by permission) and “Three Main Thoughts That Lead to Substance Abuse” are from
DuWors (1992). Ask your therapist for guidance if you would like to locate any of these sources.

162
 When Substances Control You

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Try a twelve-step group meeting, such as AA, and see how you like it.
ª Option 2: Read the following quotation:

“What can be imagined can be achieved.”

—T. Peavey

Write a description of your life as a person who is able to overcome PTSD and substance abuse. What would
your day-to-day life be like? How would you relate to others? How would you manage frustrations and disap-
pointments? If you want, give this “person” a name to better remember this vision.
ª Option 3: Create a list of rewards for yourself to choose from for every day you don’t use substances—then
really give yourself a reward if you earn it.
ª Option 4: Take a piece of paper. Draw a line down the middle. In the left column, write a list of “advantages”
of using substances. In the right column, write a list of “disadvantages” of using substances. Which side mat-
ters more?
ª Option 5: Imagine the following scene:

You have made a commitment to “try an experiment” and not use any substances for a week. By Wednes-
day, you feel overwhelmed, you can’t sleep, and you desperately want to feel better for a little while. You
fight with yourself, but end up smoking a joint.

Rehearse how you could seek self-understanding about this incident (or any other relevant scene from
your life). If possible, rehearse it out loud with a friend, sponsor, or therapist and get feedback.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

163
INTERPERSONAL

Asking for Help

SUMMARY

Each of the disorders—PTSD and substance abuse—leads to problems in asking for help. To-
day’s topic encourages patients to become aware of their need for help, and provides guid-
ance in how to do so effectively.

ORIENTATION

“It feels like the telephone weighs a thousand pounds.”

“I lose whether I get help or not. If I get help, I feel guilty; if I don’t, I feel humiliated and
alone.”

“How hard is it to ask for help? I think it’s easier to give up cocaine than to ask for help.”

“Everyone in my life has hurt me one way or another. I guess I’ll have to try to trust. It’s
not easy—I can’t take any more hurt.”

For both PTSD and substance abuse, others’ help is essential. It has been said, “The power of
drugs equals the need for help. . . . They are as closely related as supply and demand in eco-
nomics, as inseparable as pressure and volume in behavior of gasses. . . . The gun is pointed
at my head: get help or die” (DuWors, 1992, pp. 97–99). Similarly, for severe PTSD it has
been said that healing can take place only in the context of relationships (Herman, 1992).
There are good reasons why patients may find it hard to reach out for help. They may
have had no one to trust while growing up; they may feel a need to keep up an image as some-
one “strong”; they may have learned that asking for help evokes punishment. For many pa-
tients with PTSD, sufficient help was not available at the time of the trauma, and they may

164
Asking for Help 165

feel unable to seek help now when it is more available to them. Substance use may have come
to seem like the only “help” they could get. Some patients may have sought help from sys-
tems that failed them, such as treatment systems ignorant about PTSD or substance abuse, or
legal systems that may have punished them rather than providing treatment. For a descrip-
tion of one patient’s dilemmas in asking for help, see “A Patient’s Story: Why It’s Hard to Ask
for Help” at the end of this topic.
Today’s topic provides explicit instruction in how to reach out more often, and more ef-
fectively, toward others. This skill can literally save lives in times of need. Because there are
many people in patients’ lives who truly cannot or will not provide help, a key theme is learn-
ing to move on to others who can, even if only to treaters. See also the topic Setting Bound-
aries in Relationships for more on getting patients to say “yes” to help from others.

Countertransference Issues

Some therapists, particularly if they grew up in a supportive environment, underestimate pa-

tients’ obstacles in seeking help. They may believe that the problem is mostly in patients’ per-
ceptions rather than in reality, and they may be unaware of some real dangers in reaching out
for help. See “Suggestions” (below) for more on this issue.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 170. Link the quotation to the session—for example,
“Today we’ll focus on asking for help. That may feel like a big risk for some people—but it is
incredibly important to learn to take that risk and reach out.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts:
Handout 1: Asking for Help
Handout 2: Approach Sheet
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals

¨ Discuss effective ways to ask for help.

¨ Rehearse how to ask for help.
¨ Explore patients’ experiences in asking for help.
166 Treatment Topics

Ways to Relate the Material to Patients’ Lives

ê Role plays. The best situations to role-play are current, real-life situations that patients
raise. Also, patients can choose upcoming events that provide an opportunity to reach out for
help. If a patient has had any unsafe behavior since the last session (substance use, starting a
physical fight, self-cutting, unprotected sex, suicide attempt), it is strongly recommended that
this be the top priority in rehearsing the skill. For example, you might say, “Role-play the last
time you used a substance. Whom could you have called? What could you have said?” Other
role-play ideas include “Tell your therapist you don’t feel safe,” “Call a friend when you are
feeling lonely,” “Ask someone to go with you to a self-help meeting,” “Ask your partner to help
you review the material in this treatment,” or “Call someone if you feel like hurting yourself
or someone else.”
ê Work on the Approach Sheet (Handout 2). Help patients identify a current situation
that would benefit from asking for help, and process how to go about it. The goal is to get pa-
tients out of the assumptions “in their heads” and into finding out “what’s real.” Thus, guide
them to fill out the first three boxes of Handout 2, the blank Approach Sheet (what help they
need help, whom they can ask, and what they predict will happen). Then, before the next ses-
sion, they can try actually asking for the help specified and observe whether their prediction
was accurate (filling out the fourth box in the sheet).
To help create a success experience, make sure that patients are truly trying something
new and not just going through the motions; try to set up a situation with the most likelihood
of success (e.g., asking someone safe); explicitly discuss how to prepare if a request for help
doesn’t go well; explore practical and emotional obstacles to following through on the assign-
ment; and, when patients come to the next session, process what happened. If it didn’t go
well, the idea is to help patients learn something constructive from the experience (e.g., “I’m
able to take a risk,” or “Now I know I need to find other people to ask help from”). Also, find
out how they asked for help, and give honest feedback and instructions on more effective
ways.
ê Discussion
• “What do you most want help with?”
• “Why is asking for help such a crucial coping skill?”
• “Was there a time recently when you needed to call someone for help, but didn’t?”
• “Is it harder to ask for help with your PTSD, your substance abuse, or both equally?”
• “Why might PTSD and substance abuse make it hard for you to ask for help?”
• “What happens when you do not ask for help?”
• “Are there any successes you’ve had in asking for help? What made those possible?”
• “Do you think you can learn to ask for more help?”
• “How can you cope if the other person refuses to help?”
• “If you feel an impulse toward a destructive behavior, do you know whom you would
call and what you would say?”
• “Why would asking for help make you more independent in the long run?”
• “Can you ‘coach’ the other person in advance on what you want him or her to say?”
Asking for Help 167

Suggestions
✦ You may want to introduce the topic with a simple, forceful statement: “I am going to
tell you one of the greatest secrets of recovery you will ever hear. This is like a law of physics
and as solid as the ground we walk on: You need help from others to recover.” Allow patients
to respond to this, and praise any positive examples they provide of asking for help.
✦ Out-loud rehearsal is typically most effective. Having patients rehearse how they
would ask for help tends to be more engaging than a general discussion. Thus role plays and
the Approach Sheet generally work best.
✦ Note that some patients have no one safe to ask help from. This is a very real situa-
tion for some people. In this case, the goal becomes practicing asking help from treaters
(e.g., a hotline, an AA member or sponsor, a therapist). It is usually less helpful to “debate”
with patients whether particular friends or family members really would be there for
them—patients’ instincts may be accurate, and the goal of the session is to have them lo-
cate help anywhere they can. Treaters are an excellent source for mastering the skill of ask-
ing for help, and over time, patients may then be able to move on to developing a safe sup-
port network of nontreaters. Patients can be encouraged even now to get involved in
activities that will help them to build a support network (e.g., self-help groups, leisure ac-
tivities, religious organizations). However, some patients are not yet capable of utilizing
these, in which case treaters become the “fall-back” option. You may also want to offer pa-
tients resources from Handout 1 in the topic Community Resources, which provides many
toll-free numbers for obtaining informational help. Here too, just practicing reaching out is
the goal.
✦ Be sure to take very seriously that there may be valid reasons why asking for help is
genuinely dangerous for some patients at this point. Sometimes patients have abusive part-
ners who will hurt them if they seek help; at other times, emotional obstacles may be danger-
ous (e.g., “If I don’t get the help I ask for, I become suicidal”), or treaters/treatment systems
are unhelpful. The most important strategy is usually to empathize with patients’ fears and to
redirect them to safe options. For example, a patient can plan on asking for help just before or
during a therapy session (such as making a call in the therapist’s office) to be able to process
how it went. It is not helpful, in contrast, to respond with simplistic “cheerleading” such as
“Just keep trying with your partner,” or “You can do it!”
✦ Encourage patients to instruct people in their lives about the kind of help they need.
For example, one concern patients raise is that if they ask for help before using a substance,
the other person will try to talk them out of it. Try to have patients rehearse explicitly in ad-
vance what they want the other person to say—for example, “I cannot stop you from using,
but I am worried about you,” or “I will just listen to anything you want to say.” See the topic
Getting Others to Support Your Recovery for more on this.
✦ It may be safest to start with concrete, physical help rather than emotional help. For
example, asking a friend for a ride to a self-help meeting may be easier than asking for advice
on a complex emotional problem. The goal is to take a step, however small, toward reaching
out to others in a time of need. Adjusting the level of difficulty of the task (not too hard, not
too easy) is key. Also, patients should select someone who truly has the potential to help, not a
168 Treatment Topics

“hopeless case,” such as a family member who has abused them or a friend who has refused to
help in the past.
✦ Any time is better than no time. Sometimes patients believe that they can only ask for
help before using (or other such events) and once they’ve begun a self-destructive act it is too
late to reach out. Process ways to ask for help at any point in the sequence, as in this example:

Before: “Call someone when you have a drug craving, before you use.”
During: “If you’re at a bar, go to the pay phone and call your sponsor.”
After: “Call a friend the next day to discuss what happened.”
✦ Identify ways to cope with rejection before it happens. Rehearse how patients might
handle it if a person refuses a request for help. Cognitive strategies may be especially helpful,
such as explanations that are not self-blaming: “I guess the person I asked just isn’t as gener-
ous as I had thought,” “I can learn from this and try again later with someone else,” “I need to
give myself credit for trying, even if it didn’t work out as I had hoped.”
✦ Persistence matters. Patients should not give up easily. Offer suggestions, such as “You
may have to ask twice for someone to ‘hear’ you,” or “If one person can’t help you, try another
person immediately.”
✦ Patients may be afraid of becoming too dependent if they ask for help. It is often a
surprise that in fact it makes them more independent in the long run. Learning to recog-
nize and prioritize one’s needs, knowing how to put a request for help into words, tolerat-
ing the vulnerability of such a request—all of these empower patients and increase
strength and self-esteem. Asking for help means that one is not afraid of people and can
join with others safely.
✦ Notice how patients ask for help, particularly in the role plays. You may need to give
honest feedback and instructions on more effective ways to ask for help. For example, one pa-
tient said, “I told my partner that she was totally unhelpful and that she had to start helping
me from now on.” This person needed guidance in softening the approach.
✦ Some patients may not understand the quotation. You may want to emphasize that it sug-
gests the importance of taking risks in life. Not taking risks, though it may feel “self-protective,”
can keep one alone and isolated. Reaching out for help is an important risk to take.

Tough Cases
∗ “I’m always helping others, but no one helps me.”
∗ “I can ask for help in role plays, but not in real life.”
∗ “I don’t have anyone in my life to ask help from.”
∗ “Whenever I ask for help, I get rejected.”
∗ “I can’t ask for help when I feel like using—I don’t want to be talked out of it.”
∗ “I’m calling you from a pay phone and I need help right now; I’m going to kill myself.”
∗ “My family does not want me to get help from anyone except them.”
∗ “When I was growing up, I was beaten if I asked for help.”
∗ “As a Latino in this society, I can only ask for help from other Latinos.”
Asking for Help 169

A PATIENT’S STORY: WHY IT’S HARD TO ASK FOR HELP

“My trauma started around the time I was about 5 or so. Always around nighttime, when
the lights went out, it was a scary time. Bad things happened in the dark. I would pretend
to be asleep but that didn’t matter. If I closed my eyes, it would go away. But that wasn’t
true. I would hold onto my doll for comfort. Sometimes I would hold on so tight I thought
her head would pop off.
“So why didn’t I ask for help? If only I went for help, I could have stopped the whole
thing. But I didn’t. I did nothing; I let it all happen. Was I stupid? Or maybe I liked it?
Please give me the answers—I don’t have them. I feel dirty, always feeling dirty. Growing
up, and even now when I think about it, it was always my fault. I didn’t stop any of it.
Even after the rape at 11 years old, I still didn’t tell anyone. Even as an adult, I let it go on
in my marriage. An adult! I should have stopped it then. But I didn’t. I’m just a little girl
crying for help but not doing anything about it.
“Well, yes, my trauma did happen as a little girl. That’s just it—a little girl. This man
was very powerful. There was no way I could stop this person who was terrifying me. No,
I am not stupid, and I did not enjoy it. It sickens me when I think about it. I couldn’t go for
help because then my sisters would have been hurt. I was helpless. He was my father, a
very powerful figure in my life. I may not have gotten help then, but I’m getting help now.
It’s never too late to ask for help. I will get my life in order and stand on my own two feet.
If I talked then, bad things would have happened. Well, no more. I will not be hurt any
more in my life.”
 Quotation

“And the trouble is,

if you don’t risk anything,
you risk even more.”
—Erica Jong
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

170
HANDOUT 1 Asking for Help

Asking for Help

MAIN POINTS

« It is very common to have difficulty asking for help if you have PTSD and substance abuse.

« You must get help from others to recover. No one can do it alone.

« In learning to ask for help, start “small”: Practice on safe people, with simple requests.

« Try to ask for help before a problem becomes overwhelming. But you can call any time—before, during,
or after a hard time.

« Prepare how you’ll handle it if the person refuses your request for help.

« In asking for help, you don’t have to “spill” everything.

« Asking for help makes you stronger and more independent in the long run.

« Learning to ask for help may feel very awkward at first.

« If there is no one in your life to ask help from, work on building a support network.

« When asking for help, be gentle—no demands, threats, or insults.

« Discover whether your fears are accurate: Compare your prediction to reality.

« Carry in your wallet a list of phone numbers you can call.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

171
HANDOUT 2 Asking for Help

Approach Sheet

« Fill in the first three parts now. Later, after you’ve approached the person, fill in the last part.
(1) Who will you talk to?

(2) What will you say?

(3) What do you predict will happen?

(4) What did happen in reality?

« You may want to ask yourself:

u What did you learn from trying this?
u Did you get what you wanted, or at least part of what you wanted?
u Is there anything you might do differently next time?
u How do you feel about your experience?
u How difficult was it?

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

172
 Asking for Help

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Write a list of people you can call when you are having problems (e.g., wanting to talk, feeling
afraid, drug cravings, needing a ride, etc.). Include friends, family members, self-help sponsors, treaters, hot-
lines, drop-in centers, and anyone else you can think of (see example below).

List of people to call for help

1. My friend Martha: 466-4215 or 252-7655
2. My therapist (Dr. Klein): 855-1111 or can page at 855-1000
3. My AA sponsor (Barbara): 731-1502

ª Option 2: Go for it! Fill out the Approach Sheet.

APPROACH SHEET—EXAMPLE

Fill in the first three parts now. Later, after you’ve approached the person, fill in the last part.
(1) Who will you talk to?

My friend Elizabeth.

(2) What will you say?

“Please help me not drink at the party tonight—you can help

by not offering me any alcohol and checking in with me
at times during the party to see if I’m okay.”

(3) What do you predict will happen?

She won’t want to help me. She’ll think I’m pathetic.

(4) What did happen in reality?

I called Elizabeth. She was very willing to watch out for me

at the party, and also gave me the phone number for a good AA group
in town. She didn’t convey any judgment or negative views of me.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

173
BEHAVIORAL

Taking Good Care of Yourself

SUMMARY

Patients are guided to explore how well they take care of themselves, using a questionnaire
listing specific behaviors (e.g., “Do you get annual medical check-ups?”, “Do you have safe
sex?”). They are asked to take immediate action to improve at least one self-care problem.

ORIENTATION

“I need to remember that my problems are as important as anyone else’s.”

The concept of “self-care” is introduced as another means of attaining safety in one’s life.
PTSD and substance abuse almost always lead to deficits in self-care, such as not eating prop-
erly or not obtaining needed medical care. Patients are guided to recognize that self-care is a
way of treating oneself with respect, valuing one’s body, and attending to one’s needs. A few
points to keep in mind:
Self-neglect as part of PTSD. Many patients learned, as a result of trauma, that their
needs were not important. A typical thought is “If no one else cares, why should I?” Those
who were childhood victims may not even be aware that they are neglecting themselves, be-
cause they are so used to being treated badly. They need to learn to listen to their needs to
break the cycle of neglect. Even with adult-onset PTSD, self-neglect is often present and may
be associated with suicidal thinking, self-blame, or guilt (e.g., “I didn’t deserve to survive the
fire when others died; I feel bad about being nice to myself now”).
The downward spiral of substance abuse. Severe substance abuse can lead to a down-
ward spiral in which, one after another, a person’s positive connections to the world are lost:
physical health, job, family, home, friends, and money. Such deterioration needs to be
stopped by active intervention on all fronts.
Poor role models of self-care. Many patients have had poor family models of self-care,
particularly if their own parents experienced substance abuse, trauma, or psychiatric prob-

174
Taking Good Care of Yourself 175

lems. They often lack basic knowledge about what is appropriate. One patient, for example,
talked about living for months with severe pain from a toothache because it didn’t occur to
her that she should not have to live with such pain.
Vulnerability to revictimization. People with PTSD are at higher risk of being retrauma-
tized than those without PTSD, and people with substance abuse are at higher risk of being
traumatized than those without substance abuse (Fullilove et al., 1993; Herman, 1992;
Najavits et al., 1997). Thus, in addition to the task of recovering from past trauma, the need
for protection from further trauma is very real. Many patients have such low self-regard that
they put themselves in dangerous situations. The patient who drives a car at high speed or
while dissociating; the patient who starts a barroom fight; the patient who gets into an abu-
sive relationship; the patient who walks alone after dark in a dangerous neighborhood—all
are putting themselves at risk for injury. Such behaviors may also reflect “passive suicidality”:
a wish to die, but without having to kill oneself directly.
Today’s topic offers a simple questionnaire for patients to identify their self-care prob-
lems, with the goal of then making a concrete plan to remedy at least one problem.

Countertransference Issues
Therapists may want to take the Self-Care Questionnaire themselves to better relate to pa-
tients’ own struggles in these areas. Also, some therapists may find it helpful to create an im-
age of patients as small children who need to learn self-care skills—imagining what each pa-
tient was like at age 7, for example. Creating such an image may make it easier to be
compassionate about these problems (as it often takes a lot of work to succeed in helping
them).

Acknowledgments
Khantzian (1985) has written about self-care deficits in substance abuse; Herman (1992) dis-
cusses it in relation to PTSD; and Trotter (1992) explores it in relation to the dual diagnosis of
PTSD and substance abuse.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 178. Link the quotation to the session—for example,
“Today we’ll continue to talk about self-care. The quote emphasizes the need to do the best
you can with your life.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handout, Self-Care Questionnaire.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.
176 Treatment Topics

SESSION CONTENT
Goals
¨ Discuss the concept of self-care and its relationship to PTSD and substance abuse.
¨ Help patients identify their specific self-care problems.
¨ Motivate patients to commit to immediate action on at least one self-care problem.

Ways to Relate the Material to Patients’ Lives

ê Ask patients to fill out the Self-Care Questionnaire. Ask patients to report their total
score if they feel comfortable doing so.
ê Identify one self-care problem to improve. The simplest way is for patients to select
one of the self-care deficits they have identified on the Self-Care Questionnaire. They should
pick a realistic but significant goal that can be achieved before the next session. This can
serve as their commitment at the check-out, if desired. Also, help patients explore emotional
and practical obstacles that may arise in working on their chosen goal. Patients can report at
the next session how it went (e.g., what they did, how it felt, and whether they can continue
to keep it up).
ê Discussion
• “What did you learn from doing the Self-Care Questionnaire?”
• “Did any feelings come up as you were doing the Self-Care Questionnaire?”
• “What does ‘self-care’ mean?”
• “What is ‘self-neglect’?”
• “Do you have any self-care problems that were not on the Self-Care Question-
naire?”
• “Why do you think PTSD and substance abuse are associated with self-care prob-
lems?”
• “Do you know anyone who takes good care of him- or herself (e.g., friend, colleague,
AA sponsor, therapist)? What can you learn from that person about self-care?”

Suggestions
✦For “resistant” patients, explore origins of self-care problems. Patients are often en-
trenched in their self-neglect. Redirecting them back to the meaning and origin of their self-
neglect is usually more successful than “debating” whether patients should change their be-
havior. Thus a therapist might say, “Let’s explore why it is that you do that to yourself,” “Did
anyone in your family do this?”, “Is it a way of telling the world something?”, “How could you
put into words what that behavior means?”, “What message are you giving yourself when you
don’t attend to that need?”
✦ Note that some patients take issue with the quotation. Some patients may know that
Janis Joplin was a heroin addict who died of an overdose. If they mention that, a possible re-
sponse is “Yes, and that’s why it’s so incredibly important to take care of oneself—not to end
up like that,” or “Yes, and isn’t it sad that she could not take her own advice well enough?” In
short, the fact of her death does not negate the quotation.
Taking Good Care of Yourself 177

Tough Cases
∗ “I don’t deserve to take better care of myself.”
∗ “I know my psychiatric meds help, but they are a constant reminder that I’ll never
have a normal life, so I don’t want to take them.”
∗ “I don’t have money to get an annual medical exam; I’ll be okay.”
∗ “I know about unsafe sex, but in the heat of the moment, I just don’t care.”
∗ “I have a lump in my breast, but I’m not getting an exam—it reminds me of abuse to
have a doctor touch me, and anyway I don’t want more bad news in my life.”
 Quotation

“Don’t compromise yourself.

You are all you’ve got.”
—Janis Joplin
(20th-century American singer)

From Seeking Safety by Lisa M. Najavits (2002).

178
HANDOUT Taking Good Care of Yourself

Self-Care Questionnaire

« 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
❤ Get 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 overeating)? 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 or 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 whom 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 1 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

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

179
HANDOUT (page 2 of 2) Taking Good Care of Yourself

❤ 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
Your score: (total number 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 be-
cause 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 questionnaire 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.”

180
 Taking Good Care of Yourself

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Identify one self-care problem from the Self-Care Questionnaire (one “no” answer) that you want
to work on. Before the next session, make that “no” into a “yes”—solve that self-care problem. If you want
to, write out how it went: How did it feel to do it? Was it successful? Any next steps you’d like to take?
ª Option 2: Take any four of the following words and write a page on how your life could be improved by at-
tending to them (be creative—there’s no right or wrong answer to this):

Self-Care Dignity Body Attention Love Effort

Knowledge Respect Safety Physical

ª Option 3: Find someone in your life who takes very good care of her- or himself. Interview this person, asking
everything you can about how the person does it, how it feels, and how the person learned it.
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation I have a bad toothache. I have a bad toothache.

« Your Coping «
Not doing anything about it. Call dentist immediately. Say
Just trying to put it out of to myself, “Even though I
mind. wasn’t taken good care of
when I was growing up, I
need to do things better
now.”

Consequence It keeps getting worse. I This feels strange—I’m used

feel miserable. to waiting until everything
is in crisis. But I know
this was the best way to
handle it.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

181
COGNITIVE

Compassion

SUMMARY

Patients with PTSD and substance abuse typically have enormous self-loathing. They “beat
themselves up” and blame themselves. Today’s topic guides patients to replace destructive
self-talk with compassionate self-talk. They are taught that only a loving stance toward the
self produces lasting change.

ORIENTATION

Patients are often quick to recognize that they use a lot of harsh self-talk. They typically say
that they do this because “it’s true” (e.g., “I’ve messed up my life and that’s just a fact”). Or,
they believe that such harshness is a way of taking responsibility (e.g., “I used again yester-
day. What a fool—it’s my own fault, I just never learn”).
In today’s topic, patients are taught that harsh self-talk is not “truth” or “responsibility.”
Rather, it is a pattern of reabusing themselves that for many was learned in childhood. If a
parent used harshness as a method of control, they internalized that voice until it is now part
of them. It can be a surprise for them to learn that harshness is an obstacle to growth. Harsh
self-talk rarely leads to positive change, and certainly not to lasting change. It is really a de-
fense against exploring, in an honest way, a particular problem. For example, a patient who
drinks despite repeated promises to quit may say, “I’m such a loser; I can’t do anything right.
I swear I won’t drink next time, no matter what.” This sort of internal dialogue is likely to re-
sult in the patient’s drinking next time. There is no exploration of why the drinking occurred.
A compassionate inner dialogue might be: “I know drinking is dangerous for me, but I did it
anyway. There must be a good reason for it. Maybe it’s because I’m still sad about my
brother’s death. I can call my sponsor and talk about how sad I feel.”
In teaching patients the contrast between harshness and compassion, it is important to
keep in mind that compassion can feel extremely difficult, unnatural, and wrong to them. And
it may bring up intense emotion. For example, one patient said that it made her much more
aware of sadness over the lack of love she had while growing up.

182
Compassion 183

In today’s topic, patients are asked to try to understand and rehearse this new, compas-
sionate approach to themselves. In addition, an optional exercise is to create an audiotape of
compassionate self-talk for patients to use outside of sessions—literally, an attempt to replace
the “old tapes” with newer, healthier versions.

Countertransference Issues

A common misinterpretation of compassion is that it means “cheerleading” or just saying nice

things to oneself. Compassion means understanding oneself at the deepest level, which often
evokes a mix of negative and positive feelings. Ironically, the therapist who tries to teach
compassion just through “warm fuzzies” is likely to convey a lack of compassion for the pa-
tient’s experience.

PREPARING FOR THE SESSION

♦ For the optional exercise, have available a tape recorder and cassette tape.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 185. Link the quotation to the session—for example,
“Today we’ll focus on compassion. The quotation suggests that understanding yourself is
better than judgment or blame.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2 for suggestions.
Handout 1: Harshness versus Compassion
Handout 2: Ways to Increase Compassion
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals

¨ Contrast harsh versus compassionate self-talk (Handout 1).

¨ Rehearse compassionate self-talk (Handout 2).
184 Treatment Topics

Ways to Relate the Material to Patients’ Lives

ê Role play. The therapist can play the harsh voice, with the patient responding compas-
sionately. Use patients’ real-life current examples whenever possible.
ê Identify a recent situation in which the patient had a dangerous behavior. Have the
patient rehearse out loud how talking compassionately might have prevented the dangerous
behavior. For example, how could the patient have used compassionate self-talk during a
craving to binge and purge on food, so as to prevent the binge–purge episode?
ê Create a cassette tape of compassionate self-talk. One can attempt to literally “change
old tapes” by recording a cassette of compassionate statements for the patient to play at
home. The tape can be created in the session, with the patient and/or therapist recording
statements that increase compassion (using the patient’s real-life examples and main points
from the handouts). The patient can also have safe family members and friends record state-
ments onto the tape.
ê Discussion
• “What does your harsh self-talk sound like? What does you compassionate self-talk
sound like?”
• “How might compassion prevent dangerous behavior?”
• “Does it bring up any feelings when you try talking to yourself compassionately?”
• “How are PTSD and substance abuse related to harsh self-talk?”

Suggestions
✦ If a patient wants to work on a global statement such as “I’m a failure,” make sure to
identify a specific time recently when the patient thought that. Trying to change a global view
is usually not helpful; trying to process a specific recent incident usually works better.
✦ Patients may misinterpret compassion as “making excuses for using.” It is essential
that patients get the message that compassion is helpful when it is used to prevent an inci-
dence of substance use (e.g., “How could you talk to yourself compassionately when you have
an urge to use, to avoid acting on the urge?”). Compassion can also be used to explore hidden
needs that may motivate use (e.g., feeling deprived, upset, alone) but it should never be used
to say, “It’s fine that I used a substance.”
✦ If doing the cassette tape in group therapy, you can make one tape and allow all pa-
tients to speak on it (while respecting any patient’s preference not to). No names should be
included, for confidentiality reasons. Copy the tape and give one to each patient at the next
session.

Tough Cases
∗ “This is for wimps.”
∗ “But I am a failure.”
∗ “How is this going to get my ex to stop harassing me?”
∗ “I’ve tried and I just can’t do this. It doesn’t work for me.”
 Quotation

“You yourself, as much as anybody

in the entire universe, deserve your
love and affection.”
—Buddha
(5th-century B.C. Indian philosopher)

From Seeking Safety by Lisa M. Najavits (2002).

185
HANDOUT 1 Compassion

Harshness versus Compassion

How do you tend to talk to yourself—harshly or with compassion?

Harsh Self-Talk Compassionate Self-Talk
Blaming, “beating yourself up” Loving, understanding
Prevents change Promotes change
Ignores the self Listens to the self
Is easy Is difficult

An example:
Harsh Self-Talk Compassionate Self-Talk
“I drank last night. What a loser! I can’t do “I know drinking is dangerous, but I did it
anything right.” anyway. There must be a reason. Maybe it’s
because I’m upset about my brother’s death.
Next time I feel an urge to drink, I’ll try to
prevent it by calling my sponsor to talk about
how I feel.”

Ideas to consider:
Harshness may be associated with PTSD and substance abuse.
PTSD. If you feel a lot of emotional pain, you may take it out on yourself. This can take the form of putting your-
self down (“You jerk!”) or physical abuse such as self-cutting. If you were harshly criticized in childhood, you
may have “internalized” those voices and are now criticizing yourself.
Substance abuse. Self-hatred often arises after using a substance. People feel ashamed and “yell” at themselves
to try to prevent it from happening again. Yet the best way to prevent it is to explore compassionately why
you used (e.g., feelings of deprivation? loneliness? fear?). Also, next time you have an urge to use, try talking
to yourself in a compassionate way to avoid giving in to the urge (i.e., meet your needs in some other way).
Compassion promotes growth, while harshness prevents growth. You may think that harshness is “true”
or is a way to “take responsibility”—that yelling at yourself will change your behavior. But self-hatred is a cheap trick,
an illusion. It is a psychological defense that prevents growth. It is a destructive habit that is all too easy to do. Re-
search shows that punishment does not change behavior in the long term; praise and understanding do. No matter
what you have done, you can take responsibility for it without beating yourself up. Compassion means searching
with an open, nonjudgmental mind into what happened. This promotes real change. If compassion is not familiar be-
cause you did not learn it when you were growing up, it may feel difficult. You may need to practice a lot for it to
feel natural.

« Think about your own life:

• What does your harsh self-talk sound like? What does your compassionate self-talk sound like?
• When you are harsh with yourself, does it keep you stuck in old behaviors?
• Is it easier for you to be harsh rather than compassionate with yourself?

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

186
HANDOUT 2 Compassion

Ways to Increase Compassion

When you notice harsh self-talk . . .

 Ask yourself, “If I loved myself, what would I say to myself right now?”
 Ask yourself, “If I were really listening to my deepest needs, what would I say to myself?”
 Try to explore the reasons underlying your actions. For example, if you drank, maybe it was because
you were in a lot of pain. If you blew a job interview, maybe it’s because you need more help and practice.
 Use kinder language; find a softer way to talk to yourself. For example, “I am a failure” is harsh, while “I
have suffered a lot, so my progress may be slower” is kinder.
 Imagine that you are talking to a small child who has made a mistake. How would you talk to that
child with compassion? For example, you might say, “It’s okay. At least you’re safe right now. You’re a good person
and you can keep figuring it out.”
 Experiment with compassion, even for just a few minutes. If it feels very difficult, you may want to try
“thought stopping” as a first step: Say “Stop thinking that!” loudly to yourself to break the cycle of harsh self-talk.
Then try compassion.
 Try practicing! In the following situations, how could you talk to yourself compassionately to prevent un-
safe behavior?
• You feel like using a substance because you are lonely.
• You just got laid off from your job, and you feel like punching a wall.
• Your partner broke up with you, and you want to kill yourself.
• You got a poor grade on an exam, so you want to binge on food.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

187
 Compassion

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Take the statement “I am a bad person.” How could you make this more compassionate?
ª Option 2: Write a paragraph about what compassion means to you. How would your life be different if you
were more compassionate toward yourself?
ª Option 3: Change the “old tapes” in your head by literally creating a new tape! Record a cassette tape with
compassionate, soothing statements. If you want, ask significant people in your life to record statements on
it too (e.g., family members, your therapist, your AA sponsor). Play the tape whenever your harsh self-talk
comes up.
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

Old Way New Way

Situation My daughter saw me using My daughter saw me using
drugs and looked really drugs and looked really
hurt. hurt.

« Your Coping « I said to myself, “You’re no I said to myself, “I must be

good. You’re not fit to be a feeling really upset and
parent. You always screw deprived if I used in front
up.” of her. How do I need to
take care of myself better
so that this won’t happen
again?”

Consequence I felt awful, lower than I tried to focus on

low. solutions, and called my
sponsor to get ideas.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

188
BEHAVIORAL

Red and Green Flags

SUMMARY

Patients are guided to (1) identify signs of danger and safety (“red and green flags”) for PTSD
and substance abuse, and (2) create a safety plan.

ORIENTATION

“Once I get to the danger zone, it takes a Wonder Woman effort for me to put on the brakes.
The more I say out loud, ‘I’m in trouble, I feel like drinking,’ the better. The more meetings
I attend, the more honestly I speak to my treaters, the less threatened I feel. My stressful
situations are ongoing: Leaving an abusive marriage and protecting my children are trig-
gers that loom large and frightening. I am deeply grateful that I was able to arrest my re-
lapse quickly and work intensively through this group and other treaters. Now I go to AA
meetings in my home town, and I have a local sponsor I call every day. Truly, I am not
alone.”

As this patient suggests, the slide into relapse is a serious threat, yet also something that can
be mastered with effort. The course of both PTSD and substance abuse is typically an up-
and-down one, especially for patients with chronic forms of the disorders. The danger of
worsening PTSD symptoms (e.g., suicidal feelings) and substance abuse symptoms (e.g., us-
ing) is an ongoing concern for both patient and therapist.
Moreover, these disorders are highly prone to repression as an intrapsychic defense in
the form of dissociation, minimization, and denial. Patients are thus, and often when most
in need, unaware of the seriousness of their symptoms. The goal of today’s topic is thus to
increase their awareness of the pattern by which they spiral downward (“red flags”) or, by
their active recovery efforts, spiral upward (“green flags”). Discussion of the spiral upward
is important, because many patients do not know that “good feeds on good” just as “bad

189
190 Treatment Topics

feeds on bad.” The latter is more familiar to people with devastated lives; it can instill hope
to convey explicitly that things do get easier over time if they can make it through early re-
covery.
An in-session exercise for this topic is the creation of a safety plan in which patients are
asked to specify what they can do when they reach levels of mild, moderate, and extreme
danger. By systematically writing out a plan for each level, patients can truly listen to them-
selves. In both PTSD and substance abuse, patients can so lose touch with themselves that
they cannot “hear” the messages their own behavior is sending them. They may get into
fights, isolate, and stop taking adequate care of their bodies, yet not recognize that these are
all communications of distress that require immediate attention. Providing a concrete plan
for “what to do when” reaffirms the benefit of active coping, particularly if it can be done in
the early stages rather than once it hits disaster levels. In short, it is another way of saying,
“Life does not have to be tragic. You, with others’ help, can write a new script.”

Countertransference Issues
Therapists may need to be alert to providing feedback that goes beyond patients’ own under-
standing. Although it is important to validate patients’ views of their danger and safety pat-
terns, the topic is enhanced when the therapist can add additional insight based on direct ex-
perience with particular patients over time. The therapist’s ability to discern patients’
behavioral messages can model what it means to listen at a deep level.

Acknowledgments
The concept of relapse warning signs is described at length in Marlatt and Gordon (1985).
The term “red flag” is from Trotter (1992, p. 104). The safety plan (Handout 2) is derived from
a form used in the McLean Hospital Women’s Day Treatment Program, author unknown.

PREPARING FOR THE SESSION

♦ Consider asking the patient to invite safe family members and/or friends to the session
to help implement the safety plan for this topic. See “Suggestions,” below.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 193. Link the quotation to the session—for example,
“Today we’re going to talk about signs of danger and safety. Just like the person in the story,
you can learn to notice the cues and not fall into same holes over and over.”
3. Relate the topic to patients’ lives (in-depth, most of session).
Red and Green Flags 191

a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2 for suggestions.
Handout 1: Signs of Danger versus Safety
Handout 2: Create a Safety Plan
Handout 3: Key Points about Red and Green Flags
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Help patients identify their signs of danger (red flags) and safety (green flags) (Hand-
out 1).
¨ Create a safety plan (Handout 2).
¨ Discuss typical patterns in relapse (Handout 3).

Ways to Relate the Material to Patients’ Lives

ê Ask patients to think of recent incidents. Substance use, self-harm, or other recent act-
ing-out behaviors may help patients get in touch with their red flags. Likewise, recent good
coping may help them identify their green flags.
ê Customize the safety plan. Develop the safety plan (Handout 2) to fit each patient’s
particular needs. Use the red and green flags the patient has already identified on Handout 1
as the basis for it. Provide feedback as needed. If desired, ask patients to sign the plan and
give copies to other treaters.
ê Discussion

Signs of Danger versus Safety (Handout 1)

• “Which red/green flags are most prominent for you?”
• “When did you last use a substance [or had other unsafe behavior]? Which red flags
led up to it?”
• “Is there some combination of signs that really tells you you’re in danger?”
• “When your red flags occur, do you think you ‘hear’ them as messages of distress?”
• “Whom can you talk to when you begin a downward spiral?”
• “Is there anyone who knows you well enough to alert you when you are in danger?”
Create a Safety Plan (Handout 2)
• “Why might it be helpful to develop a safety plan in advance?”
• “Where could you keep the safety plan so that you’ll remember it when you need
it?”
192 Treatment Topics

• “Is there anyone to whom you could give a copy of the safety plan? (Sponsor?
Friend?)”
• “Have you learned anything new about yourself by filling it out?”
Key Points about Red and Green Flags (Handout 3)
• “Have you ever been unaware of a serious red flag until it was too late?”
• “Why do you think most substance abuse relapse occurs within 90 days of absti-
nence?”
• “Why is it essential to get help from others if you start to spiral downward?”
• “Are you able to view your red flags as signs of distress?”

Suggestions
✦ Consider covering the material over two sessions. One way would be to discuss Hand-
outs 1 and 3 in one session, and do Handout 2 at the next session.
✦ Encourage patients to invite safe significant others to the session. They can help moni-
tor the patients’ red flags and help implement the safety plan. See the topic Getting Others to
Support Your Recovery for guidelines on conducting this type of joint session (not making it
into a family therapy session, guiding the significant others to support but not enable the pa-
tient, etc.). Even if patients’ significant others cannot come to the session, they can be given a
copy of the safety plan.

Tough Cases
∗ “When I cut my arm, I wasn’t aware of what was going on until after it happened.”
∗ “A lot of the red flags are true for me right now. This is depressing. I should just give
up.”
∗ “I don’t like filling out forms.”
∗ “I can write out a safety plan, but I can’t commit to it. I need to feel that I can kill my-
self if I want to.”
∗ “Isn’t this red/green flags list all-or-none thinking? I thought you said we should find a
middle ground?”
 Quotation

Chapters of My Life
Chapter 1:
I walked down the sidewalk and fell into a deep hole.
I couldn’t get out and I couldn’t figure out why. It
wasn’t my fault. It took a long time to get out.

Chapter 2:
I walked down the sidewalk and fell into the same
hole again. I couldn’t understand. It wasn’t my fault. I
really had to struggle to get out.

Chapter 3:
I walked down the sidewalk and fell into the same
hole again. This time I understood why and it was my
fault. This time it was easier to get out.

Chapter 4:
I walked down the sidewalk and saw the same big
hole. I walked around it. I didn’t fall into that hole.

Chapter 5:
I chose another sidewalk.
—Portia Nelson
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

193
HANDOUT 1 Red and Green Flags

Signs of Danger versus Safety

Listen to the messages your behavior is sending you!

« What are your red and green flags? Check off below:

% Red Flags % – Green Flags –

Danger Safety
Isolation Spending time with supportive people.
Not taking care of my body (food, sleep) Taking care of my body
Fights with people Able to get along
Too much free time Structured schedule
Destructive behavior Behavior under control
Feel stuck Feel I’m moving forward
Lying Honesty
Negative feelings acted out Negative feelings expressed in words
Canceling treatment sessions Attending all treatment regularly
Stop taking medications as prescribed (either too Taking medications as prescribed
much or too little)
Passive (“Why bother?”) Active coping
Cynical/negative Realistic/positive
Not fighting PTSD symptoms (e.g., dissociation, self- Fighting PTSD symptoms (e.g., grounding, rethinking,
cutting) etc.)
Not learning new coping skills Learning new coping skills
Become physically sick Stay physically healthy
Believe treatment is unnecessary Believe treatment is necessary
Spend time with people who use Spend time with “clean” people
Cannot hear feedback Listen to feedback
Too much responsibility Appropriate responsibility
Think people are trying to make me look and feel bad Feel okay around people
Stop caring; stop trying Care and try
Arrogant euphoria Realistic concern
Absent from work or school Attend work or school

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

194
HANDOUT 1 (page 2 of 2) Red and Green Flags

« What are your additional red flags? « What are your additional green flags?

195
HANDOUT 2 Red and Green Flags

Create a Safety Plan

« Fill in the safety plan using the following as an example:

Mild Danger (starting to show distress) What I Will Do to Stay Safe

• Eating poorly • Increase AA to three times a week
• Missing occasional treatment sessions • Tell therapist what I’m feeling
• Getting cynical and negative • Call my friend Pat and talk with her

% Red Flags % – Safety Plan –

Mild Danger What I Will Do to Stay Safe
(Starting to show distress)

Moderate Danger What I Will Do to Stay Safe

(Getting serious—watch out)

Serious Danger What I Will Do to Stay Safe

(Emergency!!)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

196
HANDOUT 3 Red and Green Flags

Key Points about Red and Green Flags

 Red flags are messages of distress. Just as a fever is a sign that you must rest your body, the red flags are
signs that you are in emotional distress. With PTSD and substance abuse, the tendency is to push them out of mind,
unconscious, not seeing the signs as they occur. But it is essential to notice the red flags and to validate that they are
there for a reason; they are not signs of weakness or failure, but messages to attend to yourself.
 Remember “budding.” Some people are helped by the acronym “BUD”—“Building Up to Drinking.” You
could also use “Building Up to Danger.” The list of red flags in Handouts 1 and 2 can be a sign that you are gearing
up to act destructively. There is a window of opportunity during which you can stop yourself from sliding downhill if
you can see the warning signs and actively try to cope with them. Thus dangerous times in both PTSD and substance
abuse are not all-or-none events, but rather gradual buildups that allow time to save yourself.
 Help from others is essential as danger escalates. As red flags increase, the need to reach out for help
from safe people increases too. One of the most difficult aspects of PTSD and substance abuse is isolation. As symp-
toms increase, the tendency is to hide away. That’s why it is necessary to plan in advance whom you will call and to
prepare that person for how to help you through a dangerous time. Rehearse what you will say to each other.
 Listen to the “whispers” before they become “screams.” A safety plan identifies your warning signs
and ways to respond to them. The safety plan in Handout 2 has three levels so that you can attend to mild danger
signs (level 1) before they become an emergency (level 3). The earlier in the process you take action, the better.
 As danger increases, so does acting out rather than talking. Notice that many of the danger signs are
behaviors. As distress increases, it is essential to keep talking about your feelings; otherwise you’ll likely find yourself
“acting them out” in your behavior. Think of a small child who feels hurt and starts punching a wall. When the child
cannot express the feelings directly, they get acted out.
 Most substance abuse relapses occur within 90 days of abstinence. Research shows the first 90 days to
be a vulnerable time, across various substances of abuse (heroin, smoking, alcohol). Thus knowing your danger signs
is especially important in early recovery.
 Notice spiraling. In recovery, there is a process of “spiraling” or “snowballing” that can occur in both posi-
tive and negative directions. A downward spiral occurs when symptoms start to pick up speed and get worse and
worse, often rapidly. An upward spiral occurs when your recovery efforts are so persistent that good things begin to
happen. For example, you get a job, and are therefore able to get an apartment in a safer area, where you can make
friends with healthier people, and so on . . .

Acknowledgments: The concept of relapse warning signs is described in detail in Marlatt and Gordon (1985). The term “red flag” is from Trotter
(1992). The safety plan (Handout 2) is derived from a form used in the McLean Hospital Women’s Day Treatment Program, author unknown. Ask
your therapist for guidance if you would like to locate any of these sources.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

197
 Red and Green Flags

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Give a copy of your safety plan to people you trust (e.g., safe family, friends, therapist, sponsor)
and ask them for comments.
ª Option 2: Write a personal story of bravery: “How I Faced a Red Flag and Won.”
ª Option 3: Write a “How To Help Me” guide that you can give to people in your life. Describe your danger
signs and what people can do to help when they see you slipping.
ª Option 4: Write out what you can say to yourself when you’re in (a) mild danger and (b) serious danger.
ª Option 5: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.

Old Way New Way

Situation Someone cut me off in Someone cut me off in
traffic. traffic.

« Your Coping «
Pissed off, tailgated him I need to see the danger
for the next 3 miles. Feel signs earlier. As soon as I
like I can’t take the feel this stressed, it means
stress. I keep thinking using comes next. I need a
about using. buffer from the world—I’m
going to go to a meeting,
and just take a “mental
health” day off from work.

Consequence Nothing is getting better; I was okay and felt more in

I’m slipping. control.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

198
INTERPERSONAL

Honesty

SUMMARY

Patients are encouraged to explore the role of honesty in recovery and to role-play specific
situations. Issues relevant to this topic include: What is the cost of dishonesty? When is it safe
to be honest? What if the other person doesn’t accept honesty?

ORIENTATION

“I haven’t told my doctor that I’m an alcoholic. I don’t want him to take away my benzos.”

“My trauma can’t be as bad as I’ve made it out to be; I must be making things up.”

“The Department of Social Services wants you to write a letter about my progress. Can you
leave out the relapse I had last month?”

“If I tell my family about the abuse, I’ll be the black sheep.”

“I don’t want to date that guy, but I can’t say ‘no.’ ”

Honesty, with oneself and others, is a central principle of recovery in both PTSD and sub-
stance abuse. Secrecy, lies, denial, and avoidance are hallmarks of both disorders. In PTSD
(particularly early chronic abuse), patients may have been punished or ignored if they spoke
out, and thus learned to suppress their truths. One patient, for example, was severely beaten
if she criticized her father; at the start of treatment, she was not even aware of critical
thoughts about others. Patients with single-incident trauma may also have difficulty facing its
impact, trying to pretend that they’re “really okay” when they’re not. In substance abuse, the
tendency toward denial, both intrapsychic and interpersonal, is well known. The shame of us-

199
200 Treatment Topics

ing may keep people lying about their use, no matter how supportive the family or treaters
may be.
In this topic, patients are encouraged to recognize the psychic costs of dishonesty: It
alienates them from others and perpetuates the idea that something about them is unaccept-
able and must be hidden. In contrast, honesty is liberating. In the pilot study of this treat-
ment, patients were asked to report what concepts were most important to them. At both the
end of treatment and 3 months later, they gave the highest rating to “Honesty is essential,”
with an average of 2.9 on a 0–3 scale at both time points (Najavits et al., 1996b).
Although honesty might be assumed to be equivalent to assertiveness (a mainstay of
CBT), the term “honesty” conveys an ideal that goes beyond just expressing one’s views. It is
meant to convey integrity, the notion of “owning” one’s experiences, and an almost spiritual
sense of acceptance. It also emphasizes patients’ relationship with themselves, whereas
“assertiveness” is typically a solely interpersonal construct.
Honesty is a complicated topic, however, as real risks are on the line for the patient.
Honesty needs to be selective. It may not be safe, for example, for a patient to confront an
abuser. Or, early in a dating relationship, it may not be wise for the patient to reveal past
trauma and substance abuse. In short, honesty is not an all-purpose tool. It requires careful
weighing of specific situations and risks.
It is also important for patients to understand that they may need to regain others’ trust if
they have lied about their substance abuse. Family members, friends, and treaters will need
to see consistent honesty over a long period time before believing a patient’s honesty. Thus,
too, requiring urinalysis as part of treatment is a fair request.
One potentially difficult situation is when the patient asks the therapist to hide infor-
mation from another treater. With regard to substance abuse, some examples are given
above in the patient quotations at the beginning of this section. In such scenarios, it is
strongly recommended that the therapist not keep secrets from other treaters. It usually
helps to suggest that the patient try talking honestly with the other treater, setting a date
by which that will happen (such as a few days). After the specified date, the therapist then
talks to the treater directly to confirm that the information has been conveyed. Although
there may be a risk of the patient’s dropping out of treatment, the greater risk is keeping
substance abuse secrets on behalf of the patient. Not only would this reinforce lying about
substance abuse, but it puts the therapist in the position of being an “enabler” and may at
times put other people in jeopardy. With regard to PTSD, in contrast, it is legitimate for
the patient to share some information with one treater but to prefer not to have that con-
veyed to others. The differing closeness of treatment relationships, the role of the treaters,
and patients’ feelings of vulnerability are legitimate reasons for keeping trauma material
confidential. The exception, as always, would be any threat or actuality of physical harm in
which the patient engages, against either self or others.
In encouraging patients to be honest, a key issue is helping them cope with others’ nega-
tive reactions. It helps to view honesty as a positive goal in and of itself, regardless of how the
other person responds. There will be growth either way: If the person has a positive reaction,
the relationship has increased closeness; if the person has a negative reaction, the patient has
learned more about the other person and can proceed accordingly. Unfortunately, patients
too often take a negative reaction not as information about the other person, but as a condem-
nation of themselves. Preparing in advance for negative reactions is thus important.
Honesty 201

The handout for today’s topic is designed to give patients the opportunity to explore hon-
esty by:

 Discussing the concept of honesty (how PTSD and substance abuse may lead to dis-
honesty; the emotional cost of dishonesty; and the idea of honesty both with oneself
and with others).
 Learning specific strategies to express honesty.
 Role-playing being honest, and learning how to cope with negative reactions by the
other person.
 Identifying when honesty might be unsafe; for example, in a situation of domestic vio-
lence, honesty may result in physical harm.

For a commitment, the strategy of “setting up an experiment” is suggested: The patient

predicts what will happen by being honest in a particular situation, and then sees how accu-
rate the prediction was. Systematically learning from such experiments can be helpful, and
patients are often surprised by the results. If desired, the Approach Sheet, Handout 2 from
the topic Asking for Help, can help structure this exercise.

Countertransference Issues
Because it can be so difficult for patients to be honest, respecting patients’ defenses and lo-
cating areas where they are able to make some progress is more helpful than trying to con-
vince patients of goals they resist. Thus, if a patient cannot be honest in a particular situa-
tion (e.g., is unable to break up with a romantic partner), aim lower for more achievable
goals.

PREPARING FOR THE SESSION

♦ Optional: The therapist may want to read the paperback book People of the Lie by
M. Scott Peck (1997), which discusses truthfulness, mental illness, and psychotherapy.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 204. Link the quotation to the session—for example,
“Today we’ll focus on honesty. As the quotation suggests, you can find the words to break the
silence.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handout, Honesty.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.
202 Treatment Topics

SESSION CONTENT
Goals
¨ Explore the role of honesty in recovery.
¨ Actively rehearse honesty.

Ways to Relate the Material to Patients’ Lives

êRole plays. Ask the patient to identify a current specific situation in which more hon-
esty would be helpful. Then have the patient practice being honest out loud. Guide the pa-
tient with questions such as, “What are you afraid might happen if you are honest in that situ-
ation?”, “How do you predict the other person will respond to your honesty?”, “How can you
cope if the other person does not respond well?”, “Will you be able to be honest (as re-
hearsed) in the real-life situation? Why or why not?”
ê Do a walk-through. Present hypothetical situations and ask how they might be han-
dled. For example, ask, “The next time you feel suicidal, would you be able to tell someone?”,
“The next time you feel like using a substance, whom would you tell?”, “If you wanted your
partner to practice safe sex, how would you tell him or her?”
ê Discussion
• “Think of a recent example when you were dishonest—were you trying to protect
yourself in some way?”
• “When you last used a substance (or had other dangerous behavior), were you hon-
est in telling anyone about it beforehand?”
• “How can you tell if it is safe to be honest with someone?”
• “Whom do you feel you need to lie to about substance abuse? About negative feel-
ings?”
• “How does honesty relate to your PTSD and substance abuse?”
• “Can you think of any times when you were honest and it helped you?”

Suggestions
✦ If patients say they are “always honest,” probe this. It generally means that they are
not aware of their dishonesty. Some ways to get at it include, “When you last used a sub-
stance, did you tell anyone beforehand?”, “Do you ever say to yourself, ‘I’ll never drink
again’?”
✦ Frame dishonesty as “self-protection.” Help patients take responsibility for their dis-
honesty, while avoiding blame. They may have had good reasons to lie to themselves or oth-
ers, and usually lying was an attempt to protect themselves in some way. For example, lying
about substance abuse may have made them feel less humiliated when talking to others; lying
about PTSD may have protected them from further abuse.
✦ Emphasize that honesty is essential for recovery. No matter how understandable the
motivations for dishonesty (see the point above), it is essential to strive for honesty. The goal
is to experiment with more honesty and evaluate the results.
✦ Note that honesty is not an all-or-none event. It is on a continuum from “more to
Honesty 203

less.” There may be situations when partial honesty is best (e.g., refusing a drink at an of-
fice party).
✦ When rehearsing honesty, try to explore how the patient can cope if the other person
does not respond well. One of the most common mistakes is to believe that honesty is suc-
cessful only if the other person responds positively, and to feel devastated if the response is
negative. When rehearsing honesty, try to get the patient to think out explicitly how to cope if
it does not go well. The coping can be internal (how to talk to oneself) or external (what to say
to the other person). Reinforce the point in the handout that honesty is valuable in and of it-
self.

Tough Cases
∗ “It will hurt the other person if I’m honest.”
∗ “Are you telling me I’m a liar?”
∗ “I never lie directly; I just leave out information.”
∗ “Honest? How about if I tell my boss he’s a f——g jerk!”
∗ “I can’t tell my kids about my substance abuse.”
∗ “I am a very honest person, but I’m not able to get off substances. How can this topic
help me?”
∗ “I was always taught that if you can’t say something nice, don’t say anything.”
∗ “I can be honest in the role play, but in real life I could never do it.”
 Quotation

“What are the words

you do not yet have?
What do you need to say?
. . . There are so many
silences to be broken.”
—Audre Lorde
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

204
HANDOUT Honesty

Honesty

WHAT WOULD YOU DO?

« Circle one answer for each question.
1. Your 10-year-old daughter gets upset when you drink. She asks, “Did you drink today?” (and you did).
Would you: (a) Tell the truth? (b) Lie?
2. Your therapist says something that makes you mad.
Would you: (a) Tell the truth? (b) Say nothing?
3. Using a substance will get you evicted from your halfway house. You use cocaine one night. At the daily
check-in the next day:
Would you: (a) Tell the truth? (b) Lie?

How many “a” answers? How many “b” answers?

ABOUT HONESTY
Why is honesty important?

 It promotes recovery.
 It helps you respect yourself.
 It improves your relationships.
 Other reasons:

What is the cost of dishonesty?

• It keeps you hidden and alone—people don’t know what’s really going on with you.
• It makes you feel ashamed—it’s hard to respect yourself when you’re lying.
• It can hurt other people—they may feel betrayed when they find out.
• Other costs:

In both PTSD and substance abuse, honesty may be very difficult. Dishonesty is usually an attempt to pro-
tect oneself.
People with substance abuse may lie to feel better about themselves.
Dishonesty with others: Minimizing your drug use; cheating on urine testing.
Dishonesty with yourself: Denying that you have a problem with substances; telling yourself, “I can have just
one drink.”
People with PTSD may lie to avoid pain.
Dishonesty with others: Pretending to feel okay when you don’t; keeping family secrets about abuse.
Dishonesty with yourself: Not facing what happened because it feels too painful; staying in an abusive rela-
tionship rather than leaving.
The foundation for all honesty is being true to yourself. Honesty with others first requires honesty with
self: “owning” your own needs, recognizing your feelings.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

205
HANDOUT (page 2 of 2) Honesty

There are two ways to be dishonest:

♦ Active lying: You say something that isn’t true. For example, you say you didn’t use drugs when you did.
♦ Passive lying: You don’t say something that is true. For example, you are angry at a friend, but you don’t
tell the person.
There are times when it’s okay not to be honest:

* When being honest is not safe (e.g., your partner will beat you).
* When you have tried before and found the person could not “hear” you (e.g., telling your mother about
your trauma).
* When full honesty is not necessary (e.g., early in a dating relationship, you may not want to reveal your
past trauma and substance abuse).
Honesty and relationships. Honesty in a relationship is like water and sun to a plant—essential for its survival.
When people don’t express what they really think and feel, eventually the relationship will die out. Also, if you avoid
honesty, you may end up exploding with anger or acting out your feelings through actions (e.g., you are mad at your
friend, so you show up late).

HOW TO BE MORE HONEST

 Recognize that honesty with yourself and others is essential for recovery.
 Say your views calmly and kindly. No put-downs, sarcasm, or yelling.
 Use “I” statements: “I feel,” “I think,” “I want.”
 Be specific: “I’d like you to stop making racist comments,” or “I’d like you to stop offering me drugs.”
 Emphasize positives that might help the person hear you better. For example, you might want to say
that you believe that being honest will help the relationship.
 If you get a bad reaction, do whatever you need to do to protect yourself. Stand your ground, leave
the situation, or decide that the other person can’t hear you right now. But don’t blame yourself. You tried some-
thing important and deserve to give yourself credit for that.
 A key point: Honesty is worthwhile even if others do not respond well. Honesty is a liberating emo-
tional experience that is independent of how others react. Although it is nice if others accept your honesty, just by
being honest you are being true to yourself, trying to help them know you in a genuine way, and “owning” your part
of the relationship. These are values that go beyond what one gets in return. The twelve steps of AA, and all of the
world’s religions and ethical systems, value honesty for its own sake; there is a lot of wisdom to that.
« List on the back of this page any current situations where you want to be more honest. Examples might in-
clude telling your therapist how you really feel; telling yourself that it’s not safe for you to use drugs; telling someone
that you feel angry.

206
 Honesty

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Try it and see! Identify a situation where you want to be more honest. Compare what you expect
(before) with what actually happened (after).
ª Option 2: Make a list of the things you’ve never told anyone, but want to be able to talk about. (Warning:
This may be difficult. Do not do it if it is too upsetting for you.)
ª Option 3: Write an essay exploring “Honesty with Self; Honesty with Others” (or some other issue related to
honesty).
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

Old Way New Way

Situation My 10-year-old daughter asked My 10-year-old daughter asked
me if I was drinking me if I was drinking
yesterday. yesterday.

« Your Coping « She gets so upset when she Even though it’s painful for
finds out I’ve been both of us, I need to tell
drinking. I can’t do that to her the truth. Maybe her
her—I can’t bear her feeling responses will help me stay
disappointed in me again. I away from alcohol next time.
feel like such a failure. I Whatever I’ve done, lying to
told her I didn’t drink. her will only drag us down.
I need to explain to her
that the alcohol is a
serious problem for me and
that I will do everything I
can to work on it.
Consequence Felt trashy and low—I don’t Felt bad about her being
want to have to lie to my upset, but know I did the
daughter. right thing. I feel like a
person with integrity.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

207
COGNITIVE

Recovery Thinking

SUMMARY

Thoughts associated with PTSD and substance abuse are contrasted with healthier “recovery
thinking.” Patients 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 re-
thinking is demonstrated through think-aloud and rethinking exercises.

ORIENTATION

A patient’s reasons for getting high or other unsafe behavior may have numerous, complex
meanings of long-standing origin. By exploring such meanings, the therapist is much more
likely to intervene at the deepest roots of the patient’s problems. Substance use may hold par-
ticular meanings for people with PTSD, including the following:

 A cry for help. “It shows people how out of control I feel.”
 A way to access one’s internal world (feelings, thoughts, memories). “I know there’s a
lot inside me I need to get to, and I can’t do it without getting stoned.”
 A way to shut off one’s internal world. “Addiction to drugs is my way of dealing with
the garbage and trying to shut everything off.”
 A way to get back at an abuser. By using, a patient may be saying via behavior, “You
can’t hurt me more,” or “I have control over my body now.”
 A prominent part of a chaotic family life. Patients often report that trauma and sub-
stance abuse existed in their family as far back as they can remember. “The trauma I experi-
enced was partly due to my mother’s alcoholism. During my mother’s drinking binges, my fa-
ther would force her into having sex with him. That was very traumatic for me as a child.”
 A slow suicide. “I use because I just want to die anyway.”
208
Recovery Thinking 209

 A way of reabusing oneself. “I use because I just don’t care and because I hate myself.”
 A genuine attempt at self-protection (i.e., a way to prevent worse self-harm). “When
the feelings get too overwhelming, I feel that my only options are to hurt myself or drink.”
 A method by the perpetrator to set the stage for abuse. “My uncle abused me starting
at age 11. He even had the nerve to try to bribe me with a bag of pot.”

Cognitive therapy offers strategies to help patients explore and change their meaning
systems. In today’s topic, an overview of cognitive therapy is provided, with emphasis on two
main strategies: (1) identifying the meanings patients create (particularly those associated
with PTSD and substance abuse); and (2) helping patients shift from thoughts that harm to
thoughts that heal (recovery thinking). In conducting the session, it may be helpful to keep in
mind several points.

 People with PTSD and substance abuse tend to feel blamed easily when discussing
“negative” thoughts. They might say, “My thoughts are bad too,” “It’s my fault that I don’t
feel better,” “I’m stupid,” or “My problems are all in my head.” The therapist can guard
against this by conveying a collaborative, empathic stance while realistically exploring how
patients’ meaning systems are affecting their lives. Making the points that everyone has
maladaptive thoughts to some degree, and that everyone can learn to modify them, may
also be helpful.
 Identifying and changing one’s thoughts are difficult skills to acquire. Many people
view thoughts and feelings as the same phenomena; are unaware of their thoughts; or have
no labels for their thoughts, actions, and feelings. And changing thinking requires a lot of
effort.
 Use simple terms. Cognitive therapy can be thought of as “rethinking,” “creating
meaning,” or “self-talk.” These sound less abstract than discussions of “cognition.”
 Misconceptions of cognitive therapy abound (Clark, 1995; Gluhoski, 1994). These in-
clude “Cognitive therapy is dry and technical, with a lot of forms to fill out,” “Cognitive ther-
apy is about changing negative thoughts to positive ones,” “Cognitive therapy is superficial; it
just looks at thoughts, but it’s really feelings that matter,” “Cognitive therapy is easy—you
just turn your thoughts around,” “Cognitive therapy makes patients feel bad for having
‘wrong’ thoughts,” and “Cognitive therapy is about telling people what to believe.” In fact,
when done well, cognitive therapy is a deep, emotional process of exploration, with tremen-
dous power to create enduring change. When done poorly, patients may feel diminished, con-
trolled, or misunderstood.
 Patients often feel very grateful for the focus on their thoughts. It helps them to make
sense of their experience and to access their internal world.

Countertransference Issues

 Being too “schoolish” or technical (e.g., drilling the distinction between thoughts and
feelings, rather than giving a global experience of the power of rethinking). This often occurs
if the therapist feels unfamiliar with rethinking. Rereading treatment manuals on cognitive
210 Treatment Topics

therapy—for example, Cognitive Therapy of Substance Abuse (Beck et al., 1993) or Cognitive
Therapy of Depression (Beck et al., 1979)—is essential if you don’t feel skilled at working on
rethinking.
 Not providing enough guidance to patients. Some therapists ask patients to rethink a
belief without providing the necessary guided Socratic questioning. For example, they might
say, “How could you think differently about this?” or “Try thinking about that in a new way.”
Yet patients cannot simply generate a new understanding of the world; it needs to be shaped
by a series of careful and specific questions. In testing this treatment, the cognitive topics
were the most difficult for therapists to do well; many simply did not know how to help pa-
tients shift their thinking. Although it is beyond the scope of this book to teach cognitive ther-
apy, it is essential to learn cognitive techniques before you ask patients to do them. Other ver-
sions of this problem include telling patients what to believe (“Stop saying you’re a bad
person—you’re a good person”) and not knowing what to do when a patient says that rethink-
ing does not work.
 Allowing rethinking to be a superficial exercise rather than a deeply emotional one. To
make it emotional, (1) the situation must be “hot” (i.e., the patient has strong negative affect
about it); (2) the rethinking needs to get to core assumptions the patient is making; and (3) the
rethinking needs to provide a realistic new understanding (i.e., not simplistic or unrealistic
thoughts). For example, a patient says he has never had friends and feels he never will. The
therapist says, “Go to an AA meeting, and you’ll meet people there”—ignoring the possibility
that the patient may have severe social skills deficits that need serious treatment before he
can realistically cultivate friendships.

Acknowledgments
The topic of cognitive restructuring has many authors, but derives principally from the work of
Aaron T. Beck and Albert Ellis (Ellis, McInerney, DiGiuseppe, & Yeager, 1988). The substance
abuse section of Handout 1, Notice What You Say to Yourself!, is based in part on Beck and col-
leagues (1993) and DuWors (1992). The idea of listing rethinking methods in Handout 2, Re-
thinking Tools, is based on “10 Ways to Untwist Your Thinking” in Burns (1990), and the handout
contains two methods taken directly from that source (“Think of the Consequences” and “Ex-
amine the Evidence”). Parts of this “Orientation” section were written by Bruce Liese, PhD.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 214. Link the quotation to the session. You may want to
ask whether anyone knows the story of The Little Engine That Could, and tell it briefly. That
is, there was a train trying to get up a steep hill and afraid it wouldn’t be able to, but its little
engine kept saying, “I think I can, I think I can,” and the train made it up the hill. Or you
might say, “How you think determines how you feel. In the quotation, the engine is trying
supportive thinking.”
Recovery Thinking 211

3. Relate the topic to patients’ lives (in-depth, most of session).

a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See
“Section Content” (below) and Chapter 2 for suggestions.
Handout 1: Notice What You Say to Yourself!
Handout 2: Rethinking Tools
Handout 3: About Rethinking
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT

Handout 1: Notice What You Say to Yourself!

Goal
¨ Guide patients to become more aware of thoughts associated with PTSD, substance
abuse, and recovery.

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to circle the thoughts on the handout that are most
prominent for them.
ê Conduct a think-aloud exercise. Ask a patient to recall a recent specific incident of
substance abuse or other unsafe behavior. Ask the person to “replay the scene as if it were a
movie, describing in detail what you were thinking before, during, and after.”
ê Discussion
• “What’s the difference between the left side of the page and the right in this hand-
out?”
• “What thoughts do you notice in yourself?”
• “What thoughts would you most like to change?”
• “Can you see why it’s important to notice what you’re thinking?”
• “Are there other thoughts you would add to either column?”
• “What would life be like if you could think like the right side of the page? How
would you act differently? How would you relate to others differently? How would
you feel differently?”

Suggestion
✦ Notice the full range of thoughts. Patients are likely to have a mix of maladaptive
thoughts (the left side of the page in this handout) and healthy thoughts (the right side of the
212 Treatment Topics

page). As always, it is helpful to reinforce patients’ healthy aspects, in addition to focusing on

pathology.

Handout 2: Rethinking Tools

Goal
¨ Help patients experience the power of rethinking by conducting a think-aloud exer-
cise using the rethinking tools.

Ways to Relate the Material to Patients’ Lives

ê Conduct a rethinking demonstration. In the spirit of “show it rather than say it,” this is
one of the best ways to help patients experience the rethinking model. Ask a patient to iden-
tify a recent unsafe situation associated with substance abuse and/or PTSD, and then work
through that example, using the Safe Coping Sheet. State out loud which rethinking tools you
are using, to help patients clearly understand the process.
ê Self-exploration. Ask patients to circle the rethinking tools that most appeal to them.
ê Illustrate each rethinking method. You may want to go through each rethinking tool,
allowing patients to describe how they would apply that specific tool to their lives, and an-
swering questions about each method.
ê Discussion
• “Which rethinking tools do you think might help you?”
• “Are there any tools you already use that are not on the list?”
• “How can you remember to actually ‘stop, look, and listen’—that is, to interrupt a
negative conversation with yourself and apply some of these tools?”
• “Do you think the tools are likely to work for you? If not, why not?”
• “Do you ever think your thoughts are ‘wrong’ or ‘bad’? If so, how could you rethink
that?”

Suggestions
✦Consider further reading. For more rethinking tools, you may also want to use the list
in The Feeling Good Handbook (Burns, 1990, pp. 118–119), which includes methods such as
“Define Terms,” “Cost–Benefit Analysis,” “Thinking in Shades of Gray,” and the “Double-
Standard Method.”
✦ Elicit feedback about whether the exercise worked. If you conduct a rethinking exer-
cise, be sure to get patients’ feedback about whether it worked for them; if it didn’t, process it
and/or retry it.

Handout 3: About Rethinking

Goal
¨ Deepen patients’ understanding of rethinking.
Recovery Thinking 213

Ways to Relate the Material to Patients’ Lives

ê Review key points. Ask the patients to summarize the main points of the handout, and
then use these as points of departure to work on the skill. For example, “What are some of the
main ideas on the handout? Are any of the ideas relevant for you?”
ê Discussion
• “Why do you think ‘hot thoughts’ are important for rethinking to work?”
• “What’s the difference between positive thinking and realistic thinking?”
• “If you try rethinking and it doesn’t work, what might you do differently?”

Suggestions
✦ Encourage patients to learn more about cognitive therapy. Some resources are listed
at the end of the handout, for example.
✦ Help patients process what to do when rethinking does not work. One of the most
common problems patients have is not being able to make rethinking work when they are in
severe distress. It is crucial to help patients during the session, using specific examples and
exploring methods (such as those on the handout) to deepen its impact.

Tough Cases
∗ “I’ve tried positive thinking before, and it doesn’t work for me.”
∗ “I ‘think’ my trauma was miserable. Are you saying I shouldn’t view it that way?”
∗ “I tried rethinking on the Safe Coping Sheet, but I didn’t feel any better after doing
it.”
∗ “Do you use rethinking yourself?”
∗ “When we do rethinking in the session it seems fine, but I can’t do it on my own.”
∗ “Am I supposed to memorize that long list of rethinking tools?”
 Quotation

“I think I can,
I think I can,
I think I can.”
—Watty Piper
(20th-century author
of the children’s book
The Little Engine That Could)

From Seeking Safety by Lisa M. Najavits (2002).

214
HANDOUT 1 Recovery Thinking

Notice What You Say to Yourself!

Recovery thinking means talking to yourself with respect and support.

SUBSTANCE ABUSE THOUGHTS

« Compare the thoughts associated with substance use (left column) to the thoughts associated with recovery
(right column).

Substance Abuse Thoughts versus Recovery Thoughts

“I need it now” versus “I can wait”
(Wants instant satisfaction) (Self-control)

“I don’t care about the future” versus “How will I feel later?”
(Unable to plan) (Able to plan)

“Things should always go smoothly” versus “Sometimes things go wrong”

(Can’t tolerate frustration) (Can tolerate frustration)

“I can do what I want” versus “If I use, I’ll hurt my kids”

(Focused only on self) (Focused on self and others)

“I need drugs to numb the pain” versus “I can tolerate feeling down”
(Can’t tolerate bad moods) (Can tolerate bad moods)

“Abstinence will be boring” versus “I can try new things”

(Afraid of boredom) (Locates exciting activities)

“I’ll never get over this” versus “Take it a step at a time”

(Overreacts) (Balanced)

“I might as well use—my life’s a mess” versus “I matter”

(Doesn’t care) (Cares)

“I’ll only have one drink” versus “I know I can’t use”

(Unrealistic) (Realistic)

“I have no self-discipline” versus “I can learn self-discipline”

(Stuck) (Seeks to grow)

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

215
HANDOUT 1 (page 2 of 2) Recovery Thinking

PTSD THOUGHTS
« Compare the thoughts associated with PTSD (left column) to the thoughts associated with recovery (right
column).

PTSD Thoughts versus Recovery Thoughts

“I’m worthless” versus “I did that well”
(Beats self up) (Builds self up)

“I want to cut my arm” versus “I want to solve the problem”

(Self-destructive) (Constructive)

“I don’t matter” versus “I need to attend to my needs”

(Neglects self) (Takes care of self)

“There’s no point” versus “Life is what I make it”

(Chooses to die) (Chooses to live)

“I’ll always be alone” versus “I can connect”

(Isolates) (Reaches out)

“I am my abuse” versus “I am a human being”

(Narrow identity) (Broad identity)

“Nothing will change” versus “I can grow”

(Rigid) (Flexible)

“I need to drink” versus “I can work on it”

(Seeks escape) (Confronts problems)

“I’m nothing” versus “I’m a decent person”

(Devaluing) (Affirming)

“I’m bad” versus “I’m good”

(Hates self) (Loves self)

“Bad relationships are all I can get” versus “I can find good people”
(Stays with unsafe people) (Seeks safe people)

“I can’t cope” versus “I can try”

(Gives up) (Seeks solutions)

“Suffering is all there is” versus “Life is a mix”

(Sees only pain) (Sees pleasure and pain)

216
HANDOUT 2 Recovery Thinking

Rethinking Tools

Try the following tools to change your thinking.

* List Your Options *

In any situation, you have choices, and it helps to identify them. For example, David was living with his parents and
feeling “pathetic, like a loser.” Instead of continuing to put himself down, he sat down and made a list of what he
could do: (1) Go to job counseling, get a job, and earn money to move out; (2) See if I can live with a friend; (3) Ap-
ply for disability and move out; (4) Stay with my parents but spend more time on my own. He began to see that he
had choices and that it was up to him to decide among them, rather than just feeling bad about the situation.

* Notice the Source *

Who’s telling you something? Can this person be believed? What are that person’s flaws? This strategy is especially
important when you are being criticized or given advice that you disagree with. For example, Judy’s aunt kept telling
her she was fat. Judy would get depressed and eat more, until she began to see that being talked to like that was
“not okay—it was disrespectful.” She began to see that her aunt was a very unhappy person who took out her pain
on the people around her.

* Imagine *
Create a mental picture that helps you feel better. For example, Allan imagined his “heart exploding” when he
had a panic attack, and this would make him feel more anxious. He changed the image to his heart as a “com-
puter,” hard-wired and solid—computers don’t just blow up and explode. You can create any image you want, as
long as you can picture it: Imagine yourself as a coach encouraging yourself, or an explorer embarking on a
search, or an artist playing with possibilities. You can also use your imagination to “invent a possible world”—
imagine how you want the future to be, and then move toward that (as in sports training, when an athlete imag-
ines a move before doing it).

* Praise Yourself *
Notice what you did right. Decades of research show that the most powerful method of growth is positive reinforce-
ment. This is the opposite of “beating yourself up” or “putting yourself down”—neither of which works to make you
better. Find every opportunity for praise, no matter how small. And be generous—there’s no such thing as overdoing
it when it’s well earned.

* Learn from Experience *

Find a meaningful lesson that can help you next time. For example, Doug asked his roommate to take his marijuana
plants out of the house, but the roommate refused. The lesson he learned was, “My roommate is not really there for
me. I need to either move out or find a new roommate who is less selfish and won’t drag down my recovery.”

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

217
HANDOUT 2 (page 2 of 3) Recovery Thinking

* Create a New Story *

Tell “what happened” in a way that is respectful of yourself. For example, Jennifer used to think of herself as “dam-
aged goods.” Eventually she rewrote the story: “Now I think of myself as a walking miracle, and feel a sense of es-
teem when I realize how far I’ve come, and how I’m really a good and decent human being.”

* Think of the Consequences *

Evaluate the pros and cons over the long term. You feel like having a hit of cocaine. It may feel great for 15 minutes.
But in the long term? You’ve wasted money; your body will feel worn out; you may dislike yourself more; your family
may be disappointed.

* Examine the Evidence *

Like a scientist or detective, strive to look at the facts objectively. Notice both sides, pro and con. For example, Jack
said, “I can’t get off drugs.” To examine the evidence, he wrote down two lists, Pro (e.g., “I’ve been using marijuana
every day for 3 months”) and Con (e.g., “I was able to quit for 6 months 4 years ago”). Notice that the lists include
only facts, not opinions. When Jack looked at the lists, he realized that he had had some past success with recovery
and felt a little more motivated to try again.

* Brainstorm *
Try to think of as many interpretations of a negative situation as possible. For example, if someone cuts you off in
driving, you could leap to “What a jerk! No one cares about anyone else.” Or you could generate other interpreta-
tions: “Maybe he just found out his wife has gone into labor,” “Maybe he’s a doctor rushing to the hospital to do sur-
gery.” This strategy is especially important for situations where you don’t know the truth and can’t find out. In this
situation, you can’t stop the other person’s car and ask why you were cut off on the road. In short, if you can’t know
for sure, you might as well go with an interpretation that makes you feel better.

* What’s the Real Impact? *

Sometimes it helps to ask, “What is the real impact on my life?” If you apply for a job and don’t get it, you may feel
depressed and say to yourself, “I’m incompetent; I really blew the interview. This is terrible.” But if you ask yourself,
“What is the real impact?”, you might think “That was just one interview. There are many jobs out there, and I can
keep applying, or maybe get new training, job counseling, practice interviewing, or read a book on how to get a job.
This is not the end of the world.” In fact, most situations are not life-or-death.

* Make a Decision *
If you’re stuck, try just picking an imperfect road (as long as it’s safe). Sometimes people get caught up in so many
possibilities or the attempt to find a “perfect” solution that they feel paralyzed, stuck, or confused. When you get
this way, it’s actually better just to go ahead and make a decision for now, even though it may not be perfect. Down
the line you can reevaluate your decision, but for now, “Do something, anything” (as long as it’s safe!) is better than
feeling paralyzed and doing nothing.

(cont.)

218
HANDOUT 2 (page 3 of 3) Recovery Thinking

* Remember a Better Time *

Get perspective by noticing good times. Sometimes when you’re caught in a negative feeling, it seems as though it
has always been this way in the past and will always be this way in the future. Try to remember better times (e.g.,
“Last month I was able to keep myself from bingeing on food for an entire week,” or “Three years ago I was able to
hold a job”). Both PTSD and substance abuse are disorders that may be different at different times. Stacy wrote, “I
used to be Stacy, full of life and vigor, and smart. Now I don’t know me. Will I come out of this? I am a good person,
and the ‘old me’ wants back in. Can the ‘old me’ live with how I act when I’m sick? I have to remember it’s not me
now, it’s an illness.”

* Discover Rules to Live By *

Identify principles that keep you focused on recovery—for example, “Take good care of myself,” or “When in doubt,
do what’s hardest.”

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HANDOUT 3 Recovery Thinking

About Rethinking

 Everyone is thinking, all the time, even when one is not aware of it. While awake, we are always in a
“conversation” with ourselves (sometimes called “self-talk”). It ranges from the trivial (“What should I have for
lunch?”) to the profound (“Why should I go on with life?”). Much of this thinking is automatic—it just happens. In re-
thinking, the idea is to become aware of this internal dialogue and to choose thinking that helps you feel better. For
example, saying to yourself, “I’m no good,” would be depressing; saying to yourself, “I’ve had a hard life but that’s
not my fault,” might feel a little better.

 Notice how thinking impacts your life. Thinking affects how you feel and act. For example, imagine that
you are home alone at night and drifting off into sleep. Suddenly you hear a sound at the window. If you think, “It’s
the wind rustling a tree branch against the window,” you are likely to feel fine and go back to sleep. But if you think,
“It’s a robber trying to break in,” you are likely to feel anxious and call the police. The same situation occurs—hearing
a sound at the window—but how you feel and act depends on what you think.

 Rethinking does not mean “positive thinking”—it means realistic thinking. For example, if you think,
“I’m a bad person,” just flipping this around to “I’m a good person” does not work. The goal is not just to reverse
negative thoughts into positive ones, but to evaluate them realistically. Various ways to evaluate your thoughts are
described in Handout 2. But it is important to emphasize that rethinking does not mean “the power of positive think-
ing,” but rather, the power of actually exploring the way you look at the world, the meanings you create, and the re-
alities of your experience.

 Rethinking is a profound emotional experience. People sometimes believe that “rethinking” is dry, intel-
lectual, boring, or schoolish. When you learn to do it well, it is a deep experience that helps you truly feel better. It is
not about repeating to yourself things you don’t really believe, or just saying what you think you ought to say. It is
about discovering who you are and choosing how you want to approach your life. Some keys to make it work at this
powerful level include the following:
• Identify “hot” thoughts. These are thoughts that are connected to your feelings, that matter to you right
now.
• Stay specific. If you have a general thought such as “My life is hopeless,” try to break it down into what
specific and recent real-life experience set off that thought. For example, it might help to identify when
you most recently thought this (e.g., yesterday evening when you were home alone) and what it was
connected to (e.g., you had been drinking). Then you can work on changing it more easily (e.g., “I no-
tice that I feel more hopeless when I drink,” or “If I spend time with people in the evenings, I might not
feel so down”). It takes practice, but it really can help.

 Your thoughts are not wrong or bad. Some people assume, “If I need to rethink, it means my thoughts
are bad.” This is especially true for people with PTSD and substance abuse, who may already feel bad about them-
selves. But everyone has a variety of thoughts, some of which are negative. Remember that there are good reasons
why you developed the thoughts you have—they come from your life experiences. For example, if you lived through
combat during war, you may have begun to believe that “People are vicious and out for themselves.” Or if you were
repeatedly told certain things when you were a child (e.g., “You’ll never amount to anything”), after a while you be-
gan to believe it. You may notice too that how you talk to yourself resembles how people in your life have talked to
you.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

220
HANDOUT 3 (page 2 of 2) Recovery Thinking

 Rethinking takes active practice. Rethinking needs to be learned just like anything else. Remember when
you learned to tie your shoes or ride a bike? You had to practice and make mistakes along the way. You can definitely
learn rethinking—anyone can. It took a long time to develop your current way of thinking, and it may take a while to
change it. The more actively you work on it, the better you’ll get, and the quicker the results will be. When you no-
tice destructive thinking, stop yourself at that moment and ask yourself, “How can I rethink this to feel better?” You
need to make this sort of active effort for a while until a healthier way of thinking becomes automatic. It’s like build-
ing a house: Each brick adds to the strength of the building; it does not happen all at once. Just keep trying!
 Learn more about rethinking. Browse in a library or bookstore or on the Internet; there are many different
resources available under the term “cognitive therapy.” For example, there are books by Aaron T. Beck, the main
founder of cognitive therapy. Also, David Burns’s Feeling Good: The New Mood Therapy is an inexpensive, popular
paperback. Call the Institute for Cognitive Therapy to locate a cognitive therapist in your area (610-664-3020).
 Try SMART Recovery or Rational Recovery. SMART Recovery and Rational Recovery are substance abuse
self-help groups like AA, except that they focus on rethinking, do not have a spiritual component, and do not view
addiction as a lifelong disease.

Acknowledgments: Cognitive therapy was originally developed by Aaron T. Beck, MD, and Albert Ellis, PhD. The substance abuse section of Hand-
out 1 is based in part on Beck and colleagues (1993) and DuWors (1992). The idea of listing rethinking methods in Handout 2 is based on Burns
(1990), and the handout contains two methods taken directly from that book. Ask your therapist for guidance if you would like to locate any of
these sources.

221
 Recovery Thinking

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Imagine that we are living in the 22nd century. You can change your thinking just by writing a new
script. Write a paragraph on what would you want your new script to say.
ª Option 2: Read the following story and answer the questions below.

Chris has PTSD and substance abuse. He recently started a volunteer job, went three times, then woke up
the next day and said to himself, “I don’t want to go to that job; it’s boring.” He stayed home and watched
TV. He started thinking about his life and how he always feels alone. This reminded him of his childhood
and being abused by his uncle. He couldn’t get the memories out of his mind. He went out to get heroin.
“Why bother getting off drugs?”, he said to himself. “When I don’t use, I feel miserable.”

If you wanted to help Chris cope better, what would you say to him? How would you help him see “the other
side”? How would you talk to him about his drug use and his PTSD?
ª Option 3: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation My partner broke up with me. My partner broke up with me.

« Your Coping «
I’m saying to myself, “What’s Nothing is going to make this
wrong with me? I feel angry and breakup feel good, but I’ve got
hurt, and I don’t think I’m to work to not let myself go to
ever going to have a normal that dark place in my mind.
relationship. I hate being Stay balanced: I’m in pain, but
alone, but my relationships just I don’t have to think about the
keep falling apart. I feel future right now. Just take
trapped, and I’m getting older care of myself. There are
and more bitter.” things I can do and then sort
it all out emotionally later.

Consequence Depressed, angry, hate myself. I went to the drop-in clinic

Want to numb the pain with any and asked to talk to someone. I
drugs I can get my hands on. was still in pain, but at least
Ended up doing heroin. I didn’t take it out on myself.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

222
COGNITIVE

Integrating the Split Self

SUMMARY

Patients are guided to recognize the internal splits inherent in both PTSD and substance
abuse, and to explore ways to integrate them for recovery.

ORIENTATION

“It’s like a civil war is going on inside me.”

“It’s the angry, rebellious side of me that uses drugs.”

“I don’t know why I feel, think, and even see myself acting like a 3-year-old. From where
I’m sitting, you’re very large, and I have to do what I’m told ‘or else.’ Sometimes I even get
the feeling to hide so you don’t hurt me. . . . I’m hearing you from under a table, for safety.”

PTSD and substance abuse are rare among psychological disorders in that both are marked
by “splitting.” That is, one’s internal world may have different states of consciousness that
arise at different times. In substance abuse, this is sometimes referred to as “Jekyll and
Hyde,” after the famous book—one part wants to stay clean and sober (this is the side that
shows up for treatment), while another part forgets those lofty goals and uses without regard
to consequences (DuWors, 1992). Patients will say, “I don’t know what got into me; before I
knew it, I was at the liquor store.” Or “When I want to use, that’s the only thing on my
mind—there’s no conflict, no other voice.”
In PTSD, splitting also occurs. It is a well-documented defense that ranges from the ex-
treme of dissociative identity disorder (also known as multiple personality disorder—i.e.,
having separate “alters,” all with their own names and personalities) to simply having various
sides of oneself that emerge more subtly at different times. A patient may have a side that
wants to live and another that wants to die, or a side that wants to get better and another that

223
224 Treatment Topics

doesn’t. The parts of the self in a patient with PTSD may reflect different ages and emotions
related to the trauma (e.g., a “little one” who is afraid, a “big one” who is aggressive). And pa-
tients’ PTSD splits may perpetuate substance abuse: One patient talked about how she had to
be compliant for so long that her main reason for drinking was wanting people to see the
“bad” side of her that she knew only emerged with substance use.
Splitting can be identified any time a patient talks about “flipping” into a different state.
It is as though a light switch is turned on and a new state of mind appears, without awareness
of other parts of the self that may have been there a moment ago. Splitting creates a lack of
safety because one is subject to being controlled by parts of the self over which there is little
or no control. This is, in part, why both PTSD and substance abuse are such “unsafe” disor-
ders. Other disorders that are not characterized by splitting (e.g., generalized anxiety disor-
der, somatoform disorders) may be painful or uncomfortable, but may not be as unsafe as
PTSD and substance abuse.
There are several direct clinical implications of splitting. First, splitting may result in pa-
tients’ having significant ambivalence about recovery. If this issue is not acknowledged as
part of treatment, patients are likely to feel ashamed about “not wanting to get better.” Sec-
ond, it can be helpful to have patients identify different sides of themselves, so that they can
better manage these when they emerge. Note that some sides may be healthy aspects of the
self (e.g., “the adult”), and these are just as important to describe as the less adaptive parts.
Third, although rare, the splits in dissociative identity disorder can be so extreme that the al-
ter who uses substances may be completely unknown to the patient’s other alters and may
need to be attended to in treatment as a separate person.
Patients often want to reject the parts they do not like, but can be taught that all sides are
there for a good reason and need to be welcomed and accepted. Once all sides are given ex-
pression in safe ways, the need for splits no longer exists and integration occurs, so that they
can now “own” all the different sides of the self. If a patient tries to disavow a side rather than
accept it, splitting is perpetuated. This explains why patients with substance abuse often
sound extremely committed to abstinence, but then come in the next week having used, feel-
ing guilty and ashamed. If they could view the substance abuse without the guilt and shame,
they would be more likely not to use again. They may believe that “beating themselves up”
will prevent substance use in the future, but it usually increases the likelihood. Similarly, the
patient with PTSD who has learned to be “nice” all the time and never angry will be sur-
prised by the rage that erupts, try to disavow it, and the cycle repeats.
The task of integrating splits in the self, particularly in cases of dissociative identity disor-
der, is a long-term endeavor for many patients that is unlikely to be accomplished in any
short-term treatment. However, by guiding patients to start identifying and accepting all
sides of themselves, they can become more aware of the need for further work on this.

Countertransference Issues
Given the controversy and very real concerns about “recovered memories,” it is important
that the therapist not impose a particular view on patients, nor seek to have patients label
parts of themselves if they do not find it helpful.
Integrating the Split Self 225

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 227. Link the quotation to the session—for example,
“Today we’re going to be talking about different sides of oneself. Taking an accepting stance
toward all sides of oneself helps recovery.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handout, The Split Self.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Discuss the concept of the split self in both PTSD and substance abuse, and the goal of
integration.
¨ Encourage patients to discuss how aspects of themselves may emerge at different
times, and how to manage this in their recovery.

Ways to Relate the Material to Patients’ Lives

ê Rehearse out loud. Ask the patient to identify a specific situation in which acknowl-
edging different sides of the self might be helpful. For example, the last time the patient used
a substance (or had other unsafe behavior), what part of the self was present? What part of the
self was not being heard? Ask the patient to try to do a “dialogue” in which the mature,
healthy side “talks” to the less mature, less healthy side.
ê Discussion
• “What sides of yourself do you notice?”
• “Why might you have rejected some part of you?”
• “What sides of yourself do you most and least like?”
• “What is your healthiest side? How does it keep you safe?”
• “How can you try to accept all sides of you?”
• “Can you think of times when you were unsafe because a hidden side of you came out?”
• “Why might rejecting a side of yourself lead to unsafe behavior?”
• “How is your PTSD or substance abuse related to splitting?”

Suggestions
✦ Help to normalize the topic by noting that most people have splits to varying degrees.
For example, anyone with mixed feelings likely has a split.
226 Treatment Topics

✦ Note that some patients may confuse splitting with schizophrenia. Make sure to clarify
that splitting is not about being psychotic or “crazy.”
✦ Encourage emotional acceptance of all sides of the self. Patients may try to convince
you that a part of them is truly hateful (e.g., “I’d like to kill that side of me”). Validate these
feelings and try to remind patients of self-respect. For example, “Yes, I hear that you don’t
like that side of yourself. But let’s also try to respect that that side is there for a reason. The
more you become aware of that side, the less dangerous it will be.” If a patient has a side that
acts out, validate the feelings of that side, but reiterate the importance of not acting on its im-
pulses. For example, “I hear that the young side of you wants to kill yourself, but we need to
keep you safe from acting on that.”
✦ If a patient does not notice any sides, do not force the issue. You might want to reframe
it (e.g., mixed feelings) or just redirect to discussing any aspect that the patient can relate to
(e.g., having substance cravings at times).
✦ Be aware that some people give the parts of themselves names (e.g., “Maria”) or labels
(e.g., “the little one,” “the big one,” “the dark,” “the light”). This is fine if the patient initiates
it or likes it, but the therapist should never force such labeling as some patients may be dis-
turbed by it.
✦ If a patient has alters, work with whoever is in the room, but try to bring back the
most mature alter. In extreme cases of dissociative identity disorder, a patient may have dif-
ferent personalities or “alters.” This is not common, but is real. If this occurs, the best strat-
egy is to talk to whichever alter is present (the patient may have names for the different al-
ters), but also to try to bring back into the room the patient that you know (e.g., “I understand
that you’re ‘the little one’; can we bring ‘the big one’ back?”). Similarly, if a patient says that
the one who uses substances is not present, try to get that person back. Note that dissociative
identity disorder is a severe mental illness and requires intensive therapy by a trained thera-
pist. If such a patient is in group treatment and an alter emerges, normalize it for the group.
For example, you might say, “Sarah has different sides of herself, and we need to welcome
whichever part is present. She’ll be fine and there’s nothing to worry about. She’s getting
help for this.”
✦ Note that the topic of splits may be triggering for some patients. If this occurs, use all
of the main ways to help patients feel better: empathy, redirection, grounding, etc.

Tough Cases

∗ “I know I have a side of me that wants to hurt my children, and I’m afraid that if I ac-
cept it, I’ll hurt them.”
∗ “I don’t have any rejected sides of myself.”
∗ “This reminds me of my abuse, and I want to leave the session.”
∗ “This makes me think I’m just abnormal and hopeless.”
∗ “I don’t want to accept the angry side of me. I just want to get rid of it.”
 Quotation

“ . . . be attentive to what is arising

within you, and place that
above everything else . . . .
What is happening in your
innermost self is worthy of your
entire love; somehow you must
find a way to work at it.”
—Rainer Maria Rilke
(20th-century German poet)

From Seeking Safety by Lisa M. Najavits (2002).

227
HANDOUT Integrating the Split Self

The Split Self

« Do you . . .

1. Do things and not remember how they happened (e.g., find yourself at a bar, not aware of how you got
there)? Yes / No / Not sure
2. “Flip” into different emotional states (e.g., your moods shift very quickly and intensely)? Yes / No / Not sure
3. Have different sides of yourself that feel like separate people (such as “the young one,” the “big one,” “the
weak one,” “the angry one”)? Yes / No / Not sure
4. Feel opposite extremes in relationships (e.g., feel totally positive toward someone at one time and then to-
tally negative at another time)? Yes / No / Not sure
5. Frequently have mixed feelings about important decisions in your life (such as whether to stay in treatment,
whether to get a job, etc.)? Yes / No / Not sure

What Is “the Split Self”?

“The split self” refers to different sides of the self that can occur in both PTSD and substance abuse. Becoming aware
of these different sides can help you recover.
Substance abuse examples. One part of you wants to use substances while another part doesn’t. This is
sometimes called “Jekyll and Hyde.”
PTSD examples. Parts of you might feel like “a little child” who needs protection; a “fighter” who bullies; a
“teenager” who wants to have fun without worrying about tomorrow; and a “healthy one” who wants to work hard
on recovery.

Splitting Happens for a Very Good Reason

Splitting is a psychological defense in which your internal world has different states of consciousness that emerge at
different times. Just as a country needs an army for defense, so too the mind needs defenses when it is being at-
tacked by devastating life experiences. Remember, these are normal and typical in PTSD and substance abuse; they
were necessary for your survival. They do not mean that you are crazy. Also, many “normal” people have splits to
some degree; the issue is how much they have them, and how dangerous they are.
If you have splits, it means that you had a psychological need earlier in your life to reject some part of yourself.
For example, if you drove drunk and caused a terrible car accident, you may have felt extremely guilty but could not
face those feelings at the time. The guilt may keep “popping up” in various ways in your life (as in bad dreams or
flashbacks). Splits can also arise in childhood if your family rejected important parts of you. If it was not safe for you
to express anger, for example, the anger may have became split off. But the split-off side doesn’t go away—it stays
hidden and emerges at times that may surprise you. You may notice that you feel ashamed about whatever side of
yourself has been split off.
With PTSD and substance abuse, the sides that get rejected are typically those that want to use substances (you
may feel “bad” for having cravings), that get angry (you feel you should always be “nice”), or that feel vulnerable
(you feel you should always be “strong”).
None of this is your fault—it all happens unconsciously, without awareness. (If you were aware of it, it wouldn’t
be split!)
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

228
HANDOUT (page 2 of 2) Integrating the Split Self

Splitting Leads to Unsafe Behavior

You are not in control of your rejected sides, because they are hidden. When you don’t have control over them, they
can control you by emerging at times when you don’t expect them, or by “blotting out” healthier sides. This can be
unsafe.

Exploring the Different Sides of Yourself

« If you want, answer the questions below. Use the back of this page if you need more space.

1. Do you notice any sides to yourself?

Substance abuse:
PTSD:
Other:

2. Which sides do you like? Which sides do you dislike?

3. Do you notice any dangerous behaviors from your splits?

THE GOAL OF INTEGRATION

Integration Is the Way to Overcome the Split Self

The way out of splitting is to integrate and accept the sides of yourself that have been rejected. What would it be
like? If you felt angry, you would respect that the anger is there for a good reason. Rather than stifling it, you would
seek to “hear” it and to express it in a safe way. The goal is to have access to all parts of yourself whenever you
choose to. However, know that this may be difficult after a lifetime of rejecting those sides, or if they remind you of
someone you hated (e.g., an abuser).

How Can You Work with the Different Sides?

 Acknowledge, respect, and “own” these different sides, even if you don’t like them. It may feel as
though you just want to get rid of some part of you. This doesn’t work, as it is there for a good reason. A deeply car-
ing attitude toward every part of you is what helps your recovery.
 Try to remind yourself of the other sides if one side takes over. If a side emerges that wants to drink,
remind yourself that another side of you doesn’t want to. If a side of you doesn’t want to come to treatment, remind
yourself of the side that does.
 Do not punish yourself if you do something wrong. Blame, guilt, shame, and “beating yourself up” in-
crease the likelihood of maintaining splits. Why? Because they represent a lack of acceptance. If you do something
you don’t like, try to understand it calmly and respectfully.
 Create healthy dialogue among the different sides. Some people find success in “calling a conference”
among the different sides of the self, so that all sides can be heard. Or one side can try to soothe another side. Al-
lowing the sides to “talk” to one another may sound bizarre, but in fact can be very healing. Try rehearsing, out loud
or on paper, what a healthy dialogue among sides of yourself might sound like.

229
 Integrating the Split Self

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Write a letter of acceptance to a part of yourself you’ve rejected. Promise to respect and listen
to it.
ª Option 2: Think of the last time you used a substance (or had other dangerous behavior): What part of you
led to the dangerous behavior? What part of you was not present?
ª Option 3: Write a brief description of your different sides, including both those you like and those you don’t.
ª Option 4: Try having a healthy dialogue between parts of yourself (in your mind or on paper). Can one side
soothe another side, for example?
ª Option 5: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation I asked someone out and got I asked someone out and got
rejected. rejected.

« Your Coping «
Why should I keep trying to Say to myself, “It’s OK for
reach out? No one wants me. part of me to feel bad, but
I smoked marijuana. I needed that’s only one part of me.
a way to escape. Another part of me knows
that it was good that I
tried, and that it took guts
even though it didn’t work
out as I’d wanted.”

Consequence I isolated, hated myself. I felt okay about it—not

great, but not awful.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

230
BEHAVIORAL

Commitment

SUMMARY

Patients are encouraged to explore the role of commitments in their lives, to learn creative
strategies for keeping commitments, and to identify feelings that get in the way.

ORIENTATION

Keeping commitments is a key aspect of behavioral therapy. That is, much change occurs by
making a plan to do something and then doing it, no matter how one feels at the time. The
payoff is that self-esteem builds with every accomplishment. The feelings that once stood in
the way, such as anxiety or depression, lessen as one learns by experience that such feelings
are “just feelings” and not true predictors of one’s capabilities.
On another level, keeping commitments represents a way of striving for the highest ideals
in one’s relationships to oneself and others. It means keeping a promise, doing the right thing
rather than the easy thing, striving for actual results, and seeking success in demonstrable ways.
To aim for these means that one values oneself and one’s relationships with others enough to put
caring into action. It reflects the self-discipline that is the foundation of a healthy life.
With substance abuse and PTSD, the opposite often occurs. Substance abuse is by defi-
nition a series of broken promises in which a temptation in the moment overpowers all right
intent. One uses over and over, despite knowing that it is destroying one’s body, emotional
health, relationships, and functioning. After a while, one’s identity as someone who is a
“loser” or a “failure” builds, and right action seems increasingly remote. With PTSD, there
may or may not be a lack of self-discipline per se, but there is a tendency to view emotions as
the most important reality of all. The intense negative emotions of PTSD, including flash-
backs, self-harm urges, and flooding of painful feelings, become the center of one’s existence
and can lead to decreased functioning as emotions take over one’s life. The tragic downward
spiral of substance abuse and PTSD is that with increasing inability to act in one’s best inter-
est in the world, there is an accumulation of more and more real-life problems, such as hous-
ing difficulties, poverty, isolation, work problems, HIV risk, and domestic violence. As prob-
lems build, the patient becomes less able to muster the energy and will to tackle them. Some

231
232 Treatment Topics

patients grew up in homes where self-discipline was never taught or encouraged; for others,
the disorders caused a decrease in functioning somewhere along the way.
Commitment is thus worked on very explicitly in today’s topic to empower patients to make
realistic promises and keep them. The positive potential of such efforts is emphasized, rather
than self-criticism about the past. To help make the process creative, patients are encouraged to
view commitments as “problems to be solved” and to brainstorm a variety of potential solutions.
Patients are guided to anticipate setbacks along the way, to increase the likelihood of success.

Countertransference Issues
Some therapists enjoy the interpersonal and intrapsychic processes of therapy and are less in-
terested in goal-oriented outcomes. Remembering that patients with PTSD and substance
abuse are often burdened by serious day-to-day problems—they are “low” on the fulfillment
of Maslow’s (1970) hierarchy of basic needs—may help reinforce the importance of visible,
concrete progress on behavioral goals. The patient who has no job, inadequate housing, or no
financial public assistance needs to focus on these. Empathy and a good relationship with a
therapist are necessary but not sufficient. The relationship can be used to help motivate the
patient, but is not a replacement for demonstrable progress in the world.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 234. Link the quotation to the session—for example,
“Today we’ll focus on commitment. As the quotation suggests, the key to success is sheer per-
sistence.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2 for suggestions.
Handout 1: Responsibility and Promises
Handout 2: Creative Solutions
Handout 3: Overcoming Emotional Blocks
Handout 4: Action Plan
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Discuss patients’ experiences with commitments (Handout 1).
¨ Brainstorm creative strategies for completing commitments (Handout 2).
Commitment 233

¨ Explore emotional blocks to commitments and how to overcome them (Handout 3).
¨ Help patients create an Action Plan (Handout 4) to identify a specific commitment and
follow through on it.

Ways to Relate the Material to Patients’ Lives

ê Create an Action Plan. Work with patients to identify a specific commitment they
would like to accomplish, using the Action Plan (Handout 4). Identify ways to accomplish it
(with Handout 2), and discuss emotional and practical obstacles (with Handout 3).
ê Discussion
• “How can keeping your commitments help your recovery from PTSD and substance
abuse?”
• “What makes it hard for you to keep commitments?”
• “What are your favorite strategies for getting things done?”
• “How do you feel when you’ve followed through on your commitments?”
• “Do you have children? If so, what are you teaching your children about commit-
ments by your actions?”

Suggestions
✦ Emphasize positive potential rather than blame about the past. Otherwise, the topic
can make patients feel demoralized. Thus validate that everyone can learn to keep commit-
ments; notice patients’ potential; and speak in the language of “building self-respect.”
✦ “Feel the feeling but do it anyway.” The most common obstacle is patients’ belief
that feelings should guide what they do. With commitments, this becomes “I’ll try,” or “I’ll
see how I feel later.” It is essential to provide education on the idea that feelings cannot
get in the way of commitment. Be sure that patients do not interpret this to mean that feel-
ings are not important (they’ve been told that enough in their lives!). Rather, feelings can
be explored and expressed, but ultimately cannot determine their behavior. Some com-
ments that may help include, “Feel the feeling but choose the behavior” (Potter-Efron &
Potter-Efron, 1995), or “Good feelings may come after doing a commitment, not necessarily
before,” or “If you wait ’til the feelings go away . . . you may be old and gray!” See also the
topic Introduction to Treatment/Case Management for a discussion of offering patients the
option to call and leave a message on your voice mail if they cannot complete a commit-
ment due to genuine reasons.

Tough Cases
∗ “I’ll try my best, but I can’t promise to do it.”
∗ “When I feel pressured, I get paralyzed and can’t do anything.”
∗ “There’s nothing I need to commit to.”
∗ “I hate myself for all my broken promises.”
∗ “I’ll see how I feel.”
∗ “I’d like to commit to feeling positive self-esteem from now on.”
 Quotation

“Never, never, never, never, never,

never, never, never, never, never,
never give up.”
—Adapted from a speech by Winston Churchill
(20th-century British Prime Minister)

From Seeking Safety by Lisa M. Najavits (2002).

234
HANDOUT 1 Commitment

Responsibility and Promises

« Circle your answer to each question:

1. Do you break promises to other people? Rarely Sometimes A lot

2. Do you break promises to yourself? Rarely Sometimes A lot
3. Do you have problems getting things done? Rarely Sometimes A lot
4. Do you make commitments in this treatment and then not Rarely Sometimes A lot
do them?

Do these words evoke feelings: commitment . . promise . . responsibility? Some people notice negative
feelings when they think of these (tense, depressed). Other people notice positive feelings (strong, happy).
When you were growing up, what did you learn from the people around you about commitments?
Some people with PTSD and substance abuse may have grown up in homes where they learned . . .
• Not to trust promises.
• Escape and avoidance.
• The only way to get things done is to be yelled at.
• It’s okay to disappoint people.
• The children are more responsible than the parents.
• Nothing ever gets done.
• There’s something about me that’s different—I’ll never live a normal, responsible life.
« What did you learn about commitment when you were growing up?

Commitment is both personal and interpersonal. When a commitment is broken, it can make you feel mis-
erable: frustrated, weak, hopeless, worthless, anxious. It also affects the people around you, especially your family.
How do they feel if you don’t get things done? What are they learning about responsibility? How do they view you?
« How does your ability to keep commitments impact . . .
You?
People in your life?
« How would you like to handle commitments in the future? Identify any goals you have:
¨ I’d like people to believe that when I make a promise, I’ll keep it.
¨ I’d like to commit to abstinence from substances and stick to it.
¨ I’d like to keep my appointments and be on time.
¨ Other:
¨ Other:
If you have trouble with commitments, remember: It’s not your fault; you are doing what you learned. You
can become a responsible person—you are a human being like everyone else, and it is within you to become responsi-
ble.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

235
HANDOUT 2 Commitment

Creative Solutions

PTSD and substance abuse can lead to rigid thinking—limiting oneself to “same old” solutions.
PTSD. Anxiety may make you afraid to try new things. In trauma you felt powerless, so you may have come to
believe that you cannot have control over your life.
Substance abuse. By using substances to cope with problems, you are relying on short-term, impulsive solutions
rather than long-term, planned solutions.
Creative solutions are healthy, direct, adaptive, realistic, and specific.
« Check off (ü) any strategies below that might help you accomplish your commitments:

¨ Write down your commitment and put copies everywhere (refrigerator door, car dashboard, bathroom mir-
ror, paper-clipped to money in your wallet, taped to your computer). You can also send yourself a voice mail
message or letter reminding you to do it.
¨ Use the “Do something, anything” rule—start anywhere. Don’t feel you have to start with the hardest part or
at the beginning.
¨ Create an image to keep you going: Strong as steel . . . warrior . . . racing for the finish . . .
¨ Ask other people how they get things done.
¨ Get someone to help you (or go with you, if it’s an appointment).
¨ Ask your therapist if you can make a call that’s difficult during your session.
¨ Don’t drink coffee in the morning until you are already working on your commitment.
¨ Make a list of all the people you’ll hurt if you don’t do it (your family? yourself?).
¨ Schedule a time during the day to get it done.
¨ Rate your mood before and after the task. Do you feel better after?
¨ Plan a reward.
¨ Tell everyone in your life you’re going to get it done.
¨ Write your tasks on slips of paper and put them in a hat; pull out one at random and do it (or make up other
“games”).
¨ Find a good location. If it’s hard to work at home, try a library or coffee shop.
¨ Give a $50 check to a friend to keep if you don’t accomplish your goal; spend the $50 on yourself if you ac-
complish the goal.
¨ Try to make it fun: Turn on the stereo while you work.
¨ Find meaning. Figure out what most motivates you and keep repeating it (getting it over with? doing a good
job? doing it for your kids? creating a better life for yourself?).
¨ Use a special colored pen to check it off your list (these little things really can work).
¨ Buy files and use one file for each task (getting organized increases motivation).
¨ Leave brief messages on your therapist’s voice mail about your progress.
¨ If perfectionism is a problem, do small steps as “preparation” for the real thing.
¨ Record a cassette tape that motivates you to keep your commitment.
¨ Develop a “survival book” of pictures, poems, quotes, or other inspiration to keep you on track.
¨ Other strategies that work for you:

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
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236
HANDOUT 3 Commitment

Overcoming Emotional Blocks

« Identify feelings that get in the way of your completing commitments:

Overwhelmed “I’m not capable . . . There’s too much to do . . . I don’t have time.”
Hopeless: “Why bother? . . . Nothing I do ever works out . . . I might as well give up.”
Perfectionistic: “I’m not ready to start . . . I need to prepare more . . . It won’t be good enough.”
Other feelings:
« Circle any ideas below that might help you overcome your emotional blocks:

 The single most important concept: Commitment means doing what you say no matter what you are feeling.
Think of a red traffic light: You don’t decide to stop based on how you feel; you know you need to stop, and
so you do. Commitments work the same way: If you know you need to do something, the idea is to do it
even if you don’t feel like it. You can be aware of your feelings and explore them, but you still need to do the
commitment as planned.
 Commit to goals that are your own, not someone else’s.
 When people say “I’ll try my best” it often means “I’m not really committed to this.” A small goal that’s
actually accomplished is worth more than a large goal that you just “try” to do.
 Forget about what you didn’t do yesterday. Even if you failed 100 times, it’s only right now that matters. If
you wake up late, start then. If you’re behind, begin anyway.
 Use sheer persistence to fight feelings that get in the way. If you keep moving forward, eventually these
feelings will go away.
 Make your goals concrete and simple.
 Be very honest with yourself about what you can do. Sometimes people agree to do too much and then feel
terrible that they cannot do it. Stay realistic.
 Pretend you are someone who gets things done.
 Everything is a problem to be solved. It is not your identity, your self-worth, a sign that you’re not normal, or
stupidity. Interpreting tasks in such big terms does not help.
 Don’t “beat yourself up” if you fail at something. That makes you less likely to get it done next time.
 An old saying is “A good plan today is better than a perfect plan tomorrow.”
 When it gets painful, restate your commitment.
 Even if you seem to be moving three steps forward and two steps back, you’re still ahead by a step.
 If you don’t totally accomplish your goal, you can still feel good if you got further on it than before.
 You can also try to figure out why you’re having problems—old feelings from the past? Unexpressed anger?
But remember that figuring it out is not a substitute for action.
 Other strategies that work for you:

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

237
HANDOUT 4 Commitment

Action Plan

Name: Date:

« An Action Plan is a way to accomplish your goal and honor your word. Fill out the “Before” section now and the
“After” section later.

B I promise to . . .
E
F
O
R
E By when?

I will use the following strategies to accomplish my commitment:

To overcome my emotional blocks, I will . . .

It is important for me to complete this commitment because . . .

If I complete it, I will reward myself with . . .

Signed:

A Result: Describe how it went.

F
T
E
R Anything you’ll do differently next time?

If you are unable to complete your Action Plan for any reason before the next session, please leave a message with
the therapist to let her or him know. This helps keep things “on track.” You can leave your therapist a message at:

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

238
 Commitment

Idea for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option: The best commitment is to make a commitment! Fill out the Action Plan (Handout 4).

EXAMPLE OF AN ACTION PLAN

B I promise to . . . Throw out my marijuana and rolling paper. I am promising

E this to myself, to my therapist, and to my sponsor.
F
O
R
E By when? 8:00 tonight.

I will use the following strategies to accomplish my commitment: Call my sponsor, and
write myself a “letter” about why I need to do this.

To overcome my emotional blocks, I will . . . Talk to my therapist, and focus on the

good that can come of this.

It is important for me to complete this commitment because . . . My future depends on it;

my health will improve; I’ll honor my word.

If I complete it, I will reward myself with . . . A safe “treat” (a new video, book,
CD, or go out to dinner).

Signed:

A Result: Describe how it went. I hated doing it, but I did it. I miss the
F marijuana, but I feel stronger. I bought myself a nice dinner
T afterwards.
E
Anything you’ll do differently next time? No—it went okay.
R

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239
COGNITIVE

Creating Meaning

SUMMARY

Today’s topic explores the meanings patients create—with particular attention to assumptions
specific to PTSD and substance abuse, such as “Deprivation Reasoning,” “Actions Speak
Louder Than Words,” and “Time Warp.” Patients are encouraged to compare meanings that
are harmful versus healing in recovery.

ORIENTATION

In this topic, patients are guided to notice the meanings they create. “Meanings” can also be
termed “underlying assumptions,” “schemas,” or “beliefs.” They are central themes that mo-
tivate much behavior. In fact, every incidence of substance use or other problematic behavior
has its root in some assumption the patient holds.
Although cognitive therapy manuals use the term “cognitive distortions” (e.g., Burns,
1980), it was found during the testing of this treatment that using a less negative term im-
proved patients’ morale. Patients with PTSD and substance abuse tend to be extremely sensi-
tive to criticism, and a term like “distortion” can raise their defensiveness. “Creating mean-
ing” was selected, moreover, because it can apply to both healthy and unhealthy thinking
(while “distortions” focuses only on pathology); it conveys the active nature of people’s inter-
pretations; and it is an everyday term. For PTSD in particular, some interesting research has
found that patients who are able to identify some constructive meaning from their experience
are more likely to improve than those who do not (Janoff-Bulman, 1997).
The topic focuses largely on meanings specific to PTSD and substance abuse. Both
harmful and healing meanings are described. For example, the harmful meaning “I’m Crazy”
(“You believe that you shouldn’t feel the way you do”) is contrasted with the healing meaning
“Honor Your Feelings” (“Your feelings make sense in light of what you have been through”).

240
Creating Meaning 241

“Deprivation Reasoning” (“You have a right to use substances because you have suffered”) is
contrasted with “Live Well” (“A happy, functional life will make up for your suffering far more
than will hurting yourself ”). In addition, several more general cognitive therapy “distortions”
are also presented, such as “All-or-None Thinking” and “Shoulds” (Burns, 1980). Patients are
usually quickly able to recognize such assumptions when they are presented; the harder task
is helping them to change from such beliefs to more adaptive beliefs.
It is hoped that today’s topic will give you and patients a common language for future
sessions. You can help patients notice a meaning as it arises later. Such tags help provide a
short cut in rethinking (e.g., “Chris, it sounds as if you’re thinking in all-or-none terms; can
you try to find the middle ground?”).
You will likely need more than one session to cover the topic because the handout is
quite lengthy. Beware of trying to cover too much material and thus forsaking depth for quan-
tity. Keep the session paced and connected to patients’ real concerns, and then perhaps ask
patients to read the rest of the handout on their own after the session.
As part of the development of this treatment, a small study (Najavits, Blackburn, Shaw, &
Weiss, 1996a) was conducted to explore how much women with the dual diagnosis of PTSD
and substance abuse (a sample of 30) endorsed the meanings listed in the handout, compared
to women with PTSD alone (no lifetime history of substance abuse; a sample of 28). Results
indicated that women with the dual diagnosis endorsed the harmful meanings significantly
more than women with the single diagnosis. In addition, the dual-diagnosis group endorsed
the meanings particular to PTSD/substance abuse more than the general ones from Burns
(1980). This might suggest that there are indeed particular meaning systems for patients with
this dual diagnosis, and that these can be targeted in treatment.

Countertransference Issues
The difficulties therapists tend to have with this topic are summarized in the general discus-
sion of cognitive restructuring in the topic Recovery Thinking and in Chapter 2.

Acknowledgments
In the handout, several of the harmful meanings (“Feelings Are Reality,” “Mind Reading,”
“Shoulds,” “Focusing on the Negative,” and “All-or-None Thinking”) are from Burns (1980).
“Life-or-Death Thinking” and “Instant Satisfaction” are from Beck and colleagues (1993), and
“The Good Old Days” is from Earley (1991).

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 244. Link the quotation to the session—for example,
“Changing your thinking can change your life. Today we’re going to explore the meanings you
create.”
242 Treatment Topics

3. Relate the topic to patients’ lives (in-depth, most of session).

a. Ask patients to look through the handout, Creating Meaning.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨Help patients identify meanings associated with PTSD and substance abuse—both
those that harm and those that heal.
¨ Guide patients to shift from harmful meanings to healing meanings.

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to look through the handout and circle any meanings
that feel relevant to them. The handout is very long, so covering it over more than one session
is suggested. Note: For group treatment, you could ask one patient to read the first meaning
(reading across the row), then have another patient read the second, and so on.
ê Replay the scene. If a patient resonates to a particular harmful meaning, ask whether
there are any recent examples of it. Have the patient “replay the scene” by trying to rehearse
out loud the healing meaning in that situation. You could use the Safe Coping Sheet for this
or just do it out loud.
ê Identify key points. For example:

 It is human nature to create meaning from life experiences. If you’ve had a dif-
ficult life, you may have derived meanings that are quite painful (e.g., “I have no fu-
ture,” “I’m a failure,” etc.). As you continue in recovery, you will find that your as-
sumptions change. For example, early in recovery, you may say that “No one can be
trusted.” This might be called “All-or-None Thinking” on the handout. As recovery
progresses, you may begin to notice that some people can be trusted, while others
can’t. This shift in perspective can open up important new avenues: new friendships,
less substance use, increased safety.
 The handout says “creating meaning” because we are always actively interpret-
ing the world—making assumptions, evaluating, deciding. By choosing to create
meanings that help you to become more safe, you are helping your recovery process.
 Meanings may be at a very deep level; they may be unconscious for a long
time.
 The goal is to remain open to new possibilities. Your meanings may be true for
your past; our goal is to try for better meanings in the future.
 Meanings are not wrong or right, but they are either helpful or harmful.
 Everyone struggles with harmful meanings at times, not just people with PTSD
and substance abuse.
Creating Meaning 243

ê Discussion
• “Which meanings are important for you?”
• “Which meanings are most associated with your substance abuse? With your
PTSD?”
• “How do you think you’d feel if you believed the healing meanings were true?”
• “Are there any current examples in your life where you notice these meanings?”
• “Why do you think the handout says ‘creating meaning’? Are you aware of any other
key meanings that aren’t on the sheet?”
• “When you are stuck in a harmful meaning, how could you remind yourself of a
healing meaning?”

Tough Cases
∗ “My thoughts are bad, just like I’m bad.”
∗ “How will this put money in my bank account?”
∗ “How do I get myself from the harmful meanings to the healing meanings?”
∗ “But the harmful meanings really are true!”
∗ “Positive thinking never works for me.”
∗ “This sounds great on paper, but I can’t do it in real life.”
 Quotation

“Watch your thoughts;

they become your words.
Watch your words;
they become your actions.
Watch your actions;
they become your habits.
Watch your habits;
they become your character.
Watch your character;
it becomes your destiny.”
—Frank Outlaw
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

244
 HANDOUT Creating Meaning

Creating Meaning

Below are some meanings typical of people with trauma and substance abuse. Read each meaning and, if you want, rate how much you believe
each one from 0% (never) through 100% (all the time). If you can think of examples from your own life, write them in the margins.

Rate
Meanings (0%–
That Harm Definition 100%) Examples Meanings That Heal
Deprivation Because you have suffered a lot, “I’ve had a hard time, so Live Well. A happy, functional life will make up for your
Reasoning you need substances (or other self- I’m entitled to get high.” suffering far more than will hurting yourself. Focus on
destructive behavior). “If you went through what positive steps to make your life better.
I did, you’d hurt yourself
too.”
I’m Crazy You believe that you shouldn’t feel “I must be crazy to feel Honor Your Feelings. You are not crazy. Your feelings
the way you do. this upset.” make sense in light of what you have been through.

245
“I shouldn’t be having this You can get over them by talking about them and
craving.” learning to cope with them.
Time Warp Your sense of time is distorted; “This craving won’t stop.” Observe Real Time. Take a clock and time how long it
you believe that a negative feeling “If I were to cry, I would really lasts. Negative feelings will usually subside after a
will go on forever. never stop.” while; often they will go away sooner if you distract
with activities.
Beating In your mind, you yell at yourself “I’m a bad person.” Love—Not Hate—Creates Change. Beating yourself up
Yourself Up and put yourself down. “My family was right: I’m may echo what people in the past have said to you. But
worthless.” yelling at yourself does not change your behavior; in
fact, it makes you less likely to change. Care and
understanding promote real change.
The Past Is the Because you were a victim in the “I can’t trust anyone.” Notice Your Power. Stay in the present: “I am an adult
Present past, you are a victim in the “I’m trapped.” (not a child); I have choices (I am not trapped); I am
present. getting help (I am not alone).”

(cont.)

From Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
 HANDOUT (page 2 of 4) Creating Meaning

Rate
Meanings (0%–
That Harm Definition 100%) Examples Meanings That Heal
The Escape An escape is necessary (e.g., food, “I’m upset; I have to binge Keep Growing. Emotional growth and learning are the
substances, gambling) because on food.” only real escape from pain. You can learn to tolerate
feelings are just too painful. “I can’t stand cravings; I feelings and solve problems.
have to smoke a joint.”
The Good Old You remember the wonderful “Cocaine made me feel See Both Sides. The drug may have felt good but the
Days highs from something (a drug, an happy.” cost was losing your job; the relationship may have had
abusive relationship), but ignore “I still love my partner, even some positives, but it had some serious negatives too.
the tragedy of it. though he abused me.”
Feelings Are Because something feels true, you “I feel like I’ll never recover, Listen to What You Know. Use your mind rather than
Reality believe it must be a fact. so I might as well drink.” your feelings as a guide. What do you know to be best
“I feel depressed, so I for you? Feelings are valid, but they are not reality.
might as well kill myself.”

246
Ignoring Cues If you don’t notice a problem, it “If I ignore this toothache Attend to Your Needs. Listen to what you’re hearing;
will go away. it will go away.” notice what you’re seeing; believe your gut feeling.
“I don’t have a problem
with substances.”
Dangerous You give yourself permission for “Just one won’t hurt.” Seek Safety. Acknowledge your urges and feelings, and
Permission self-destructive behavior. “I’ll buy a bottle of wine then find a safe way to cope with them.
for the recipe I want to try.”
The Squeaky If you get better you will not get “If I do well, my therapist Get Attention from Success. People love to pay
Wheel Gets as much attention from people. will focus on sicker patients.” attention to success. If you don’t believe this, try doing
the Grease “No one will listen to me better and notice how people respond to you.
unless I’m in distress.”
Mind Reading You believe you can tell what “I know he didn’t say hello Check It Out. Ask the person! You may be amazed by
other people are thinking without because he hates me.” what you find out.
having to ask. “My sponsor would feel
burdened if I called her
late at night.”

(cont.)
 HANDOUT (page 3 of 4) Creating Meaning

Rate
Meanings (0%–
That Harm Definition 100%) Examples Meanings That Heal
It’s All My Everything that goes wrong is due “The trauma was my fault.” Give Yourself a Break. You do not have to carry the
Fault to you. “If I have a disagreement world on your shoulders. When you have conflicts with
with someone, it means others, try taking a 50–50 approach (50% is their
I’m doing something wrong.” responsibility, 50% is yours).
If This . . . You put off something important “If I get a job, then I’ll Stay in the Present. Whatever you need to do, start
Then That while waiting for something else. stop smoking pot.” now. Every step forward counts. Putting off an
“If I lose weight, then I’ll important goal will not help.
go to AA.”
Actions Speak You show your distress by actions; “The scratches on my arm Break through the Silence. Put feelings into words.
Louder Than otherwise, people won’t see your will show what I feel.” Language is the most powerful way for people to know
Words pain. “I’d like my partner to find you.
my body after I’ve killed
myself.”

247
I Am My Your trauma is your identity; it is “My life is pain.” Create a Broad Identity. You are more than what you
Trauma more important than anything else “I am what I have have suffered. Think of your different roles in life, your
about you. suffered.” varied interests, your goals and hopes.
The You alone have a particular “Unless you’ve lived Reach Out. Give people a chance to help you. Find a
Uniqueness problem; no one else could through what I have, you safe person to talk to (therapist, AA sponsor) and try
Fallacy possibly understand. can’t help me.” opening up.
“Why bother talking? No
one will get it.”
No Future The future is bleak; there is no “My life is wasted already.” You Have Choices. No matter what has happened so
hope. “I might as well give up.” far, you control the present and future. Notice your
choices and choose wisely.
Life-or-Death Things take on life-or-death “I’ll never get over the fact Keep Perspective. What is the worst that can happen?
Thinking meaning in your mind. that she (or he) left me.” If you suffer a loss, you can learn to mourn and move
“I’ll die if I don’t get that job.” on. The possibilities in life are endless.

(cont.)
 HANDOUT (page 4 of 4) Creating Meaning

Rate
Meanings (0%–
That Harm Definition 100%) Examples Meanings That Heal
Confusing You want something very badly, “I need to relax with Recovery Is the Need. You may want many things, but
Needs and so that means you have to have it. heroin.” needs are few. You may want heroin, but you do not
Wants “I need to find a romantic need heroin. Needs are essentials: food, shelter,
partner.” clothes—and your recovery!
Short-Term You focus only on your feelings “I’m more sociable when I Think of the Consequences. Imagine how good you’ll
Thinking today rather than tomorrow. drink.” feel about yourself tomorrow if you do what you know
“I’m buying that new outfit is right. Imagine how low you’ll feel if you give in to the
even if I can’t afford it.” moment.
Shoulds You have rules about how the “My friend should invite Soften Your Language. Try to ease the tension (e.g.,
world should work. If the rules are me over.” “I want my friend to invite me over.”). You may still
violated, you feel angry. “I should not have to deal want what you want, but you may feel more tolerant.
with the PTSD.”

248
Instant You seek immediate satisfaction. “I need it now.” Work Hard. The most enduring satisfactions come from
Satisfaction Life should be easy. “I should always feel working hard and having patience: at your job, at
good.” relationships, at recovery.
Focusing on You notice the negatives in a “That person is a total Notice the Good. What went right? What is good
the Negative situation and ignore the positives. jerk.” about you? What was a positive aspect of the situation?
“I can’t do anything right.”
All-or-None Things are either all good or all “Life is only misery.” Seek a Balanced View. Life is more complex and
Thinking bad. There is no middle ground. “I have no power.” interesting than “all or none.” Look at things with a
balanced view; find the middle ground. Look at what
went well, what went badly, and what was neutral.

Acknowledgments: In this handout, several of the harmful meanings (“Mind Reading,” “Shoulds,” “Focusing on the Negative,” “All-or-None Thinking,” and “Feelings Are Reality”) are from Burns
(1980), with the latter termed “emotional reasoning” in his book. “Life-or-Death Thinking” and “Instant Satisfaction” are from Beck and colleagues (1993) and “The Good Old Days” is from Earley
(1991). Ask your therapist for guidance if you would like to locate any of these sources.
 Creating Meaning

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Take one harmful meaning from the handout and write out in detail how you can respond to it.
ª Option 2: Describe and name a meaning that you have observed in yourself or others that is not already on
the handout.
ª Option 3: Identify one major meaning that gives your life purpose (e.g., your children? your job? your spiritu-
ality? your recovery?). Write out how that meaning can help keep you focused on your recovery.
ª Option 4: Write out how you can talk to yourself the next time you feel like doing something that is unsafe.
ª Option 5: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation My therapist is going on My therapist is going on
vacation. vacation.

« Your Coping « Thought to myself, “I’m I’m using “Deprivation

being abandoned; no one Reasoning”—thinking I have a
really cares about me.” right to drink because of
Drank half a bottle of wine. suffering. Also, I’m using
“All-or-None Thinking”. In
fact, there are people who
care about me, and my
therapist going away doesn’t
mean she doesn’t care about
me.
Consequence Drinking didn’t get my By noticing the meanings I’m
therapist back from vacation— creating, I feel a little
it made me feel better for a more in touch with myself.
few hours, then worse for a I’m going to talk to my
few days. therapist about how I feel.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

249
INTERPERSONAL

Community Resources

SUMMARY

A list of national resources is offered to aid patients’ recovery (including advocacy organiza-
tions, self-help groups, newsletters, and other nonprofit organizations). Also, guidelines are
offered to help patients take a consumer approach in selecting and evaluating treatments.

ORIENTATION

“I’m so close to taking an overdose or hurting myself, but my kids need me. I can’t live with
the pain, but I have to. I can’t go to the crisis center, since I went yesterday—go twice in a
row and they’ll hospitalize me.”

“I never knew there was a free parenting class I could go to.”

Patients may feel they do not have sufficient treatment options or may not be aware of
what resources are available. A goal of this topic is to empower patients to take a consumer
stance toward their health care, in the hope that they will “shop around” and choose re-
sources that fit their needs. In contrast to the topic Asking for Help, which explores inter-
nal, psychological issues in obtaining help, today’s topic focuses on external, practical re-
sources. Today’s topic is also different from Introduction to Treatment/Case Management in
providing a specific list of national resources and specific guidance to help patients evalu-
ate their treatments.
In discussing community resources, the therapist may encounter complaints, such as “I
tried AA and it didn’t help.” It is strongly suggested that the therapist follow the patient’s lead
and seek to evaluate whether there may be additional resources the patient has not yet
tried—for example, “Okay, you didn’t like AA, but how about trying Rational Recovery?” or
“Which AA meeting did you go to? Maybe we can locate a different one that you might like

250
Community Resources 251

better”). It is generally more helpful to have the patient try new options than to insist on par-
ticular types of help that the patient is rejecting. The patient may well have valid concerns
about the care. For example, a literature review on psychotherapy for substance abuse found
a very wide range in therapists’ ability to achieve positive outcomes with their patients
(Najavits & Weiss, 1994b). In the PTSD field, it is widely known that difficult
countertransference reactions by therapists are common (Pearlman & Saakvitne, 1995).
Moreover, for patients who grew up in abusive homes, asking them to remain in treatments
they do not like is too similar to a past in which they had to stay with poor caretakers. Of
course, patients will eventually need to work through their distrust of treaters. But many
more patients appear to stay in treatments that are not working for them than leave treat-
ments that are effective. Giving patients a sense of control over their choices is a great free-
dom that you can offer, which in and of itself has therapeutic value. Needless to say, splitting
must be avoided before making any recommendations regarding a patient’s treatment. It is
essential to call existing treaters and discuss any concerns you have, as well as directing the
patient to do so too. Finally, it is worth noting that patients with PTSD and substance abuse
can strongly ally with treatment. Data from the pilot study on this treatment, for example,
showed that patients reported very strong alliance and satisfaction with the treatment, and
that attendance was high (Najavits et al., 1998e).

Countertransference Issues
When patients complain about their treatment, the therapist may identify more with other
treaters than with the patients and may, whether consciously or not, convey a lack of empathy
for the patients (e.g., “Just stay in the therapy with Dr. Bruce; try to work it out,” or “Ms.
Hoffman has an excellent reputation; how about focusing on what you can get out of the ses-
sions?”). Although these responses may be relevant for some situations, it is usually helpful to
start by exploring what the patient does not like about an existing treatment and taking the
stance that at least some part of it is a legitimate concern not due solely to the patient (e.g., it
may be due to some genuine weakness in the treater or some systems issue in the clinic
where the patient is being seen). Validating at least some part of the patient’s concern pro-
vides a more balanced starting point from which to proceed, on both an emotional and a prac-
tical level. Needless to say, if a patient complains about treatment with you, these suggestions
may also apply.

PREPARING FOR THE SESSION

♦ Create a list of community resources in your local area and add it to Handout 1.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 254. Link the quotation to the session—for example,
252 Treatment Topics

“Today we’re going to be talking about community resources. The goal is to do everything
you can with what’s available to you.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2 for suggestions.
Handout 1: National Resources
Handout 2: Consumer Guidelines for Treatment
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Review a list of community resources and empower patients to seek out the help they
want (Handout 1).
¨ Discuss the importance of a consumer approach to treatment and guidelines for evalu-
ating psychotherapy (Handout 2).

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. For Handout 1, ask patients to identify resources that appeal to them.
In addition, give patients feedback about what you think might be helpful based on your
knowledge of them. You will also likely need to continue processing emotional obstacles to
reaching out for help (see the topics Introduction to Treatment/Case Management and also
Asking for Help for suggestions). For patients who need extra preparation, consider role play-
ing making a phone call.
ê Call a community resource during the session. Have a patient actually call one of the
phone numbers right now, and then process how it went.
ê Explore aftercare options. Use this topic as an opportunity to continue to work on pa-
tients’ case management needs, particularly for aftercare when this treatment ends.
ê Help patients evaluate their current treatments. Explore with patients how helpful
they find their current treatments. Help identify a plan for any treatments that feel unproduc-
tive. This is a delicate area that could create negative splitting among treaters, however.
ê Discussion
• “Can you identify any organizations on Handout 1 that might be able to help you?”
• “Have you ever called such organizations before? How does it feel to do that?”
• “What would you say when you call up?”
• “Do you currently have enough treatment and support? What else do you feel you
need?”
• “What are some options if you find a particular treatment is unhelpful?”
Community Resources 253

Suggestions
✦ Depending on patients’ level of need on this topic, you may want to conduct this topic
in two sessions. You could work on Handout 1 in one session and Handout 2 in another.
✦ Allow patients to mention bad treatment experiences they may have had, but do not let
the session get bogged down in this for more than a few minutes. Rather, validate patients’
bad experience in a simple way (e.g., ”It sounds as though you had a terrible experience, and
I am so sorry to hear that”), and then try to look toward the future by helping patients find
something that may be helpful now.
✦ Convey that patients can ”shop around” until they find resources that work for them.
Assess patients’ comfort level in taking a consumer approach, and help them process emo-
tional obstacles to taking such a stance (e.g., “I thought the doctor always knows best,” or “I’d
feel guilty if I left my therapist”).
✦ Some patients may already have enough help. If patients already have enough treat-
ment and community resources in place, consider just providing the handouts for future ref-
erence, and skip to another topic instead.

Tough Cases
∗ “I’ve never been able to find anyone who really helped me.”
∗ “My last therapist had a sexual relationship with me, but I don’t want to report it.”
∗ “I just can’t make a phone call.”
∗ “I’ve been in psychotherapy for 5 years and it doesn’t feel like it helps, but I feel too
guilty to leave.”
∗ “My partner says treatment is just a big ripoff and doesn’t do any good.”
∗ “My doctor is giving me a lot of benzodiazepines. I know I’m addicted, but I don’t
want to tell her that.”
 Quotation

“Do what you can,

with what you have,
where you are.”
—Theodore Roosevelt
(20th-century American President)

From Seeking Safety by Lisa M. Najavits (2002).

254
HANDOUT 1 Community Resources

National Resources

The following are all free, nonprofit, national resources dedicated to helping people. Included are advocacy organiza-
tions, self-help groups, and newsletters.

SUBSTANCE ABUSE/ADDICTIONS

Al-Anon (for relatives and friends of alcoholics) 800-344-2666

Al-Anon Family Group Headquarters 800-356-9996
Alateen (for teen relatives and friends of alcoholics) 800-344-2666
Alcohol and Drug Healthline 800-821-4357
Alcoholics Anonymous (World Service) 212-870-3400
American Council for Drug Education 800-488-DRUG
American Council on Alcoholism 800-527-5344
Center for Substance Abuse Treatment: National Drug Information, Treatment 800-662-HELP
and Referral Hotline
Cocaine Anonymous (World Service) 310-559-5833
Co-Dependents Anonymous (addictive relationships) 602-277-7991
Division on Addiction—Harvard Medical School 617-432-0058
Families Anonymous (for families with substance abuse) 800-736-9805
Gamblers Anonymous (GA) 213-386-8789
Harm Reduction Coalition 212-213-6376
Join Together (for communities working to reduce substance abuse) 617-437-1500
Narcotics Anonymous (World Service) 818-773-9999
National Clearinghouse for Alcohol and Drug Information 800-729-6686
National Council on Alcoholism Information Line 800-NCA-CALL
National Institute on Drug Abuse Info-Fax Service 888-NIH-NIDA
Rational Recovery (main office) 530-621-4374
Secular Organization for Sobriety/Save Our Selves (SOS) 310-821-8430
SMART Recovery (national office) 440-951-5357
Sexaholics Anonymous (national office) 615-331-6230

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

255
HANDOUT 1 (page 2 of 5) Community Resources

TRAUMA/PTSD/ANXIETY DISORDERS

Anxiety Disorders Association of America 301-231-8368

Cavalcade Videos (on trauma, for patients and therapists) 800-345-5530
The Healing Woman (trauma survivor newsletter) P. O. Box 28040
San Jose, CA 95159
www.healingwoman.org
International Society for Traumatic Stress Studies 847-480-9028
Many Voices (trauma survivors newsletter) 513-751-8020
National Center for PTSD and PILOTS Database (extensive literature on PTSD) 802-296-5132;
www.ncptsd.org
National Institute of Mental Health Information Line 800-647-2642
National Victim Center Infolink 800-FYI-CALL
PTSD Research Quarterly (summary of new research) 202-512-1800
Sidran Traumatic Stress Foundation (trauma information, support) 888-825-8249

DOMESTIC VIOLENCE

National Domestic Violence Hotline 800-799-7233

National Resource Center on Domestic Violence 800-537-2238

MENTAL HEALTH

Depression Awareness, Recognition and Treatment 800-421-4211

Grief Recovery Helpline 800-445-4808
National Alliance for the Mentally Ill 800-950-6264
National Foundation for Depressive Illness 800-248-4344
National Mental Health Association 800-969-6642

HIV/AIDS/SEXUALLY TRANSMITTED DISEASES (STDS)

AIDS Hotline 800-235-2331

American Social Health Association (sexually transmitted diseases) 919-361-8422
Centers for Disease Control National AIDS Clearinghouse 800-458-5231

(cont.)

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HANDOUT 1 (page 3 of 5) Community Resources

Centers for Disease Control National AIDS Hotline 800-342-2437

Gay Men’s Health Crisis Hotline 212-807-6655
Planned Parenthood 800-230-7526

PARENTING/RELATIONSHIPS

American Academy of Husband-Coached Childbirth 800-4A-BIRTH

Child Abuse Prevention Center 888-273-0071
International Childbirth Association 800-624-4934
National Adoption Center 800-TO-ADOPT
National Resource Center 800-367-6724
Parents Helping Parents (free self-help support groups) 800-882-1250

NUTRITION

American Dietetic Association Consumer Nutrition Hotline 800-366-1655

Food Safety Information Line 800-535-4555

MEDICAL PROBLEMS

24-Hour Poison Control Hotline 800-682-9211

Alzheimer’s Association 800-272-3900
Alzheimer’s Disease Education and Referral Center 800-438-4380
American Cancer Society 800-ACS-2345
American Diabetes Association 800-232-3472
American Heart Association 800-242-8721
American Heart Association—Stroke Information 800-553-6321
American Kidney Fund 800-638-8299
American Liver Foundation 800-223-0179
American Lung Association 800-586-4872
American Optometric Association 314-991-4100
American Paralysis Association 800-225-0292

(cont.)

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HANDOUT 1 (page 4 of 5) Community Resources

American Parkinson Disease Association 800-223-2732

American Red Cross 800-737-8300
Asthma and Allergy Foundation 800-7-ASTHMA
Asthma Information Line 800-822-2762
Brain Injury Association Helpline 800-444-6443
Breast Cancer Hotline 800-877-8077
Cancer Care 212-302-2400
Crohn’s and Colitis Foundation 800-932-2423
Cystic Fibrosis Foundation 800-FIGHT-CF
Dial-a-Hearing Screening 800-222-3277
Endometriosis Foundation 800-992-3636
Guillain–Barré Syndrome Foundation International 610-667-0131
Huntington’s Disease Society 800-345-HDSA
Impotence Information Center 800-843-4315
Juvenile Diabetes Association 800-533-2873
Lupus Foundation of America 301-670-9292
March of Dimes Birth Defects Foundation 888-MO-DIMES
Myasthenia Gravis Foundation 800-541-5454
National Cancer Institute (information about all forms of cancer) 800-4-CANCER
National Council on Aging Information Center 800-222-2225
National Down Syndrome Society 800-221-4602
National Easter Seal Society 312-726-6200
National Hemophilia Foundation 800-42-HANDI
National Kidney Foundation 800-622-9010
National Marrow Donor Program 800-MARROW-2
National Multiple Sclerosis Society 800-FIGHT-MS
National Neurofibromatosis Foundation 800-323-7938
National Organization for Rare Disorders 800-999-NORD
National Psoriasis Foundation 503-297-1545
National Stroke Association 800-STROKES

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HANDOUT 1 (page 5 of 5) Community Resources

Prevent Blindness 800-331-2020

RP Foundation Fighting Blindness 800-683-5555
Spina Bifida Association of America 800-621-3141
Stuttering Foundation of America 800-992-9392
Sudden Infant Death Syndrome Alliance 800-221-7437
Tourette Syndrome Association 800-237-0717
United Ostomy Association 800-826-0826

WOMEN’S HEALTH

National Women’s Health Information Center 800-994-WOMAN

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HANDOUT 2 Community Resources

Consumer Guidelines for Treatment

When you seek out any services, remember that you are a consumer. This means that you have choices and rights,
and that if you are not satisfied with the treatment you are receiving you can ”shop around” to find treatments that
fit better for you.1 Some guidelines are as follows:

* The quality of treatment differs widely. There are many health care professionals who can be enormously
helpful to you. Unfortunately, there are also professionals who are not helpful, and some who are actually harmful.
Research on psychotherapy, for example, shows that therapists differ widely in their effectiveness, and that such dif-
ferences are not associated with number of years’ experience, type of training (e.g., social worker vs. psychiatrist
vs. psychologist), recovery status (whether the person has overcome an addiction problem), or how much is charged.
This means that when selecting a therapist, you will need to evaluate the person based on factors other than these.
* Find specialists. Because you are struggling with two particular disorders—PTSD and substance abuse—you
should seek out the best available help you can from people who are up to date on specialized treatments for these
types of problems (and similarly for any other problem for which you need help).
* Shop around. Before deciding on a treatment, especially in mental health, try to ”shop around” by visiting
several treaters. For example, you may want to have at least one session with three different therapists to find out
who feels most helpful. Keep trying additional ones until you find one you truly like. Treaters differ in their styles,
and, just as in other relationships, there are some combinations of people who work better with each other. Try to
notice whom you feel most ”heard” by, and what style you like (e.g., highly supportive? very direct? confrontational?
warm? intelligent? informative?). Notice whether you feel you can truly open up to this person.
* Ask questions. When you are talking with a potential treater, you have a right to ask questions such as
“What is your model of treatment (and are there any other types of treatment for my problems)?”, “How would you
help me?”, “How long would treatment last?”, “Have you worked with patients like me before?”, “Where did you
complete your training?”, “Do you accept my health insurance?”, “How much will treatment cost?”, “Are there any
less expensive treatments available?”
* Stay only in treatments that work for you. If you try a treatment and don’t like it, remember that you can
leave. Never stay in a treatment out of guilt that you’ll hurt the treater’s feelings or because you feel pressured. See
“How to Evaluate Your Psychotherapy,” below.
* Report unethical treaters. If a treater is unethical (e.g., propositions you sexually), you can report the
treater by contacting the head of the clinic or hospital, calling a state board that licenses the treater (e.g., the state
medical board), contacting the office of consumer affairs in your state, or contacting the ethics board of the treater’s
professional association (e.g., the American Psychological Association, the National Association of Social Workers, or
the American Psychiatric Association).
* Locate consumer information. Some states are beginning to provide phone information designed for con-
sumers of health care. For example, in Massachusetts, the Massachusetts Medical Society (800-377-0550) provides a
listing of all physicians in the state (including psychiatrists), their credentials, and any disciplinary actions against
them for ethical violations. Also, the Internet has a multitude of information, which you can access at many public li-
braries.

1If you are mandated by a court to attend treatment, many of these guidelines may not apply until you have completed the man-
dated treatment. However, even if mandated, you may have choices of which treatment to attend.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 2 (page 2 of 4) Community Resources

* Know your insurance benefits.

a. Find out about your insurance coverage. Insurance plans differ widely. Contact your insurance com-
pany before selecting a treater; give the company your identification number (even within insurance plans,
the amount covered may vary); and find out everything you can about the amount that can be covered, for
how long, whether you need ”preauthorization” to have services covered, whether there is a list of treaters
for that particular insurance plan that you can obtain (using such a list may reduce the cost you have to pay),
whether the amount paid will differ depending on the treater, and whether coverage will at any point be de-
termined by a clinical review of your case (e.g., some patients with depression cannot get psychotherapy cov-
ered for more than a few sessions unless they take antidepressant medication as well). Keep a list of the peo-
ple you talked to and on what dates.
b. Confidentiality of your records may be a concern. You will need to sign a waiver that allows the in-
surance company to have access to confidential information about you and your treatment. If there is infor-
mation that you do not want anyone ever to have access to (e.g., that you are on antidepressant medica-
tion), you may choose to pay directly rather than having this covered by your insurance.
c. Know that it is up to you—not your treater—to protect your financial interests. Indeed, many treaters
will not even ask you about your insurance coverage. As with buying any other service or product, it may be
wise to do some comparison shopping. You can pay very different amounts for the same treatment. When
contacting treaters, it is fine to ask how much they charge before booking an appointment.
Also, many people do not know that under Blue Cross/Blue Shield, Medicare, or Medicaid, a treater
who is listed as a provider for any of these and who agrees to treat you is legally obligated to accept that in-
surance first before any private practice billing. Some treaters do not accept patients with these types of in-
surance, and it is entirely legal to do so. But if a treater is listed as a provider and accepts you as a patient,
then the treater must accept that insurance. This means that there are limits on the amount that can be “bal-
ance-billed” (i.e., each of these plans sets maximum rates that are allowed, and the provider is obligated to
accept these until the insurance runs out for that calendar year). Note, however, that the treater is not obli-
gated to ask you if you have insurance, so unless you ask, you may end up paying for services that would be
covered. In short, know your insurance and be clear at the beginning of treatment about how billing will
occur.

HOW TO EVALUATE YOUR PSYCHOTHERAPY

Psychotherapy can be enormously helpful to many people, but it can be one of the most difficult treatments to evalu-
ate. It consists of treatment techniques that vary greatly, and its effectiveness depends on the personalities of both
you and the therapist, as well as on the relationship you develop together. Although psychotherapy is based in sci-
ence, it is also an art. Unlike other areas of medical care, it is not typically a ”procedure” that gets uniformly applied
the same way for each person.

u Remember that good psychotherapy is available, and as with most good things in life, you “know it
when you see it.” Many people with PTSD and substance abuse have been able to find treatment that feels beneficial
to them after some making the effort to shop around. If you have had a bad treatment experience, try not to give up
on treatment or blame yourself. Respect and validate your feelings, and search until you find someone you feel
better about.
u Evaluate your treatment after the third session. Research indicates that how helpful a psychotherapy
feels by the third session stays largely consistent throughout treatment even years later. If you have had three ses-
sions with a therapist and the treatment feels unhelpful, you may be better off finding someone new than sticking
with it.
(cont.)

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HANDOUT 2 (page 3 of 4) Community Resources

u Expect some ups and downs as long as the treatment feels helpful overall. Be aware that there are
likely to be times when you feel angry or disappointed by the therapist. This is a normal part of psychotherapy. But if
it feels like an ongoing problem or frequently feels too intense, you may need to evaluate it more. If you have gener-
ally felt helped by the treater, it is usually advisable to stay in the treatment and try to work it through (which may
provide you with a real opportunity for important growth). If you have generally not felt helped by the treater, then it
may be advisable to leave.
u Remember that your life decisions are your own, as long as you choose safely. If a therapist gives you
advice to stay or leave a particular job or relationship, to confront your abuser, to go to AA, or any other major ad-
vice, view it as input that you can accept or reject (as long as you are safe).
u One of the most common complaints about psychotherapy is that the therapist is kind and sup-
portive, but does not promote growth (e.g., give direct feedback, help identify important issues to work on, help
you develop new skills). A good psychotherapy is both supportive and growth-producing. If you feel you are just talk-
ing a lot but not moving on in visible ways in your life, or that the therapist is “nice” but not really helpful, you may
want to find someone who has more to offer you.
u Stay in treatment as long as it feels helpful. How long does psychotherapy last? Most
psychotherapies end because the patient decides to leave rather than because the therapist suggests it. As long as
you are safe and functional (e.g., not suicidal, not actively abusing substances, able to take care of your responsibili-
ties), the general guideline is to stay in treatment as long as it feels beneficial to you and you want to attend. Talking
with the therapist about your wish to leave, getting feedback, and going through a termination process can all be
helpful. But as long as you are safe, it is up to you when to be in treatment and when to leave. If you decide to end a
treatment, do not feel guilty, ashamed, or bad about it. If you are not currently safe, as described above, you may
need to stay in treatment until you feel more stable or at least until you find a new treatment.
u If a treatment feels as if it is not working . . .

• Try telling the treater, stating the problem directly but respectfully.
• If you have specific requests, state them. For example, you might say, “I would like to request that you
stop asking me to go on medication; I do not want it at this time.”
• You can request consultation with a senior person in the field. Many people do not know that this is an
option. A consultant is hired by you to meet with you and the therapist (usually in separate meetings)
and then to make recommendations. This is typically used in long-term therapy if the therapy reaches an
impasse that you and the therapist cannot overcome, or if the therapist insists on treatment recommen-
dations with which you do not agree.
• Be aware that it is legal and acceptable to tape your psychotherapy sessions (using your own tape re-
corder and tapes) as long as you let the therapist know. Some people do this as a way to get more out
of the sessions, listening to them later. It may also be useful if you want someone else to hear the ses-
sions (e.g., if you hire a consultant to evaluate the treatment).
• Know that many clinics will allow you to switch therapists if you ask. If you feel that you cannot work
with the person to whom you’ve been assigned and you have given it a reasonable chance, find out
whether you can switch (e.g., ask the therapist and clinic director).
u Be wary of treaters who . . .
• Convey that impasses in treatment are all your fault (e.g., they’re all due to your “resistance,” “lack of
motivation,” or “defensiveness”). While there are issues that may be due to you, if a treatment feels
stuck for a long time (e.g., more than a month), it is generally due to both the therapist and the patient.
A high-quality therapist is able to help you move beyond an impasse and does not just blame it on you.
• Give you the sense that their needs are being met rather than yours, such as repeatedly directing you to
topics that you feel are not important to you

(cont.)

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HANDOUT 2 (page 4 of 4) Community Resources

• Convey harsh negativity. This refers to therapists who get mad at you repeatedly, get into intense power
struggles, or make you feel “put down” as a person. However, it does not refer to constructive feedback
that feels painful to hear but is supportive.
• Insist that you stay in a treatment that feels as if it’s not working for you, particularly if you’ve already
tried to work it out with that treater.
u If a therapist has inappropriate boundaries, you can just leave. If a therapist attempts to initiate sexual
activity with you, invites you to social events or to sessions in places that are not an office, makes inappropriate com-
ments about your attractiveness, or engages in any other serious unprofessional behavior, the best advice is never to
return. You do not need to explain your decision or talk to that treater again.

RESOURCES TO EVALUATE HEALTH CARE TREATMENTS

ü Books. There are numerous books that can give you more information about how to evaluate your treat-
ment. See a local bookstore or library.
ü The Internet. You can search under terms such as “PTSD,” “substance abuse,” “psychotherapy,” outcomes,”
and “treatment.” There is a wealth of information on state-of-the-art knowledge and treatments.

Note: A growing trend is advertising “patient satisfaction” data. Much of the research on patient satisfaction does
not undergo rigorous scientific evaluation and may be more promotional than informative.

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Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Identify a community resource that might be of help to you, and contact it before the next session.
ª Option 2: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation Having terrible flashbacks Having terrible flashbacks
late at night; couldn’t late at night; couldn’t
sleep. sleep.

« Your Coping « Took Valium (more than I could cope better by

prescribed). calling a 24-hour hotline
(never tried that before).
Also, there are a lot of
resources on Handout 1 in
today’s session that are new
to me. I could call some of
them and try to get more
help.

Consequence I was able to get to sleep, I’d feel stronger if I was

but feel like I’ll never get making an active attempt to
over my substance abuse. I do these things, rather than
feel weak. just popping pills.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

264
INTERPERSONAL

Setting Boundaries in Relationships

SUMMARY

Boundary problems are described in two forms: too much closeness (difficulty saying “no” in
relationships) and too much distance (difficulty saying “yes” in relationships). Ways to set
healthy boundaries are described.

ORIENTATION

“I don’t trust people and I can’t reach out to them. What happened in Viet Nam is too horri-
ble to talk about. I lost faith in the human race.”

“Every time I have run into trouble with my sobriety, it has been because of a man. I
picked up coke for the first time because of a man; picked up alcohol after rehab because
of wanting to please a man. I also have been in some very abusive situations—physical
and sexual—that I am sure did not help my PTSD. My relationship with Steve now is not
healthy. He is married, uses coke, controls me, does not encourage mental health or posi-
tive feedback, and does not like me out at AA or any other functions. I am aware now that
if I enter into this relationship again, it will be very risky for me. At this point it is very dif-
ficult for me to say no. But now I’m practicing.”

The concept of “boundaries” is explored, with attention to how PTSD and substance abuse
can lead to boundary problems and how boundary setting can be practiced. Boundary prob-
lems usually translate into either too much closeness or too much distance. Thus, in today’s
topic, two simple strategies are offered: saying “no” (to create distance from unhealthy rela-
tionships) and saying “yes” (to create closeness in healthy relationships).
When patients have difficulty saying “no” in relationships, it typically represents an ill-
fated attempt at love that ultimately results in isolation or exploitation. They try too hard to
please others and in the process lose themselves. Often there is a fear that if limits are set in a

265
266 Treatment Topics

relationship, others will respond negatively with anger, abandonment, emotional abuse, or
even physical violence. This may represent both realistic fears based on their life experiences
and, at the same time, an overgeneralized distrust in which their traumatic past overshadows
the present. Learning to say “no” in the present, therefore, requires them to differentiate who
is safe versus unsafe, as well as how and when to say “no.” Saying “no” to abusive relation-
ships is a crucial issue for some patients and is addressed in its own handout. (It is also sug-
gested that if a patient is in a situation of domestic violence, the therapist contact a hotline
that specializes in this very complicated area, and seek consultation and supervision.) For pa-
tients who are prone to violating others’ boundaries (another form of boundaries that are too
close), see the topic Healing from Anger, which addresses that in detail. Finally, it can also be
observed that too-close boundaries may be a source of strength at times, allowing patients to
connect fluidly with others to initiate relationships and, in psychotherapy, creating an intense
attachment can serve as a developmental stage toward later healthy relationships.
Learning to say “yes” is important for patients who have isolated themselves too much
from others. Reaching out, making meaningful connections, and allowing one’s vulnerable
side to show through are all essential parts of rebuilding trust in relationships. This may be
especially difficult for men and/or war veterans (who may feel a need to appear “strong”),
and for survivors of interpersonal trauma in which humiliation or shame was prominent.
Healthy boundaries are usually emphasized in interpersonal relationships but are
equally important intrapersonally (within oneself). For example, how can patients talk to
themselves to avoid going out and buying drugs, or to leave their jobs at a normal time rather
than overworking? Such internal role plays can be just as useful as external ones for some pa-
tients, and they keep the focus on changing oneself rather than trying to change others. It also
can help patients to see that the inter- and intrapersonal realms are often parallel—how they
treat themselves is similar to how they treat others. If it is hard to say “no” to oneself, it may
be hard to say “no” to others. If it is hard to say “yes” to oneself, it may be hard to say “yes” to
others too.

Countertransference Issues

The main countertransference issue is making sure to fully understand what makes it difficult
for a patient to say “no” or “yes” in a particular situation. Sometimes it is easy to conduct role
plays in ways that do not go deep enough—that do not address the very real emotional obsta-
cles that prevent setting healthy boundaries. For example, a patient may conduct a role play
beautifully on saying “no” to a friend about getting high, but when probed says, “In real life, I
wouldn’t be able to say that.” Processing that level of the patient’s struggle then becomes the
focus. Also, a caveat: When exploring a patient’s destructive relationships, the therapist may
be drawn to convey judgment or criticism of people in the patient’s life (e.g., “Your aunt is not
there for you at all”). It is important that the therapist to respect the patient’s attachments.
Even in damaging relationships there are usually some genuinely positive aspects that make
it difficult for the patient to leave. Supporting the patient’s own critique of others can be
helpful, as is offering honest feedback from the perspective of the patient’s needs (e.g., “I’m
concerned that you may not be getting from your aunt what you feel you need”).
Setting Boundaries in Relationships 267

Acknowledgment
Handout 5, Boundary Problems Associated with PTSD and Substance Abuse, is drawn
largely from Herman (1992).

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 271. Link the quotation to the session—for example,
“Today we’re going to talk about setting boundaries in relationships. Really listening to your
inner needs can help.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Cover them in multiple sessions if you have the time. See “Session Con-
tent” (below) and Chapter 2.
Handout 1: Healthy Boundaries
Handout 2: Too Much Closeness: Learning to Say “No” in Relationships
Handout 3: Too Much Distance: Learning to Say “Yes” in Relationships
Handout 4: Getting Out of Abusive Relationships
Handout 5: Boundary Problems Associated with PTSD and Substance Abuse
(optional)
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT

Handouts 1, 2, and 3: Setting Boundaries in Relationships

Goals
¨ Discuss healthy versus unhealthy boundaries (Handout 1).
¨ Explore ways to say “no” in relationships, for patients who are too enmeshed (Hand-
out 2).
¨ Explore ways to say “yes” in relationships, for patients who are too detached (Hand-
out 3).

Ways to Relate the Material to Patients’ Lives

ê Role plays. Rehearse out loud how patients can set boundaries with themselves and
others. Handouts 2 and 3 have lists of scenarios to role-play if a patient has difficulty identify-
ing a real-life current situation. When a patient is role-playing setting a boundary with her- or
268 Treatment Topics

himself, the therapist may want to play the patient’s “inner voice.” For example, if the “inner
voice” wants to work too many hours, how would the patient respond to that voice to set a
boundary?
ê Drug refusal training. This is role playing specifically focused on saying “no” to sub-
stances. It is one of the most essential safety skills for patients to learn. Patients should re-
hearse out loud and memorize at least one or two ways to say “no” to themselves and others
when tempted by substances.
ê Discussion
• “Do you have more difficulty setting a boundary with yourself or with others?”
• “Do you think your boundaries are too close or too distant?”
• “How can setting boundaries keep you safe?”
• “Why is setting boundaries in relationships important?”
• “Why might PTSD and substance abuse make it hard for someone to establish
healthy boundaries?”
• “Do you have problems setting boundaries in relationships? What are some exam-
ples in your life right now?”
• “Can you remember any recent example in which you were successful in setting a
boundary with yourself or someone else? What made that possible?”
• “If someone says to you, what would you say to set a boundary?”
• “If you say to yourself , what would you say to set a boundary with
yourself?”

Suggestion
✦ Although most patients are fine with this topic, very occasionally someone feels upset
when reading about boundary problems. If this occurs, it is helpful to be reaffirming and
comforting with the patient. For example: “You don’t have to keep reading this if you don’t
want to—you can set a boundary right here in the session and say ‘no’ to this sheet!”, “It
makes sense that it might be upsetting to read this,” or “Everyone has problems in relation-
ships.”

Handout 4: Getting Out of Abusive Relationships

Goal
¨ Help patients evaluate whether they are in any destructive relationships, and identify
ways to protect themselves from those.

Ways to Relate the Material to Patients’ Lives

êSelf-exploration. Ask patients to take the brief self-test at the top of the handout to de-
termine whether they are currently in a destructive relationship. If a patient has no destruc-
tive relationships, you may want to skip this handout. You could then return to the other
handouts as needed.
Setting Boundaries in Relationships 269

ê Process perceived obstacles. The remainder of the handout has ideas on how patients
can protect themselves from destructive relationships. Help identify issues such as emotional
obstacles to leaving the relationship, ways to increase self-protection, and beliefs that may
help alleviate guilt or fear.
ê Encourage the patient to call a hotline during the session. Many people in domestic
violence situations cannot easily leave due to the extraordinary power their abusers have over
them. Help them obtain information and support that may strengthen their ability to safely
manage the situation.
ê Discussion
• “How can you get out of destructive relationships?”
• “What keeps you in destructive relationships?”
• “What kind of help do you need to detach from your destructive relationship?”
• “Why is it ‘better to be alone than in a bad relationship’?”

Suggestions
✦ It may be unclear whether a relationship is destructive. Many relationships may have
both good and bad qualities. The key signs are a repeated pattern of serious emotional harm
or any incident of physical abuse.
✦ A patient may not recognize a destructive relationship. If you perceive a clear danger,
give the patient direct, honest, empathic feedback. This may help overcome the patient’s de-
nial or confusion.
✦ Seek supervision and expert advice on domestic violence issues. There can be extreme
danger for someone leaving a situation of domestic violence; many people are killed by their
abusers when they try to leave. Before intervening, seek supervision from someone who is
trained in the treatment of domestic violence. Call the numbers in the handout to obtain in-
formation as well. You can also call the local police department for information. If you work in
a hospital or clinic that has an attorney (most hospitals do), it may be helpful to talk to that
person. Work with the patient to obtain information and honestly evaluate the risks.

Handout 5: Boundary Problems Associated with PTSD and Substance Abuse

Goal
¨ Help patients explore various forms of boundary problems associated with trauma and
substance abuse.

Clinical Warning
In testing this treatment, it was found that while most patients benefited from reading Hand-
out 5, a few became very upset. Do not provide it to patients unless you know them well and
feel they are ready. Even then, inquire whether or not they want to read it, and if you observe
any significant upset, have them stop reading and help them de-escalate (through validation,
empathy, grounding, etc.).
270 Treatment Topics

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to check off the boundary problems they notice in them-
selves.
ê Discussion
• “How does your trauma relate to the types of boundary problems you have?”
• “How does your substance abuse relate to the types of boundary problems you
have?”
• “Can you view your boundary problems with compassion, yet still work on them?”

Tough Cases
∗ “I can try boundaries in a role play, but in real life I wouldn’t do it.”
∗ “I can’t say ‘no.’ It makes me feel I’m being mean, like my abuser.”
∗ “I’m all alone. I just can’t trust people.”
∗ “What do you mean by ‘set a boundary with myself ’?”
∗ “When I say ‘no’ to my partner, I get hit.”
∗ “I want to set a boundary with you—stop telling me to get off substances! I’m not
ready.”
∗ “I know I’m in a destructive relationship, but I can’t leave.”
∗ “You can tell me to reach out to others, but I feel safer staying alone.”
∗ “My cousin keeps offering me crack, no matter how much I say not to.”
 Quotation

“Let your heart guide you.

It whispers, so listen closely.”
—Molly Goode
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

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HANDOUT 1 Setting Boundaries in Relationships

Healthy Boundaries

Healthy boundaries are:

• Flexible. You are able to be both close and distant, adapting to the situation. You are able to let go of
relationships that are destructive. You are able to connect with relationships that are nurturing.
• Safe. You are able to protect yourself against exploitation by others. You are able to read cues that someone
is abusive or selfish.
• Connected. You are able to engage in balanced relationships with others and maintain them over time. As
conflicts arise, you are able to work them out.
Both PTSD and substance abuse can result in unhealthy boundaries. In PTSD, your boundaries (your body
and your emotions) were violated by trauma. It may be difficult for you now to keep good boundaries in relation-
ships. In substance abuse, you have lost boundaries with substances (you use too much, and may act in ways you
normally would not, such as getting high and saying things you don’t mean). Learning to establish healthy bound-
aries is an essential part of recovery from both disorders.
Boundaries are a problem when they are too close or too distant.

Boundaries can be too close (letting people in too much; enmeshed). « Do you:
o Have difficulty saying “no” in relationships?
o Give too much?
o Get involved too quickly?
o Trust too easily?
o Intrude on others (e.g., violate other people’s boundaries)?
o Stay in relationships too long?

Boundaries can be too distant (not letting people in enough; detached). « Do you:
o Have difficulty saying “yes” in relationships?
o Isolate?
o Distrust too easily?
o Feel lonely?
o Stay in relationships too briefly?

Note that many people have difficulties in both areas.

Boundary problems are a misdirected attempt to be loved. By “giving all” to people, you are trying to win
them over; instead, you teach them to exploit you. By isolating from others, you may be trying to protect yourself,
but then don’t obtain the support you need.
Healthy boundaries can keep you safe.
Learning to say “no” can . . . keep you from getting AIDS (saying “no” to unsafe sex); keep you from using sub-
stances (saying “no” to substances); prevent exploitation (saying “no” to unfair demands); protect you from
abusive relationships and domestic violence.
Learning to say “yes” can . . . allow you to rely on others; let yourself be known to others; help you feel sup-
ported; get you through tough times.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 1 (page 2 of 2) Setting Boundaries in Relationships

Setting good boundaries prevents extremes in relationships. By setting boundaries, you can avoid painful
extremes: too close versus too distant, giving too much versus too little, idealizing versus devaluing others. Neither
extreme is healthy; balance is crucial.

It is important to set boundaries with yourself as well as with others.

You may have difficulty saying “no” to yourself. For example, you promise yourself you won’t smoke pot, but
then you do. You may overindulge in food, sex, or other addictions. You may say you won’t go back to an
abusive partner, but then you do.
You may have difficulty saying “yes” to yourself. For example, you may deprive yourself too much by not eating
enough, working too hard, not taking time for yourself, or not allowing yourself pleasure.
People with difficulty setting boundaries may violate other people’s boundaries as well. This may ap-
pear as setting up “tests” for other people, intruding into other people’s business, trying to control others, or being
verbally or physically abusive.
If you physically hurt yourself or others, you need immediate help with boundaries. Hurting yourself or
others is an extreme form of boundary violation. It means that you act out your emotional pain through physical
abuse. Work with your therapist to set a Safety Contract. (See the topic Healing from Anger for more on this.)

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HANDOUT 2 Setting Boundaries in Relationships

Too Much Closeness: Learning to Say “No” in Relationships

Why is it important to say “no”? It means setting a limit to protect yourself in relationships. For example, “If you
show up with coke, I’m leaving,” or “Unless you stop yelling at me, I’m walking out.” Saying “no” is an important
skill for setting boundaries. At a deeper level, setting boundaries is a way of conveying that both people in a relation-
ship deserve care and attention. It is a healthy way of respecting your separate identity.

SITUATIONS WHERE YOU CAN LEARN TO SAY “NO”

u Refusing drugs and alcohol.
u Pressure to say more than you want to.
u Going along with things that you do not want to do.
u When you’re taking care of everyone but you.
u When you do all the giving in a relationship.
u When you make promises to yourself that you do not keep.
u When you’re doing things that take your focus away from recovery.
« Any others that you notice? Write them on the back of the page.

EXAMPLES: SAYING “NO” IN SUBSTANCE ABUSE AND PTSD

With Others With Yourself

Substance “No thanks; I don’t want any now.” “Self-respect means no substances today.”
Abuse
“Drinking is not allowed on my diet.” “If anybody offers me drugs at the party, I
need to leave.”
PTSD “I need you to stop talking to me like that.” “Working as a prostitute is making my PTSD
worse; I need to stop.”
“Please don’t call me again.” “Seeing war movies is triggering my PTSD; I
need to stop.”

HOW TO SAY “NO”

* Try different ways to set a boundary:

• Polite refusal: “No thanks, I’d rather not.”
• Insistence: “No, I really mean it, and I’d like to drop the subject.”
• Partial honesty: “I cannot drink because I have to drive.”
• Full honesty: “I cannot drink because I’m an alcoholic.”
• Stating consequences: “If you keep bringing drugs home, I will have to move out.”

* Remember that it is a sign of respect to say “no.” Protecting yourself is part of developing self-respect.
Rather than driving people away, it helps them value you more. You can be vulnerable without being exploited. You
can enjoy relationships without fearing them. In healthy relationships, saying “no” appropriately promotes closeness.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 2 (page 2 of 2) Setting Boundaries in Relationships

* How much or how little you say is up to you. However, if you can comfortably provide an explanation,
this can make it easier on the other person.

* You will find the words if you are motivated to say “no.” Once you commit to protecting your needs,
the how will present itself.

* Take care of yourself; let others take care of themselves. You can only live your life, not theirs.
* If you are afraid of hurting the other person, remember that it may take repeated work, both with the
other person and within yourself. Over time, you will realize that healthy people can tolerate hearing what you think
and feel.

* You can set a boundary before, during, or after an interaction with someone. Try discussing a difficult
topic beforehand (e.g., discuss safe sex before a sexual encounter), during an interaction (e.g., try saying “no” to al-
cohol when it is offered), or afterward (e.g., go back and tell someone you did not like being talked to abusively).

* Be careful about how much you reveal. PTSD and substance abuse are sensitive topics, and discrimination
against these disorders is very real and harmful. You can never take back a statement once it has been said. You do
not need to be open with people you do not know well, people in work settings, or people who are abusive to you.

* Be extremely careful if there is a possibility of physical harm. Seek professional guidance.

ROLE PLAYS FOR SAYING “NO”

« Try rehearsing the following situations out loud. What could you say?

With Others
→ You are at a holiday party and your boss says, “Let’s celebrate! Have a drink!”
→ Your partner says you should “just get over your trauma already.”
→ A friend tells you not to take psychiatric medications because “that’s substance abuse too.”
→ Your sister wants to know all about your trauma, but you don’t feel ready to tell her.
→ Your partner keeps drinking around you, saying “You need to learn to deal with it.”
→ Your date says, “Let’s go to my place,” and you don’t want to.
→ Your boss gives you more and more work, and it’s too much.
→ You suspect that your uncle is abusing your daughter.

With Yourself
→ You want to have “just one drink.”
→ You keep taking care of others but not yourself.
→ You promised to stop bingeing on food but keep doing it.
→ You are working too many hours, with no time left for recovery activities.

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HANDOUT 3 Setting Boundaries in Relationships

Too Much Distance: Learning to Say “Yes” in Relationships

Why is it important to say “yes”? It means connecting with others. It is a way of recognizing that we are all
human and all need social contact. It is a healthy way of respecting your role as part of a larger community. It means
becoming known to others.

SITUATIONS WHERE YOU CAN LEARN TO SAY “YES”

u Asking someone out for coffee.
u Telling your therapist how you really feel.
u Asking someone for a favor.
u Joining a club or organization.
u Calling a hotline.
u Being vulnerable about your “weak” feelings.
u Letting people get to know you.
u Soothing “young” parts of yourself.

« Any others that you notice? Write them on the back of the page.

EXAMPLES: SAYING “YES” IN SUBSTANCE ABUSE AND PTSD

With Others With Yourself

Substance “I am having a drug craving—please help talk “I can give myself treats that are healthy
Abuse me through it.” rather than destructive.”
“Please come with me to an AA meeting.” “I will try speaking at an AA meeting.”
PTSD “I need your help—I am scared.” “I need to reach out to people when I’m
upset.”
“I would like you to call and check in on me “I can start creating healthy friendships step
to see if I’m okay.” by step.”

HOW TO SAY “YES”

* Try different ways:

• Share an activity: “Would you like to go to a movie with me?”
• Say how you feel: “I feel so alone; it is hard for me to talk about this.”
• Focus on the other person: “Tell me about your struggles with cocaine.”
• Watch how others do it: Go to a gathering and listen to others relate.

* Plan for rejection. Everyone gets rejected at times. It is a normal part of life. Let go of that person and move
on to someone else who might be available.

* Practice in advance, if possible. Therapy may be a safe place to rehearse.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 3 (page 2 of 2) Setting Boundaries in Relationships

* Choose safe people. Select people who are friendly and supportive.
* Know that it’s normal to make mistakes along the way. It will feel uncomfortable to reach out to others
at first. Allow yourself room to grow—it will get easier over time.

* Set goals. Keep yourself moving forward by making a clear plan, just as you would in other areas of your life.
Decide to make one social call a week, or try one new meeting a week.

* Recognize that you may feel very “young.” Parts of you may feel vulnerable, like a child who is just learn-
ing how to relate to people. That is expected, as parts of you may not have had a chance to develop due to PTSD or
substance abuse.

* Start small. Start with a simple event (e.g., saying hello or smiling) rather than a huge one (e.g., asking
someone out on a date).

* Notice what you have in common rather than how you are different. Work hard to see your similarities
with others; this can make it easier to connect.

ROLE PLAYS FOR SAYING “YES”

« Try rehearsing the following situations out loud.

With Others
→ You talk about your impulse to hurt yourself before doing it.
→ You ask someone at work to go to lunch.
→ You tell your therapist you missed her when she was away on vacation.
→ You call your sponsor when you feel like drinking.
→ You tell someone, “I love you.”
→ You tell someone how alone you feel.
→ You admit a weakness to someone.
→ You talk to your friend honestly about your anger at him.
→ It is 4:00 A.M. and you are so depressed you can’t sleep. Whom can you call?
→ The weekend is coming and you have no plans with anyone. What can you do?

With Yourself
→ You feel scared; how can you soothe yourself?
→ You have worked hard; how can you give yourself a safe treat?
→ Part of you (“the child within”) feels hurt. How can you talk to that part?
→ You are angry at yourself for failing a test. How can you forgive yourself?

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HANDOUT 4 Setting Boundaries in Relationships

Getting Out of Abusive Relationships

« Are you in any relationship right now in which someone:

1. Offers you substances or uses in your presence after you’ve asked the person Yes No
not to?
2. Repeatedly criticizes you, invalidates your feelings, or humiliates you? Yes No
3. Manipulates you (e.g., threatens to harm your children)? Yes No
4. Is physically hurting you or threatening to? Yes No
5. Discourages you from getting help (e.g., medication, therapy, AA)? Yes No
6. Lies to you repeatedly? Yes No
7. Betrays your trust (e.g., tells your secrets to others)? Yes No
8. Makes unreasonable requests (e.g., demands that you pay for everything)? Yes No
9. Exploits you (e.g., sells pornographic pictures of you)? Yes No
10. Ignores your physical needs (e.g., refuses safe sex)? Yes No
11. Is controlling and overinvolved (e.g., tells you what to do)? Yes No

If you said “Yes” to any of the questions above, read the rest of this handout. You deserve better than destructive
people!

HOW TO DETACH FROM DAMAGING RELATIONSHIPS

If you have difficulty with boundaries, you may not notice dangerous cues in others. This makes sense if you lived in a
past in which a veil of silence was imposed, you were not allowed to express your feelings, or you could not tell oth-
ers about your trauma. You may need to make special efforts now to notice your reactions to people and to learn
when to end relationships that are hurtful.

€ If someone doesn’t “get it,” give up for now. In early recovery, don’t waste your energy on changing
other people; just focus on helping yourself. If someone doesn’t understand you after you’ve tried to communicate
directly, kindly, and repeatedly, find other people.

€ Even if you cannot leave a damaging relationship, you can still detach from it. If it is someone you
must see (such as a family member), protect yourself by not talking to that person about vulnerable topics, such as
your trauma or your recovery.

€ If enough reasonable people tell you a relationship is bad, listen to them. You may feel so confused
or controlled that you have lost touch with your own needs. Listen to others.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 4 (page 2 of 2) Setting Boundaries in Relationships

€ It’s better to be alone than in a destructive relationship. It may be that for now, your only safe relation-
ships are with treaters. That’s okay.
€ Destructive relationships can be as addictive as drugs. If you cannot stay away from someone you know
is bad for you, you may be addicted to that person. Destructive relationships may feel familiar, and you may be
drawn to them over and over if your main relationships in life were exploitative. The best strategy is the same as for
all addictions: Actively force yourself to stay away, no matter how hard it feels to do so.
€ Remember that you are no longer a child, forced to endure bad relationships. You have choices.
€ Recognize the critical urgency of detaching from bad relationships. They impair your recovery from
PTSD and substance abuse. They prevent you from taking care of yourself and others (e.g., children).
€ Once you make a decision to leave a damaging relationship, the “how” will present itself. If you do
not know how to leave, it usually means that you have not yet made the decision to leave.
€ If you feel guilty, remember that it is your life to live. You can decide how to live it.
€ Expect fallout. When you leave a bad relationship, others may become angry or dangerous. Find ways to
protect yourself, including the support of people “on your side,” your treatment team, and a shelter if necessary.
€ You do not have to explain yourself to the other person; you can just leave.
€ Create an image to protect yourself. For example, you are a knight in armor and you don’t have to let the
person in; you are a TV and you can change the channel.
€ Try Co-Dependents Anonymous. This is a twelve-step group for people who become dependent on dam-
aging relationships (( 602-277-7991).
€ You should never have to tolerate being physically hurt by anyone. If you are in a situation of domes-
tic violence, this is very serious and requires expert help. You can call:
( National Domestic Violence Hotline 800-799-7233
( National Resource Center on Domestic Violence 800-537-2238
€ If someone is physically hurting you, don’t buy into “I’ll be different next time.” If there is a pattern
of abuse after you have given someone repeated chances to treat you decently, get out. Listen to the person’s ac-
tions, not the words.

* Take care of yourself! *

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HANDOUT 5 Setting Boundaries in Relationships

Boundary Problems Associated with PTSD

and Substance Abuse

Note: Some people become upset when reading the list below. Only read it if you feel safe to do so, and stop if it is
too upsetting.

People with PTSD and substance abuse may be prone to boundary problems, such as the following:

• Extremes: trusting too much or too little; isolation or enmeshment.

• Relationships that are brittle (easily damaged, fragile).
• Tolerating others’ flaws too much; doing anything to preserve the relationship.
• Use of substances as an attempt to connect with others.
• Avoiding relationships because they are too painful.
• Overcompliance at times; too much resistance at other times.
• Always being the one to give.
• Spending time with unsafe people.
• Not seeing the hostility in others’ words or actions.
• Being overly angry, with a hair-trigger temper; often ready to “blow up.”
• Difficulty expressing feelings; expressing them in actions rather than words (acting out).
• May respect men for being “strong” and disrespect women for being “weak.”
• Feeling that one can never get over a loss; not knowing how to mourn; fear of abandonment.
• Difficulty getting out of bad relationships.
• Confusion between fear and attraction (i.e., feeling excited when it is really fear).
• Relationships with people who use substances.
• Living for someone else rather than yourself.
• Manipulation: guilt, threats, or lying.
• Reenactments: getting involved in repeated destructive relationship patterns (e.g., recreating the trauma
roles of abuser, bystander, victim, rescuer, or accomplice).
• “Stockholm Syndrome”: feeling attachment and love for the abuser.
• Wanting to be rescued; wanting others to take responsibility for the relationship.
• Confusion about what is appropriate in relationships: What can one rightly expect of others? When should a
relationship end? How much should one give in a relationship? Is it okay to say “no” to others?
• ”Identification with the aggressor”: believing the abuser is right.

Acknowledgment: This handout is drawn largely from Herman (1992). Ask your therapist for guidance if you would like to locate the source.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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 Setting Boundaries in Relationships

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: In a real-life situation this week, try setting a boundary with either yourself or someone else.
ª Option 2: Memorize your top three ways to say “no” to substances.
ª Option 3: Pick a role play from Handout 2 or 3, and write out how you would handle it.
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation My mother keeps criticizing My mother keeps criticizing
my decisions. my decisions.

« Your Coping « I get overwhelmed and I set a boundary by asking

resentful. I just let her her to stop criticizing me—
talk at me until she’s done. it is hurting my recovery,
Sometimes I go out and I cannot listen to it
afterwards and smoke crack right now and will leave the
so I can get a “holiday” room if necessary.
from her.

Consequence I feel walked over. I know I feel better, like I’ve

the crack is destroying my taken control. She seemed
body and my bank account. surprised and didn’t like
hearing it, but it was okay.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

281
COGNITIVE

Discovery

SUMMARY

Patients are encouraged to use “Discovery” to find out if their beliefs are true, rather than
“staying stuck.” They are provided with ways to discover (“Ask Others,” “Try It and See,”
“Predict,” and “Act as If ”) and prepared for how to cope with negative feedback.

ORIENTATION

“Inventing a Possible World”

“Contrary to what I once thought . . . progress did not consist simply in observing, in
accumulating . . . facts. . . . It began with the invention of a possible world . . . which
was then compared by experimentation with the real world. And it was this constant
dialogue between imagination and experiment that allowed . . . an increasingly fine-
grained conception of what is called reality.”
—François Jacob (1988)

Today’s topic provides patients with a way of improving their conception of reality through a
process of discovery similar to that described in the quotation above. Indeed, one of the best
definitions of mental health is “the ability to perceive the world accurately.” Unfortunately,
PTSD and substance abuse are typically marked by cognitive rigidity. It is common for pa-
tients to stay stuck in assumptions such as “The world is a bad place,” “I can’t trust anyone,”
“My only solace is drinking,” and so on. These are often well-worn beliefs learned over many
years and may be frustrating both to patients and to therapists
Cognitive therapy at its best provides patients with a way out, but—and this is key—not
through persuasion, but rather through discovery. Sometimes called “empirical hypothesis
testing” (Beck et al., 1985), “discovery” means guiding patients to find out whether their be-
liefs are true. Without this process, most cling for years to damaging beliefs that become rea-

282
Discovery 283

sons not to try, to keep using substances, and to stay right where they are. When cognitive
therapy is done poorly, the therapist tries to just tell, lecture, or instill a new belief system:
“But you are a good person!” or “You can cope without drinking!” The methods of discovery,
in contrast, help patients set up a way to find out and then draw their own conclusions from
the results. It creates a feedback loop for patients to explore their experiences. The idea is to
keep refining their model of the world, not settling for what others tell them or what they ex-
perienced in the past. It is a search for new knowledge.
Part of the difficulty with the discovery process is that patients’ worst fears may come
true—getting an HIV test and finding out one is HIV-positive; searching for a job and not
finding one. Helping patients face such truths openly and honestly, and learning from them
productively, requires careful preparation to tolerate the distress of such discoveries. The
guiding principle is that all knowledge is helpful, even painful knowledge. Hiding from real-
ity is a short-term solution with long-term costs.
In the handouts, patients are offered several strategies for discovery and a Discovery Sheet
to start working on a belief. They are asked to brainstorm “How can I find out?” with specific ex-
amples from their lives. In addition, metaphors are used to increase patients’ motivation to try
the discovery process: explorer, scientist, artist, child, or detective. (And trying out a metaphor
is in and of itself a method of discovery—the strategy “Act as If ” described in one handout.)
Finally, at the end of the handouts is a written example by a real patient, illustrating the positive
results that can be obtained as well as some of the difficulties that can arise.
The net result, when discovery is done well, is that patients find a new outlook and feel
more in touch with their inner lives and with the assumptions they make. They can view the
world more from the stance of adults who have choices rather than as powerless victims. This
can be liberating.

Countertransference Issues
Therapists may be drawn, often unconsciously, into reinforcing patients’ difficulty with taking
responsibility. For example, a male patient went to a dance and didn’t meet anyone. The ther-
apist tried to focus on the idea that “They just didn’t appreciate who you are” and “It may go
better next time”—anything except getting the patient to discover why he might be genu-
inely unappealing to women. A more productive approach might be to help the patient think
of what he can do to make it go better next time: “Perhaps you could dress better?”, “Could
you read a book on how to converse in dating situations?”, “Would it help to do some relax-
ation exercises before going?” In short, sometimes negative feedback in discovery indicates
that the patient needs to take more responsibility to make things go better; other times, it
may be someone else’s fault; or it may be a negative event that is no one’s fault (e.g., the pa-
tient showed up at the dance and there was no one there his age). The therapist’s task is to
help the patient realistically process these diverse possibilities.

Acknowledgments
The term “guided discovery” comes from cognitive therapy (e.g., Beck et al., 1985; Young,
1999). The quotation at the start of this orientation is from François Jacob (1988), winner of
284 Treatment Topics

the 1965 Nobel Prize in Physiology or Medicine. The idea of “setting up an experiment” un-
der “Try It and See” in Handout 2 is derived from Burns (1990).

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 286. Link the quotation to the session—for example,
“Today we’re going to talk about discovery. As the quote suggests, I hope that you’ll find ad-
venture in this session and in discoveries in your life.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts:
Handout 1: Discovery versus Staying Stuck
Handout 2: How to Find Out If Your Belief Is True . . .
Handout 3: Discovery Sheet
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals

¨ Contrast “discovery” with “staying stuck” in a belief (Handout 1).

¨ Teach strategies for discovery—ways of testing beliefs (e.g., “Try It and See,” “Ask Oth-
ers”), as well as ways how to cope with negative feedback (Handout 2).
¨ Guide patients to identify a specific belief they can test out through the Discovery
Sheet (Handout 3).

Ways to Relate the Material to Patients’ Lives

êWork on the Discovery Sheet. Help patients identify a real-life situation that would
benefit from discovery and process how to go about it. Guide them to fill out the first two
boxes of the blank Discovery Sheet (Handout 3) now, and to fill out the last two boxes before
the next session.
ê Discussion
• “Have you made any discoveries recently that you would like to share?”
• “Do you tend to feel stuck sometimes? If so, do you think discovery could help?”
• “What might be hardest for you about discovery?”
• “Why is it important to test specific beliefs when trying discovery?”
Discovery 285

Suggestions
✦ Make sure patients pick a belief that they can actually work on. That is, it is testable,
specific, and they feel ready to try the process of discovery on it. Examples of testable beliefs
are described in Handout 2. Examples of beliefs that are difficult or impossible to test are
“The world is a dangerous place” or “The future is hopeless.” These are too vague and global.
If a patient starts with these, you can ask questions such as “Is there anything specific right
now that feels dangerous?”, and “Is there anything in the near future that feels hopeless?”,
until a current specific situation is brought to light.
✦ Try to help patients recognize that discovery versus staying stuck is a choice they can
make. Often they do not recognize that they can choose to actively test out their belief sys-
tems. Also, consistent with this, remember that it is up to patients to decide what beliefs to
test.
✦ If a patient does not like using an image, let it go. Do not spend time in the session try-
ing to create one—it is not essential for the discovery process, but is merely a playful element
that some patients enjoy.
✦ Discovery is best applied to the present or future. For example, if a patient says, “I be-
lieve that my father hated me when I was a child,” there may be no way to find this out now.
✦ Help set patients up for a success experience. If they take on something too hard, they
may not be ready for the consequences. For example, if a female patient who is being physi-
cally abused by her partner decides to test the belief that “If I tell him how I feel, he’ll
change,” she is likely to fail and may get beaten up. Make sure the belief is challenging
enough to promote growth but not impossible. There needs to be some uncertainty about the
results yet some possibility that it can go well.
✦ Discuss how patients will feel if their worst fear comes true. How will they cope with
it? You don’t want patients to go out and use substances because they are not prepared for
negative feedback.
✦ If patients have difficulty coming up with beliefs to test, you can help by thinking of
what you know about them. For example, if you’ve been working with a patient who has been
unwilling to go to AA even once, you may want to use this session to see whether the patient
would be willing to try a one-time visit to AA.
✦ Note that the Safe Coping Sheet is not used because of the Discovery Sheet.

Tough Cases
∗ “I can’t bear to find out the truth. It would kill me.”
∗ “My belief is ‘Life is not worth living.’ ”
∗ “I want to test the belief that I’m your favorite patient. Am I?”
∗ “I tried discovery and found out that my partner is having an affair with my best
friend.”
∗ “I know the truth about my situation. I don’t need to try discovery.”
∗ “I can’t think of any belief to test.”
∗ “My belief is ‘I can’t give up drugs.’ ”
 Quotation

“Life is never what one dreams. It

is seldom what one desires, but,
for the vital spirit and the eager
mind, the future will always hold
the search for buried treasure and
the possibility of high adventure.”
—Ellen Glasgow
(20th-century American novelist)

From Seeking Safety by Lisa M. Najavits (2002).

286
HANDOUT 1 Discovery

Discovery versus Staying Stuck

Discovery is one of the most powerful tools in recovery.

“Discovery” means finding out . . . learning from experience . . . adapting . . . curiosity . . . openness . . . moving
forward . . . growth.
Discovery is what children do naturally—they try to explore, find out, and have fun in trying new things. Other
people who discover are explorers, artists, scientists, detectives, and hopefully you!
Staying stuck is the opposite of discovery.
“Staying stuck” means assuming . . . avoiding . . . rigid thinking . . . hiding . . . living in the past . . . being closed
to the world.
One of the difficulties of PTSD and substance abuse is staying stuck. For example, if you’ve had PTSD for years
without getting better, you may not feel like trying any more. Or, if you’ve been using heroin to feel relaxed,
you may not search for other ways to relax.

A STORY
Situation: Amy has been lying to her therapist, Dr. Burke, about her cocaine use because she feels ashamed.
She believes he’ll stop working with her if he finds out.
Compare two different endings to the story:
Amy tries discovery. She tells Dr. Burke the truth because she thinks, “It’ll be better to find out than to keep liv-
ing with this shame.” Dr. Burke asks her to start getting weekly urine tests, because the treatment cannot
work if Amy hides her substance use. Amy resents this, but also sees that Dr. Burke is trying to help and will
keep working with her.
Amy stays stuck. She keeps hiding the truth from Dr. Burke. Eventually she feels so bad that she stops attending
treatment altogether because she can’t take the self-hatred. She uses more and more cocaine.

THE PROCESS OF DISCOVERY

1. Notice your belief. For example:
“I believe that if I tell my friend I’m angry with him, he’ll leave.”
“I believe calling a hotline will make me feel more depressed.”
“I believe I’ll never get a job.”
“I believe AA will be boring.”
2. Find an image (optional). If you want, think of an image that helps you discover:
An explorer . . . embarking on a search
A detective . . . trying to find out
A child . . . interested and curious
An artist . . . playing with possibilities
A scientist . . . searching for the truth
Or write your own image here:
3. Try discovery. Create a plan to actually find out if your belief is true. Some ways are listed in Handout 2.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

287
HANDOUT 2 Discovery

How to Find Out If Your Belief Is True . . .

* Ask People *
“Ask People” means that you check out your belief by hearing what others think of it. The more people you ask, the
better, so that you can see how much agreement there is about your belief.
Example: Sarah believed, “If I let myself cry, I’d never stop.” She decided to ask another patient (who was fur-
ther along in recovery) and her therapist, and to read a book about PTSD. The result: All three sources conveyed the
idea that while it is very common to feel this way, it is not true—everyone stops crying eventually.

* Try It and See *

“Try It and See” means “go for it”—try doing something and see what happens. You can also think of it as setting up
an experiment because, like a scientist, you design a test and then observe what happens.
Example: Doug was living with a roommate who grew marijuana in the house. He believed, “My roommate
won’t be willing to stop.” He decided to use “Try It and See” by asking the roommate directly. The roommate re-
fused. Doug decided that it would be unhealthy to keep living with someone so unsupportive of his recovery, so he
decided to move out.

* Predict *
“Predict” means comparing what you think will happen versus what actually happens.
Example: Judy believed, “No matter how hard I try, I’ll never learn to use my computer.” She felt stupid. To dis-
cover the truth, she decided to take a computer class at the local adult learning center. With instruction and practice,
she was able to learn the basics, and this made her want to continue with it.

* Act as If *
“Act as If” means trying on a more positive belief to see how it feels. It is especially helpful in situations where you
cannot actually find out the truth.
Example: Rick was driving down the highway and a car cut him off. He said, “That jerk! People are so rude.” He
felt furious. He decided to try acting as if he believed, “That man is driving his pregnant wife to the hospital to have a
baby—no wonder he’s in a rush!” He felt better and slowed down when he assumed this belief. Since he couldn’t
find out the truth of the situation—why the car cut him off—he might as well choose to believe the gentler explana-
tion that made him less mad. At the end of the handouts, you can read about a real patient who tried this strategy
by going through a weekend “acting as if I liked myself.”

 What does it feel like to try discovery? It may feel okay, or it may feel scary, risky, or awkward. Don’t
worry if it doesn’t feel good right now; it just matters that you try it. In the long run, you are likely to feel good about
it.

 Remember safety. As always, make sure that what you set out to do is safe. For example, don’t try discov-
ery with anyone who might physically hurt you, such as an abusive partner.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

288
HANDOUT 2 (page 2 of 2) Discovery

COPING WITH BAD NEWS

If you try discovery and things go well, you’ll naturally feel much better. But sometimes you’ll get negative feedback
from your process of discovery. It may feel as though your worst nightmare has come true. For example:
 You may find out that no matter how hard you try, you can’t find a job.
 You may get an HIV test and find out you have HIV.
 You may find out that when you tell the truth to your friend, the friend rejects you.
Some people respond to negative feedback by hurting themselves, giving up on life, getting mad at the world, or try-
ing to avoid getting feedback again. Here are some suggestions for healthier ways to cope with negative feedback:
1. Give yourself credit for having had the courage to try discovery. No matter what happens, you were brave,
open, and on the right path just by trying.
2. Figure out, “What’s the worst that can happen?” For example, you may lose a friend but gain self-
respect. You may have HIV but can get medical care to prevent it from getting worse.
3. Never take it out on yourself by self-destructiveness, such as drowning your sorrows in substances, self-
harm, or self-hatred.
4. Remember that negative feedback is just information, nothing more. If you can listen to it, you can
learn much even if it’s painful. The most painful truth is better in the long run than the most positive lie. (And if you
don’t believe this—try using discovery to find out!)

289
HANDOUT 3 Discovery

Discovery Sheet

Name: Date:

(1) Your Belief

(2) Discovery
How can you find out if your
belief is true? Some ways to
find out:
*Ask Others
*Try It and See
*Predict
*Act as If

(3) Results
What did you find out from
your discovery process?

(4) What’s Next?

Where do you want to go from
here?

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

290
 Discovery

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Use the Discovery Sheet (Handout 3) to help you in your process of discovery.

EXAMPLE OF THE DISCOVERY SHEET

(1) Your Belief I’ll never find a job that pays above minimum wage.

(2) Discovery I’ll try applying for five jobs (that all pay above
minimum wage) within the next 2 weeks and see what
How can you find out if your
happens.
belief is true? Some ways to
find out:
*Ask Others
*Try It and See
*Predict
*Act as If
(3) Results I didn’t get any offers. I asked some of them why,
and they said I don’t have any computer skills.
What did you find out from
Even though I’m disappointed, at least I know what
your discovery process?
I need to do next. Instead of believing “I’ll never
find a job,” I now believe that “I can get a job
if I learn new skills.”

(4) What’s Next? I need to take a class in computers or apply for

other jobs that fit my current skills better.
Where do you want to go from
here?

ª Option 2: Try, for one day, to “act as if you like yourself.” Later, write out how it went. Below is an example
of one person’s attempt to do this.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

291
IDEAS FOR A COMMITMENT (page 2 of 2) Discovery

EXAMPLE OF ONE PERSON’S “ACT AS IF” DISCOVERY

One person decided to try the “Act as If” method of discovery by “acting as if I like myself” for a day. These were the
results.

“On Friday, I kept having to remember to like myself. It is a funny feeling but it puts a smile on my face. I don’t
act so self-destructive when I try to like myself. I walked. I went to the College Club play, and out afterwards. I
had no desire to drink.
“Saturday I woke up in positive spirits. Went to an AA meeting. One of the first in ages. I had to keep think-
ing I like myself; it’s hard when I’m used to thinking negative. Walked the dogs with Chris from group and en-
joyed the day. Even talked to some of the people in AA.
“Saturday night I’m not sure what happened. I was alone, isolating, and I forgot to like myself. I really have
to think about it to remember to like myself. But I became very depressed, lonely, and for comfort turned to my
old friends alcohol and food. Maybe it is that the ‘old way’ with the ‘old escapes’ is easier because that’s what I
know. It is scary for me to be out in the real world—with people, at AA, etc. I have never felt more alone than I
did Saturday night. I felt no one would ever love me, that I will never have a positive relationship with anyone,
or have friends. All I felt was pain.
“Sunday morning I remembered that I was supposed to be liking myself. It was kind of a ‘yeah, right’ feel-
ing. But I made an attempt. But the day was so-so. For the first time in ages I prayed on Sunday morning. I
know that sounds hokey, like you hear in AA all the time—but I did. I asked not to drink, to get better, and with
help to let go of the fears which hold me back in life, from getting better, from getting help, etc. I took the dogs
to the woods and walked them. Sunday afternoon I isolated and slept. Sunday night, I did not drink but felt sad.
I obviously was forgetting to like myself.
“Monday I woke up more determined than ever to get the help I need and not give up. To treat myself as if
I liked myself—like I would another person. That thinking helped. I took more care with my appearance. And be-
came more assertive with my therapist about getting more help. I’d rather get help before there is a crisis. I took
steps to take care of myself and meet some of my needs. Followed steps after therapy to try and get more help.
Also talked to my parents honestly about the need for more help and not be so worried instead about pleasing
them, others, etc. Feel good about these steps but a little scared.
“What I learned from this assignment is that by trying to like myself, I act in a more positive fashion. It is
hard to do this all the time and for me feels like being on shaky ground. However, I want to keep trying to think
and feel this way because if I keep working on it I will take better care of myself and my needs—hopefully creat-
ing a more positive world for myself where I handle and cope with life’s ups and downs in an honest, straight-
forward fashion. I want to like myself so that the relationships I develop are positive ones, not destructive rela-
tionships that only serve to feed into my past old escapes. I hope that with practice, liking myself will be more
comfortable than the past comfort of disliking myself.”

292
INTERPERSONAL

Getting Others to Support

Your Recovery

SUMMARY

Today’s topic helps patients elicit support from important people in their lives, provides a let-
ter to give to those people, and offers the option of inviting family members or friends to the
session.

ORIENTATION

“When I get upset, my partner says, ‘Don’t be so sensitive; stop living in the past!’ ”

“My AA sponsor told me that I shouldn’t be on any psychiatric medications for my PTSD—
that they’re just as bad as drugs like heroin or cocaine.”

“My cousin won’t stop offering me marijuana.”

“My counselor told me that I need to drink to get into a detox, because I only use PCP and
they won’t let me in for that.”

“My biggest trigger is my family.”

“My medical doctor told me he doesn’t believe in trauma.”

Patients are surrounded by people who can influence their recovery for better or worse.
Those people may be family members, friends, treaters, and self-help group members. In-
deed, all of the quotations above are from real patients.
Today’s topic encourages patients to notice how supportive or destructive the people in

293
294 Treatment Topics

their lives are. They are guided to educate others about how to be most helpful during the
vulnerable stage of early recovery. A letter is provided that patients can give out for this pur-
pose.
Patients are also invited to bring safe significant people to a session to discuss how best to
offer support. This is not family therapy, but simply an educational session designed to in-
crease patients’ persistence with the tasks of recovery. In substance abuse treatment, such
sessions are widely recommended. For group treatment, all patients can bring guests to the
same session. It will likely have more of the quality of a classroom experience, in which the
therapist summarizes information and guides the discussion.

Countertransference Issues
The major difficulty therapists tend to have with this topic is that guests come to the session
and it starts getting out of control with complaints, accusations, and heightened emotion. See
the “Suggestions: Sessions with Guests” section for ways to minimize this. A second issue is
hearing upsetting material about how destructive some people are toward patients. There
may be a tendency to believe the patient is exaggerating because some of the stories are so
horrible. Believing the patient and seeking support from colleagues are advised.

Acknowledgments
The idea of inviting family members to an educational session derives from multiple sources,
including the NIDA Collaborative Cocaine Treatment Study (Crits-Christoph et al., 1997),
Galanter’s (1993) network therapy, Hunt and Azrin’s (1973) community reinforcement ap-
proach, and Higgins and colleagues’ (1993) behavioral therapy, among others.

PREPARING FOR THE SESSION

♦ Ask patients in advance if they want to bring anyone to the session, making clear the
framework: (1) It is just for one session; (2) it is educational and supportive to help the pa-
tients’ recovery (not family therapy); and (3) the people coming in need to be basically “safe”
(not abusive and free of substance abuse problems themselves). Such people can include fam-
ily members, friends, sponsors, or treaters, with as many as the patient prefers. If the patient
plans to bring guests to the session, consider extending it to an hour and a half to allow suffi-
cient time.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 299. Link the quotation to the session—for example,
“Today we’re going to discuss how to get people in your life to support your recovery. As the
quotation suggests, break through silence and let people know what you need!”
Getting Others To Support Your Recovery 295

3. Relate the topic to patients’ lives (in-depth, most of session).

a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2.
Handout 1: Three Types of People Who Can Influence Your Recovery
Handout 2: A Letter to People in Your Life
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT

Handout 1: Three Types of People Who Can Influence Your Recovery

Goals
¨ Ask patients to evaluate people in their lives in three categories: supportive, neutral,
or destructive (and discuss what to do about destructive people).
¨ Help patients articulate what help they need from others during early recovery.

Ways to Relate the Material to Patients’ Lives

ê Rehearse out loud. Have patients identify current situations in which they can tell oth-
ers what they need at this stage of recovery. Ask them to try saying it out loud. Give feedback
as needed, and process perceived obstacles to following through.
ê Discussion
• “How can you educate people about what you need in your recovery?”
• “If no one in your life is supportive, how can you start to find healthy relationships?”
• “Why is it important to set limits with destructive people?”
• “What help can people in your life give to you? Can you ask for this help?”

Handout 2: A Letter to People in Your Life

This can be covered in two different ways: (1) with patients alone (no guests in the session), or
(2) with the patients and guests present. Each format is described below.

Goals
¨ Offer patients Handout 2, A Letter to People in Your Life, to promote support of their
recovery.
¨ If patients have brought in guests, provide educational information and discuss how
they can assist the recovery process.
296 Treatment Topics

Ways to Relate the Material to Patients’ Lives: Session with Patients Only
ê Self-exploration. Ask patients to check off the parts of the letter that are most mean-
ingful to them. Explore whom they might want to give it to.
ê Discussion
• “Is there anything you’d like to add or delete from the letter?”
• “Would it be helpful to give it to someone in your life? If so, who?”
• “What do you most want people in your life to understand about your recovery
process?”
• “What do you want people in your life to know about PTSD? About substance
abuse?”

Suggestions: Session with Patients Only

✦ The letter is designed for patients to give to important people in their lives who want
to help the patients recover (e.g., friends, family members, sponsors, treaters, etc.).
✦ It is up to patients to decide whether to give the letter to anyone, and if so, to whom.
The only exception: If a patient is being domestically abused, the letter should not be given to
the abuser; it is dangerous to intervene with an abuser even with something as simple as this
letter.
✦ Encourage patients to rehearse out loud asking help from others for recovery. Try this
even if in real life there are reasons why they may not be able to do it.
✦ If a patient has relationships only with destructive people or is totally isolated, fo-
cus on seeking more help from treaters. Trying to help the patient start new relationships
with healthy people is an important goal but will likely take a long time to achieve. In the
meantime, the patient may only be able to establish safe connections with treatment staff,
which is fine for now. Use the handout to discuss what the patient wants to convey to
treaters.
✦ To help the patient detach from destructive and/or abusive relationships, see the topic
Setting Boundaries in Relationships. Also, note that if a patient is in a situation of domestic
violence, this requires immediate and serious attention.
✦ Some patients prefer to write their own letter. This can be very beneficial. You may
want to review it before the patient gives it to others, however.

Ways to Relate the Material to Patients’ Lives: Session with Guests

ê Protocol
1. Introduce yourself, thank the guests for coming in, and set the session agenda (e.g.,
“to work together to help support patients’ recovery”). You may want to repeat the
parameters described above (i.e., this is a single session, for education and support
only).
2. Have both patients and guests look through the handouts, with emphasis on the
letter.
Getting Others To Support Your Recovery 297

3. Answer questions, provide information, and discuss how the guests can assist pa-
tients’ recovery (based on what patients want).
4. Encourage the guests to consider pursuing Al-Anon, family or individual therapy,
and any of the resources listed in the letter, if they are willing.

ê Discussion
To patients:
• “How can your guests be most helpful to your recovery?”
• “Can you describe what your recovery process feels like?”
• “What is your understanding of PTSD and substance abuse recovery?”
To guests:
• “What would you like to know about PTSD and substance abuse? About this
treatment?”
• “If you need more support for yourself, are therapy or Al-Anon possibilities for
you?”
• “If you become concerned about the patient’s safety, could you call to let me know?”

Suggestions: Session with Guests

✦ Remember that the session is solely educational; it is not family therapy, Stay fo-
cused on how the guests can support patients’ recovery. Inevitably someone will bring up
family therapy issues (complaints about each other, upset over what has happened in the
relationship, etc.). Keep directing the discussion back to education and support, or it can
become a damaging session. Remember that your role is to be the patient’s advocate; you
are not trying to balance each person’s needs, judge the validity of complaints, or assess the
relationship.
✦ Emphasize the benefits of external resources. These include individual therapy for
the guest, family therapy, Al-Anon, and/or any of the other resources listed in this handout.
Describe these resources and offer specific referrals in your community if guests are ame-
nable to this. You may want to inquire whether they have ever tried any of these resources
before.
✦ Try to find some opportunity to praise patients’ recovery efforts in front of the guests.
For example, “Celia has done a terrific job attending treatment,” or “I have been so im-
pressed that Roger has achieved 30 days clean.”
✦ You may want to give guests a copy of some handouts from this treatment. For exam-
ple, handouts from the topic Introduction to Treatment/Case Management may be useful to
convey the focus of treatment; Handout 1 in the topic Detaching from Emotional Pain
(Grounding) describes a skill that guests can assist patients with when needed; and Handout
2 in the topic Red and Green Flags provides the patient’s Safety Plan.
✦ If patients make unreasonable requests (e.g., “I’d like my partner to lie to my boss for
me”), gently redirect them to productive topics. Try to avoid negating or embarrassing the pa-
tients in front of the guests (e.g., “You can’t ask for that”).
298 Treatment Topics

Tough Cases
∗ “Every time I get into a relationship, it ends up harmful to me.”
∗ “I have no idea what kind of help I need.”
∗ “I don’t trust treaters. I’ve never gotten any real help from them.”
∗ “I want to ask my brother to shoot me so I can die without it being a suicide.”
∗ “No one was there for me during the trauma, so I don’t want any help now.”
∗ “I’m doing just fine on my own.”
∗ “I want my partner to lie to my boss when I’m late for work.”
∗ “I can’t trust anyone.”
 Quotation

“It takes two to speak the truth—

one to speak, the other to hear.”
—Henry David Thoreau
(19th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

299
HANDOUT 1 Getting Others to Support Your Recovery

Three Types of People Who Can Influence Your Recovery

› Supportive people help your recovery.

They truly care . . . They listen without judging . . . They never offer you substances if you ask them not to . . . They
want to help you get better . . . They believe you about the trauma.

Who is supportive of your recovery?

— Neutral people neither help nor harm your recovery.

They may be too involved in their own lives to support you . . . They may not know how to be supportive, but they
are basically good people who don’t want to hurt you.

Who is neutral toward your recovery?

Í Destructive people harm your recovery.

They undermine you . . . They offer you substances after you tell them not to . . . They abuse you emotionally or
physically . . . They tell you to “just get over it” . . . They blame you, judge you . . . They criticize your attempts to get
treatment . . . They tell you the trauma never happened.

Who is destructive of your recovery?

A SIMPLE GOAL

↑ Increase the supportive people in your life

and
↓ Decrease the destructive people in your life.

HELPING OTHERS TO HELP YOU

You may need to educate people about what you need for recovery.

 Give A Letter to People in Your Life (Handout 2) to someone in your life, or write a letter of your own.
 Tell people directly and specifically what you need. Some examples:
♦ “Please never offer me drugs or alcohol.”
♦ “Please do not tell me your opinions about my recovery.”
♦ “Please do not ask me to take on new demands right now.”

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

300
HANDOUT 1 (page 2 of 2) Getting Others to Support Your Recovery

♦ “Please do not criticize me right now. Only supportive statements are helpful to me.”
♦ “Please accept that sometimes I need to cry and get upset.”
♦ “Please do not use drugs or alcohol when you are around me.”
♦ “I need you to respect where I am right now; it is my recovery process.”
♦ “Please do not ask me about my trauma.”
♦ “Please do not get ‘on my case’ about going to AA—I’ll go if I want to.” (Or: “Please remind me to go to
AA—I find that helpful.”)
♦ “This is a difficult time—you can be helpful by [fill in here: picking up the kids from school, coming with
me to my appointments, checking in by phone].”
♦ “The best way for you to help is to read about PTSD and substance abuse. I will give you material to
read.”
♦ “You can help me by going to Al-Anon so that you get more support.”

301
HANDOUT 2 Getting Others to Support Your Recovery

A Letter to People in Your Life

HELPING SOMEONE RECOVER FROM PTSD AND SUBSTANCE ABUSE

* Your genuine support can make all the difference in the world.
* Posttraumatic stress disorder (PTSD) is a medical condition. It is a devastating illness that occurs after
someone has been through a trauma. A “trauma” is a terrible life event in which some sort of physical harm or threat
was present that was out of the person’s control (e.g., child abuse, accident, fire, crime victimization, combat, rape,
hurricane). Symptoms of PTSD include sleep problems, nightmares, intense negative feelings, difficulty functioning in
life, physical distress, and other problems.
* Substance abuse is also a medical condition. It means that a person cannot stop using a substance even
though it is causing clear damage to the person’s life (e.g., physical or emotional harm, legal or financial problems,
inability to work or take care of family responsibilities). Substance abuse is not about “laziness,” “being bad,” or “just
wanting to have a good time.”
* The combination of PTSD and substance abuse is very common. Among women with substance abuse,
up to 59% have PTSD; among men, up to 38% have PTSD. It is not yet known what causes people to develop PTSD
and substance abuse. Biological reasons, life circumstances, or some combination can lead to developing these prob-
lems.
* Recovery from PTSD and substance abuse is difficult. Recovery is definitely possible, but it is not easy.
The person you care about suffers a great deal of emotional pain. The person may have “roller-coaster” mood
swings, self-destructive behavior, difficulty trusting people, and intense negative feelings. These are common prob-
lems after surviving trauma. PTSD and substance abuse are sometimes called “double trouble” because it is so diffi-
cult to fight both disorders at the same time.
* The goal of this treatment is safety above all. Safety includes ending substance use and other self-harm,
learning to take better care of oneself, gaining control over intense feelings, and establishing trusting relationships.
In the treatment, we spend time practicing coping skills to achieve safety. Some of the topics are Honesty, Asking for
Help, Setting Boundaries in Relationships, Taking Good Care of Yourself, Compassion, Recovery Thinking, Creating
Meaning, Self-Nurturing, and Respecting Your Time.
* The worst thing you can say is “Just get over it and move on.” If it were that easy, it would have been
done long ago. The path of recovery may be slow, with many ups and downs. The only way out is by steady prog-
ress. Ignoring PTSD or substance abuse, or pretending that they are not serious problems, does not make them go
away; it makes them more destructive in the long run.
* You can help the person you care about in specific ways if the person wants your help. Remember, how-
ever, that it is entirely up to the person to decide if and how you can help.
« Encourage the person to complete commitments between sessions. Commitments are goals the person
agrees to complete between sessions to move forward in recovery. If the person wants to, it may help to go
over them with you.
« Read about PTSD and substance abuse so you can understand these disorders better. Go to a library,
search the Internet, or call some of the resources listed at the end of this handout for more information.
« Read the handouts from this treatment to know what the person is learning. If desired, work on them
together. You can help the person practice the treatment skills outside of sessions.
« Encourage the person you care about to attend treatment. It is normal for the person to have mixed
feelings about treatment, but the only way to move forward is to show up and talk about those feelings.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 2 (page 2 of 5) Getting Others to Support Your Recovery

* Recognize the two main themes for people with PTSD and substance abuse.
• Secrecy is the need to hide important feelings, memories, thoughts, and behaviors. The more you earn
the person’s trust, the more she or he can confide these to you directly. To earn trust you need to listen
without judgment, without “solving” the problem, and without being offended by what is said. Also, re-
spect what the person does and does not want to tell you. For example, if the person does not want to
talk to you about substance use, it will likely only lead to lying if you insist on it.
• Control is the need to feel power after having been powerless for so long (both in trauma and in sub-
stance use). The more you allow the person to take healthy control, the better. Avoid power struggles
(arguments, coercion), as they rarely help and often harm.

* In this stage of treatment, called “early recovery,” do not ask for details about the trauma. It is im-
portant to honor the person’s boundaries. It may be too upsetting to reveal what happened. And what happened is
less important right now than learning to cope with current problems. Respect that the person may choose to tell
you when he or she is ready.
* With substance abuse it is best if you:
« Never offer substances of any kind.
« Encourage honesty about substance use, but recognize that it may not always be possible. In substance
abuse recovery, it is normal to feel intense shame over using; hiding or lying about use is common.
« Never blame, attack, or judge the substance use. Using substances has been a way for the person to
cope with the severe pain of trauma; it may take a while to learn other ways to cope.
« Never “enable” the substance abuse. This means that you should never lie about the person’s substance
use to protect him or her, buy substances for the person, pretend the substance abuse is not a problem, pro-
mote substance use in any way, or agree to anything that violates your values.
« Remember that you cannot force the person to recover. It is up to the person to find the motivation to
move forward. You cannot force recovery through guilt or punishment. Know that recovery may take a long
time, and that most people “slip” (use substances) sometimes along the way.

* If you notice any dangerous behavior, please contact the therapist or take the person to the nearest
emergency room. Dangerous behavior includes suicidal actions (or an immediate and definite plan to commit sui-
cide), abuse of other people such as children, or an extreme increase in substance use.
« Name of therapist: Therapist emergency phone number:

* It is natural to become frustrated at times by someone with such major problems. However, to the ex-
tent that you can focus on the person’s needs, listen nonjudgmentally, and give the person time and space to focus
on recovery, you will be making a valuable contribution.
* If you notice yourself frequently having intense negative feelings toward the person, consider get-
ting help. A list of resources for you is provided below. For example, Al-Anon provides self-help to families and
friends of people who abuse substances. Or you may want to consider brief therapy to help you manage the stress of
the relationship. People in recovery from just one disorder—PTSD or substance abuse—can be challenging to deal
with; people in recovery from both may be doubly challenging.
* If you feel you cannot be helpful during recovery, it is best to do nothing rather than to be destruc-
tive. Also, respect the person’s feedback about how helpful or destructive you are. There is no right or wrong to
these views; it is how the person feels, and that is very real, even if you do not agree with it. If the person asks you to
back off, back off.
* Above all, treat the person you care about with great kindness and respect. “A loving heart is the tru-
est wisdom.” (cont.)

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HANDOUT 2 (page 3 of 5) Getting Others to Support Your Recovery

ORGANIZATIONS THAT CAN BE HELPFUL

The following are all free, nonprofit, national resources dedicated to helping people. Included are advocacy organiza-
tions, self-help groups, and newsletters.

Substance Abuse/Addictions

Al-Anon Family Groups (for relatives, friends, and teen relatives of alcoholics); 800-344-2666 OR
www.alanon.org 800-356-9996
Alcoholics Anonymous (World Service); www.aa.org 212-870-3400
American Council for Drug Education; www.acde.org 800-488-DRUG
American Council on Alcoholism; assistedrecovery.com 800-527-5344
Center for Substance Abuse Treatment: National Drug Information, Treatment 800-662-HELP OR
and Referral Hotline; www.samhsa.gov/treatment 800-729-6686
Cocaine Anonymous (World Service); www.ca.org 310-559-5833
Co-Dependents Anonymous (addictive relationships); www.coda.org 602-277-7991
Division on Addiction—Harvard Medical School; divisiononaddictions.org 781-306-8600
Families Anonymous (for families with substance abuse); 800-736-9805
www.familiesanonymous.org
Gamblers Anonymous (GA); gamblersanonymous.org 213-386-8789
Harm Reduction Coalition; harmreduction.org 212-213-6376
Highland Ridge Helpline 800-821-4357
Join Together (for communities working to reduce substance abuse); 617-437-1500
www.drugfree.org/join-together
Narcotics Anonymous (World Service); na.org 818-773-9999
National Council on Alcoholism and Drug Dependence; ncadd.org 800-NCA-CALL
National Institute on Drug Abuse (NIDA); www.nid.nih.gov
Rational Recovery (main office); rational.org 530-621-2667
Secular Organization for Sobriety/Save Our Selves (SOS); www.cfiwest.org/sos 323-666-4295
SMART Recovery (national office); smartrecovery.org 866-951-5357
Sexaholics Anonymous (national office); sa.org 866-424-8777

(cont.)

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HANDOUT 2 (page 4 of 5) Getting Others to Support Your Recovery

Trauma/PTSD/Anxiety Disorders

Anxiety Disorders Association of America; www.adaa.org 240-485-1001

Cavalcade Videos (on trauma, for patients and therapists); 800-345-5530
www.cavalcadeproductions.com
International Society for Traumatic Stress Studies; www.istss.org 847-480-9028
Many Voices (trauma survivors newsletter); www.manyvoicespress.com 513-751-8020
National Center for PTSD and PILOTS Database (extensive literature on PTSD); 802-296-6300; and
www.ptsd.va.gov/professional/pilots-database/pilots-db.asp www.ncptsd.org
National Center for Trauma-Informed Care; www.samhsa.gov/nctic 866-254-4819
National Center for Victims of Crime; www.ncvc.org 202-467-8700
National Institute of Mental Health Information Line; www.nimh.nih.gov 800-615-6464
PTSD Research Quarterly (summary of new research); www.ptsd.va.gov/
professional/newsletter/ptsd-rq.asp
Sidran Traumatic Stress Foundation (trauma information, support); 410-825-8888
www.sidran.org

Domestic Violence

National Domestic Violence Hotline; www.thehotline.org 800-799-7233

National Resource Center on Domestic Violence; www.nrcdv.org 800-537-2238

Mental Health

Grief Recovery Helpline; www.ggcoa.org 800-445-4808

Mental Health America; www.nmha.org 800-969-6642
National Alliance for the Mentally Ill; www.nami.org 800-950-6264
National Institute of Mental Health Information Resource Center 800-421-4211

HIV/AIDS/Sexually Transmitted Diseases (STDs)

AIDS Hotline; www.aac.org/hotline 800-235-2331

American Social Health Association (sexually transmitted diseases); 919-361-8400
www.ashastd.org
Centers for Disease Control National AIDS Hotline; www.cdc.gov/hiv 800-232-4636

(cont.)

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HANDOUT 2 (page 5 of 5) Getting Others to Support Your Recovery

Gay Men’s Health Crisis Hotline; www.gmhc.org 212-367-1000

National Prevention Information Network; cdcnpin.org 800-458-5231
Planned Parenthood; www.plannedparenthood.org 800-230-7526

Parenting/Relationships

American Academy of Husband-Coached Childbirth; bradleybirth.com 800-4A-BIRTH

Child Abuse Prevention Center; childabusepreventioncenter.org 214-370-9810
International Childbirth Education Association; www.icea.org 800-624-4934
National Adoption Center; www.adopt.org 800-TO-ADOPT
National Child Traumatic Stress Network; www.nctsn.org 310-235-2633
Parents Helping Parents (free self-help support groups); 800-632-8188
www.parentshelpingparents.org

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 Getting Others to Support Your Recovery

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Give Handout 2, A Letter to People in Your Life, to someone in your life. Or write a letter of your
own titled “How You Can Help My Recovery.”
ª Option 2: Identify someone who is destructive toward your recovery, and make a plan for how to protect
yourself from that person.
ª Option 3: Write out what you need to say to someone in your life to get more support for your recovery.
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation My partner won’t stop My partner won’t stop
hassling me about my hassling me about my
drinking. Every time I have drinking. Every time I have
a glass of wine, there’s an a glass of wine, there’s an
argument. argument.
« Your Coping « I say, “Shut up—it’s my There are a few things I
life.” I try to just drink could do to handle this
when my partner won’t see better:
it, because I can’t take 1. Give my partner the Al-
this pressure. Anon number to get help.
2. Say clearly what I want
(without being rude): “I am
working in treatment on my
substance abuse. I need you
to refrain from commenting
on my drinking. I need to
work on my own recovery.”
Consequence I feel alone. I feel like A little better. At least
I’ve alienated everyone I’m trying to do something
around me. constructive.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

307
BEHAVIORAL

Coping with Triggers

SUMMARY

Patients are encouraged to actively fight triggers of PTSD and substance abuse. A simple
three-step behavioral model is offered (“who, what, and where”): Change who you are with,
what you are doing, and where you are.

ORIENTATION

“Small things set me off, and before I know it, I’m thinking suicide.”

“When I see someone light up, the world narrows and all I can feel is the need to get high.”

In both PTSD and substance abuse, external events, known as “triggers,” can set off extreme
reactions. A patient hears a child cry and is overwhelmed by a flood of sad feelings as it re-
minds her of her childhood. Another patient sees a crack pipe and gets an intense craving.
Thus, while both disorders can be chronic (with symptoms enduring throughout the day),
they are also susceptible to large spikes of reactivity—much like a radar screen on which high
and low blips appear. Helping patients manage these trouble spots and keeping them safe
from subsequent harmful behavior is necessary for recovery. Over time, patients can learn to
notice sooner when they are entering the danger zone of a trigger, and can learn to move
more quickly and effectively to a safe place.
A simple behavioral model is provided to help patients become more conscious of their
triggers and to fight them more actively. The model is “who, what, and where”: Change who
you are with, what you are doing, and where you are. This model is similar to the AA phrase
“Change people, places, and things.” The “who” involves reaching out toward safe people
(e.g., sponsors, clean and sober friends, therapists); the “what” involves participating in activi-

308
Coping with Triggers 309

ties that prevent self-destructive behavior (e.g., physical exercise, watching a comedic movie,
taking up a hobby); the “where” involves placing oneself in healthy environments (e.g., going
to an AA meeting rather than out to a bar with friends).
Note that all three of the methods—who, what, and where—are ways to establish safe
emotional distance from a trigger. Distancing from dangerous situations is particularly impor-
tant for patients with PTSD, who typically vacillate between too little distance (e.g., over-
whelming affects, flooding of memories, enmeshed relationships) and too much distance
(numbing, dissociation, isolation). Similarly, patients with substance abuse find themselves at
extremes of too little distance (e.g., feeling cravings intensely) and too much distance (e.g.,
the “pink cloud” in which they feel they’ll never be tempted to use again).The concept of op-
timal distance is the desirable balance between the two—aware, conscious, and in touch with
reality, but also able to manage and tolerate it.
The who, what, and where methods are generally considered behavioral in that each in-
volves taking an action of some sort. However, they broach the cognitive and interpersonal
domains as well. Just as triggers can be behavioral (e.g., seeing one’s dealer), cognitive (e.g.,
the thought “I need to use”), or interpersonal (e.g., a fight with a friend), so too can the meth-
ods of fighting these triggers be all three. Note that the who, what, and where methods can
also be summarized in several other ways: “ACE” (activities, connection, environment), or
“Change people, places, and things” (the AA phrase mentioned above). The therapist can feel
free to substitute one of these other memory devices as preferred. Who, what, and where is
selected for today’s topic because it is simple to remember and it provides different language
from AA’s for patients who prefer this.
An option is also presented in today’s topic for an “exposure intervention” for therapists
who are conducting individual therapy with a patient who is already good at coping skills.
Such exposure work can be very powerful because it allows the patient to experience, during
the session, both intense triggered feelings and also success at overcoming those feelings.
Note, however, that the focus here is only on current triggers without any discussion of the
past, and that it emphasizes the rehearsal of active coping strategies to decrease anxiety. The
need for prior training, supervision, and careful planning are strongly emphasized. Resources
for further reading on such exposure interventions are also provided.

Countertransference Issues
Triggers are among the most common day-to-day experiences in both PTSD and substance
abuse, but may be foreign to therapists who have never struggled with either disorder (unlike
many of the other issues addressed in this treatment, which may be more universal—e.g.,
compassion, honesty, self-care, rethinking). Trying to get a grasp of how incredibly intense
and disturbing they can be is important. As you listen to patients describe their experiences
with triggers, it may be helpful to try to relate these as best as possible to some difficult expe-
rience in your own life—perhaps some period of intense emotional pain that felt difficult to
get out of.
310 Treatment Topics

Acknowledgments

This topic draws heavily on Marlatt and Gordon (1985). As noted above, the phrase “Change
people, places, and things” is from the AA literature.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 313. Link the quotation to the session—for example,
“Today we’ll talk about coping with triggers. As the quotation says, putting all of your effort
into it can make all the difference.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handout, Coping with Triggers.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals

¨ Explore the importance of triggers in PTSD and substance abuse, and the need to ac-
tively fight them.
¨ Discuss and rehearse a simple model for coping with triggers: who, what, and where.

Ways to Relate the Material to Patients’ Lives

êRehearsal. Ask patients to describe how they would actually apply the who, what, and
where model to cope with current triggers. For example, if a patient had any substance use
(or other unsafe behavior) in the past week, you might ask the patient to “replay the scene,”
identifying the trigger that set off the substance use and describing how the trigger might
have been fought.
ê Discussion
• “Are there any triggers you could eliminate from your life?”
• “What is one of your hardest triggers, and how might you apply who, what, and
where to cope with it?”
• “What would you do if you see an ad for vodka—how might you fight that trigger?”
(Or select another example that relates to what you know about the patient.)
• “Do you think triggers cannot be totally eliminated from your life?”
• “What does ‘fight the good fight’ mean?”
Coping with Triggers 311

Suggestions
✦ Attend to whether the discussion triggers patients. Check in and ask them whether
they feel triggered, and if they are, move on to the next section more quickly. Particularly if
the treatment is conducted in a group format, it is suggested that you only go over one or two
examples until patients get the idea of what a trigger is, and that you do not allow patients to
tell “war stories” about PTSD or substance abuse that might trigger others. However, it is
also important for patients not to be afraid or feel something has gone wrong if they feel trig-
gered in a session. Indeed, this may be an ideal place for them to try to actively cope with it,
with help from the therapist (see the last suggestion, below).
✦ Help patients understand that they are likely to feel bad as they cope with a trigger.
They may feel a lot of anxiety, upset, anger, or deprivation (e.g., at not using a substance).
However, even though they may not feel good as they cope with a trigger, hours later they
will feel good for having conquered it.
✦ Be prepared for some patients not to know what triggered them. They suddenly just
find themselves dissociating or using a substance. If this occurs, ask the patient to try replay-
ing it as if it were a slow-motion movie, to understand better what the trigger was (e.g., “Who
were you with?”, “What were you doing?”, etc.).
✦ An analogy may be helpful to describe triggers (Marlatt & Gordon, 1985, pp. 53–54):
Imagine that you are driving on the highway. There are both hard and easy stretches—places
you need to slow down (due to ice or curves in the road), and places where you can speed up.
The good driver watches for warning signs of difficult areas.
✦ Note that patients cannot arrange their lives so as never to face triggers. The goal is to
learn to feel confident in managing them when they arise. For example, if a patient is afraid of
getting into an elevator because she was assaulted in one, the task is to learn to ride elevators
again, not to avoid them. This issue is tricky, however, with regard to substance abuse. Pa-
tients will sometimes face a dangerous trigger unnecessarily—for example, “I went to a bar
last night because I wanted to see if I could overcome my cravings.” Thus a helpful rule is to
avoid triggers whenever possible, but when it is not possible, learn to manage them.
✦ Use whatever language the patient prefers. If the patient prefers to use the AA lan-
guage, you can refer to “Changing people, places, and things.” For patients who dislike AA,
the who, what, and where language may feel better. (It is reframed in today’s topic as who,
what, and where for precisely this reason.)
✦ Exposure to current triggers can be combined with today’s topic, under certain very
carefully monitored conditions. Exposure, in relation to current triggers, means that you ac-
tually promote the patient to feel triggered early in the session and help the patient actively
rehearse coping skills right then and there to gain control over the triggered feelings (e.g., by
using grounding, rethinking, or any of the other safe coping skills). However, use of such
strategies is recommended only (1) with a therapist who has had formal training and supervi-
sion in how to conduct exposure interventions; (2) when conducting individual therapy; (3)
with a patient who already has solidly mastered some coping skills, and who understands and
agrees to the exposure work; (4) in a treatment that is long enough to help the patient fully
master the triggers (i.e., one session is unlikely to be enough); and (5) in relation to current
312 Treatment Topics

PTSD or substance abuse triggers only (not to discussions of past trauma, which is a much
more intensive intervention, as per the safety parameters described in Chapter 2 under
“Treatment Guidelines”). Note that exposure may be unsafe for group therapy because it
could trigger other patients who are not prepared to cope with it; and as a therapist you may
not have enough time to attend to each patient sufficiently in the session to decrease the anxi-
ety that would be evoked. For more on exposure models, see in the Reference list at the end
of this book works by Foa and Rothbaum (1998) regarding exposure for PTSD, Back and col-
leagues (2001) regarding exposure for PTSD and substance abuse, and Childress and col-
leagues (1988) regarding exposure for substance abuse.
✦ Consider providing examples of triggers. The list below was originally included in the
handout for this topic, but in testing the treatment, some patients felt triggered by it. It is pro-
vided here for your information. If you decide to conduct the exposure work described above,
you may want to show it to patients.

Typical Triggers

In Substance Abuse In PTSD

Seeing a drug dealer Hearing a child cry
Ads for alcohol Anniversary dates of the trauma
Drug paraphernalia A sudden sound
Parties and social situations Pain in your body
Money Sad music
A beeper Someone who resembles your abuser
Celebrations Being criticized or yelled at
A thought, such as “Just one drink is okay” A thought, such as “I’m bad”
A feeling, such as excitement or anger A feeling, such as closeness or sadness
PTSD symptoms Substance abuse symptoms
A time of day or season (such as night) A time of day or season (such as summer)

Tough Cases
∗ “I have no willpower.”
∗ “Everything sets me off.”
∗ “I don’t know what sets me off. Before I know it, I’m using.”
∗ “I think it’s important to let myself feel whatever feelings come up.”
∗ “I just applied for a job as a bartender.”
∗ “I’ve been trying for years to cope with triggers, and nothing works.”
∗ “My family triggers me, but I can’t leave them.”
 Quotation

“When you do a thing, do it with

all your might. Put your whole soul
into it. Stamp it with your
personality. Be active, be energetic,
be enthusiastic and faithful, and
you will accomplish your object.”
—Ralph Waldo Emerson
(19th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

313
HANDOUT Coping with Triggers

Coping with Triggers

FIGHT THE GOOD FIGHT—COPE WITH TRIGGERS

uA trigger is anything that sets off PTSD symptoms or substance use: seeing a crack vial, hearing sad
music, having money, hearing a sudden noise. Just about anything can be a trigger. The more you learn to actively
avoid and fight them, the stronger you’ll be.

u What are the most common triggers? For substance abuse, one major study found that the most com-
mon triggers were negative emotions (35%), social pressure (20%), relationship conflicts (16%), urges and tempta-
tions (9%), positive emotions with others (8%), testing personal control (5%), positive emotions alone (4%), and
negative physical states (3%).

u Stay far away from triggers. The safest plan is to stay away from triggers whenever possible. Don’t watch
the upsetting TV show; don’t go near the bar. Avoid “avoidable suffering” by protecting yourself from triggers ahead
of time.

u Never “test” yourself” with triggers. This is a mistake some people make in early recovery. They may
think, “I’ll go to a party tonight to see if I’m strong enough to tolerate drug triggers.” Don’t do it! Just as you would
not test yourself by getting into a new trauma, never test yourself to see whether you can tolerate triggers. It is hard
enough to recover without setting yourself up.

u Triggers are part of life—but you can “fight the good fight.” Even if you do everything you can to avoid
triggers (and hopefully you will!), some will occur just because it is impossible to live “in a bubble.” As you go
through your day, you will be faced with triggers at times. The main point is to cope heroically when they do occur.
Fight them; resist them; do not give in to them.

u Strive for balance. With PTSD you may feel too much at times (e.g., overwhelming, intense emotions) and
too little at other times (e.g., numbness, dissociation). With substance abuse you may also feel too much (e.g., in-
tense cravings) or too little (e.g., the “pink cloud” in which you feel you’ll never be tempted to use again). To best
fight triggers, the goal is balance: being aware, conscious, and in touch with reality so that triggers will not control
you.

u Cope with triggers before, during, or after they occur. The best way is to cope before by preparing in
advance, but you can cope well at any time in the process. Never give up!

u Triggers can be very sudden. That’s what makes them so dangerous. They may appear when you least ex-
pect them.

CHANGING WHO, WHAT, AND WHERE TO COPE WITH TRIGGERS

You can get to safety by changing who, what, and where.

Who Are You With?

Detach from unsafe people (dealers, users, abusers). Move toward safe, positive people. Call your sponsor, or a
safe friend or family member. Call before, during, or after a trigger occurs (preferably before!). You can talk about

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

314
HANDOUT (page 2 of 2) Coping with Triggers

how you are feeling, or just discuss “light” topics such as movies or sports to distract yourself. Also, stay connected
with important people in your life by carrying photographs of them. If you get triggered, pull out the photos and ask
yourself, “What do I need to do right now? How will my substance use affect them?”

What Are You Doing?

Switch to safe activities. Try reading, TV, calming music, exercise, taking a walk, or doing a craft or hobby. Keep
busy in general by having a structured schedule that focuses your attention away from triggers.

Where Are You?

Change your environment. If you feel triggered, find a safe place by leaving the room, the area, or the neighbor-
hood; taking a drive or a walk; throwing out the drug accessories; or changing the TV channel.

In short, put as much space between you and the trigger as possible.
Create a safety zone by changing who, what, and where.

Acknowledgments. This topic and the major study mentioned in the handout are drawn from Marlatt and Gordon (1985). The concept of who,
what, and where is similar to the phrase “Change people, places, and things” in the AA literature. Ask your therapist for guidance if you would
like to locate either of these sources.

315
 Coping with Triggers

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Eliminate one major trigger from your life this week. For example, throw out all of the alcohol in
your house, or tell your dealer never to call you again.
ª Option 2: Write a list of your top three triggers and how you can cope with them.
ª Option 3: Imagine a Star Wars scene in which you heroically battle a major trigger. What images help you?
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation Saw a movie that triggered Saw a movie that triggered
me. me.

« Your Coping «
I felt upset. I didn’t cope If I were to try using “who,
well at all—I got high to what, and where” to create
escape. distance from the trigger, I
could:
WHO: Call a friend.
WHAT: Leave the movie.
WHERE: Go outside and take
a walk.

Consequence I felt better for a little I’d feel safer.

while, but then felt more
hopeless.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

316
BEHAVIORAL

Respecting Your Time

SUMMARY

Patients are asked to explore how they spend their time, as a way to better understand their
approach to recovery. Do they use their time well? Is recovery their highest priority? Pa-
tients’ use of time is one of the best clues to the value they place on their lives. Patients are
guided to try to use their time to its fullest advantage, while respecting that recovery from
PTSD and substance abuse means that their use of time may be different from people with-
out these disorders. Balancing structure versus spontaneity, work versus play, and time alone
versus time in relationships are also addressed.

ORIENTATION

Patients vary considerably in their approach to time. Some have no structure, do little, and
consequently feel quite worthless. Their day may revolve entirely around getting, using, and
recovering from substance use. Others may do too much productive work and have no time
for themselves. Either way, today’s topic asks patients to take stock of how they use their
time.
At a deeper level, exploring patients’ schedules helps to understand the meaning they
bring to their lives. Do they live chaotic, disorganized lives in which time is wasted? Do they
use time productively to move forward with recovery? Do they balance competing needs that
pull them in different directions? By exploring the meanings associated with time, they will,
it is hoped, clarify how their day-to-day life impedes or assists their recovery efforts. Exam-
ples for two patients are as follows.

1. “Too busy.” One patient was able to identify that she worked far too many hours, with
only 2 days off in the past month. She saw that her drinking several glasses of wine once she
got home each night was a way to “unwind” and to give herself the only pleasurable, relaxed
feelings she had all day. Using a blank schedule, she worked on specifying a reasonable time

317
318 Treatment Topics

to end her work day (e.g., by 7:00 P.M.) and planned time after work for enjoyable activities
that didn’t involve drinking (e.g., watching a video). She agreed to try the schedule for 1 week
to test whether it would help reduce the drinking. Her therapist also encouraged her to ex-
plore how her schedule represented self-neglect, which prevented her from taking time to
feel her feelings, socialize, go to self-help groups, and exercise. The aim now was thus to
build these activities back into her day and give herself a life worth living, without alcohol.
2. “Can’t get anything done.” Another patient observed that his marijuana use had be-
come his “career.” He was spending most of his day smoking, was living on disability, and
somehow never managed to pursue his larger goals of starting his own business. That dream
had begun to fade over the years and seemed more and more impossible. He worked with the
therapist to map out at least 4 hours a day that would be spent learning skills that might help
him in business (e.g., taking a computer class). They discussed how his current dysfunctional
life reflected a loss of ideals after his trauma—he had given up on life and himself. The new
schedule plan was thus more than just a way to organize his time; it was a way to regain a
sense of purpose in life.

Countertransference Issues
The main issue in today’s topic is connecting the emotional with the behavioral. Conducting
the in-session exercise on schedules may be dry unless there is an attunement to “big pic-
ture” emotional issues as well. It will make the topic more interesting for you and, it is hoped,
more helpful to the patient. In the service of this, you may want to explore your own issues
about time. For example, if you work too hard, what emotional needs lead you to do that? If
you are disorganized, what are your obstacles to improving this? Since “time” is a universal
experience, everyone struggles with these issues. It may be helpful to honestly recognize
your own time problems to better help patients with theirs.

PREPARING FOR THE SESSION

♦ Make two copies of Respecting Your Time (Handout 1) for each patient.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 322. Link the quotation to the session—for example,
“Today we’ll focus on respecting your time. Time is one of your most valuable resources in re-
covery.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts:
Handout 1: Respecting Your Time
Handout 2: Are You Respecting Your Time?
Respecting Your Time 319

Note that Respecting Your Time (Handout 1) can be used in two different ways (focus-
ing on the present, focusing on the future); these can be done separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2 for suggestions.
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT

Handouts 1 and 2: Focus on the Present

Goals
¨ Help patients take inventory of how they use time. Explore whether their time is used
well or squandered, chaotic or organized, balanced or extreme.
¨ Explore how problems with time may relate to PTSD and substance abuse.

Ways to Relate the Material to Patients’ Lives

ê Fill out Respecting Your Time (Handout 1) for the past week. First, ask patients to fill
in the Respecting Your Time schedule for today and the previous 6 days, as best they can.
Next, have them complete Are You Respecting Your Time? Ask patients what they can learn
about themselves and their recovery from looking at their schedules.
ê Discussion
• “Do you feel good about the way you spent time last week?”
• “Do you notice any patterns in your use of time: Are you spending a lot of time on
recovery activities? Wasting a lot of time? Procrastinating? Feeling pulled in too
many directions? Feeling like you have no time to yourself?”
• “How are PTSD and substance abuse related to your use of time?”
• “How does your use of time relate to your self-respect?”
• “What did you learn about time when you were growing up?”
• “Is your use of time promoting your recovery?”
• “Do you notice that the way you spend time is similar to how you spend money? For
example, are you wasting it too easily? For many people, such patterns do occur.”
• “What obstacles in your life prevent you from using your time to its best advantage?
For example, are there people who keep you from using your time well?”

Suggestions
✦ Patients may need help coping with the feeling that they’ve wasted a lot of time. Re-
gret about the past is less helpful than just starting from this moment on. Everyone wastes
time to some degree. Encourage patients just to get on track with goals now.
✦ Comparing oneself to others is not helpful. Other people may not have suffered PTSD
320 Treatment Topics

or substance abuse, may have had more guidance when they were growing up, may have had
more financial resources, may have obtained a better education. In short, respecting and vali-
dating one’s own history are important.
✦ Notice how substance abuse wastes time. It prevents growth, development, and learn-
ing. Think of time as a bank account—with substance abuse, one is tossing “money” away.
✦ If short on time(!), you can ask patients to complete Handout 1 at home. Rather than
filling out Respecting Your Time in the session, patients can do it as a commitment and you
can focus the session on the questions in Handout 2.

Handout 1: Focus on the Future

Goals
Discuss recovery as the most important priority for patients’ time.
¨
¨ Help patients “respect their time” by planning schedules that focus on healthy, pro-
ductive activities.

Ways to Relate the Material to Patients’ Lives

êFill out Respecting Your Time for the future. Ask patients to fill in their schedule to re-
flect how they would like to use their time in the near future (e.g., the next week or next
month). Some strategies that may help include the following:
 Set recovery as the #1 priority. If desired, have patients make a ranked list of ad-
ditional priorities. Keep the focus on a few key goals rather than taking on too much.
 Encourage unemployed patients to find work or a volunteer job, but if a patient is
a “workaholic,” suggest a reduction in work time.
 Ask patients to spend time around high-functioning people to find out how other
people use their time (e.g., by joining a club, doing volunteer work, participating in
church or other activities. Encourage patients to find role models who use time well.
 Strongly recommend the use of physical aids to take control of time, including
weekly planners, “to-do” lists, self-help books on time management, electronic and com-
puter organizers, or Internet-based “reminder” sites.
 One of the best books to read on time management is listed at the end of the
handouts (The Seven Habits of Highly Effective People). This book provides the usual ar-
ray of time management techniques, but also addresses at a deep level how to make one’s
use of time consistent with personal values.
 Help patients to increase time spent in safe leisure and social activities. Note that
the topic Self-Nurturing provides more on this as well.

ê Discussion
• “What do you need to do to make better use of your time?”
• “What emotional blocks might get in the way of carrying out your new time plan?
How can you overcome those?”
• “How will you feel if you can accomplish your new time plan?”
Respecting Your Time 321

Suggestions
✦ It is up to each person to choose the balance between structure versus spontaneity,
work versus play, and time alone versus time in relationships. There is no right amount as
long as safety is present. Some people have greater needs than others for particular domains.
✦ It may feel anxiety-provoking to change one’s use of time. Patterns are often long-
standing and arose in one’s family.
✦ People with PTSD may need a slower schedule and less stress than people without
PTSD until they have gone through the three phases of recovery from PTSD (safety, mourn-
ing, and reconnection). Realistically respecting one’s needs is the goal.
✦ Procrastination may not be a problem unless the patient cannot achieve because of it.
Some people are “plan-ahead” types who get everything done ahead of schedule and would
feel too anxious to work in a rush at the last minute. Other people are “last-minute” types
who get everything done, but do most of it in a rush at the end. The latter is fine as long as
one is accomplishing goals and getting things done on time. Sometimes “last-minute” people
believe they have to change and become “plan-ahead” types, but in fact both types can do
equally well in actual performance. It can be damaging to tell patients to reverse their per-
sonality with regard to time and work. Rather, the goal is to accept one’s personality as long as
the results are functionality, responsibility, and ability to meet deadlines.

Tough Cases
∗ “I keep losing my schedule.”
∗ “I try to get up before 2:00 in the afternoon, but can’t.”
∗ “I need more money, not more time.”
∗ “Looking at this makes me feel very depressed.”
∗ “My brother is doing great—he has a good job and marriage. I have nothing.”
∗ “No one around me uses their time well, so I can’t either.”
 Quotation

“The future depends on what we

do in the present.”
—Mohandas K. Gandhi
(20th-century Indian leader)

From Seeking Safety by Lisa M. Najavits (2002).

322
HANDOUT 1 Respecting Your Time

Respecting Your Time

TIME SCHEDULE

Explore how you use your time, and what it says about you and your recovery. Remember that time is more than a
clock—it is a profound element of human existence. We all have limited time, and we will never have these moments
to live again. Use your time well!

« There are two ways to use the schedule below.

1. Focus on the present. Fill out the schedule as best as you can for today and the past 6 days. Then answer
the questions in Handout 2 to explore what it says about you.
2. Focus on the future. Fill out the schedule to reflect how you would like to use your time. Prioritize your re-
covery, productive work, time in safe relationships, and other healthy activities.

½¾¿ÀÁÂ
Time Schedule
Mon. Tues. Wed. Thurs. Fri. Sat. Sun.
7 A.M.

8 A.M.

9 A.M.

10 A.M.

11 A.M.

Noon

1 P.M.

2 P.M.

3 P.M.

4 P.M.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

323
HANDOUT 1 (page 2 of 2) Respecting Your Time

5 P.M.

6 P.M.

7 P.M.

8 P.M.

9 P.M.

10 P.M.

11 P.M.

Midnight

324
HANDOUT 2 Respecting Your Time

Are You Respecting Your Time?

« When looking at your current schedule, do you feel that you:

1. Are using your time well? Yes Sometimes No

2. Have prioritized your recovery above all else (e.g., time in Yes Sometimes No
treatment and safe activities)?
3. Take care of your needs, not just other people’s needs? Yes Sometimes No
4. Use daily “to-do” lists to make the most of your time? Yes Sometimes No
5. Have enough time for yourself? Yes Sometimes No
6. Have a good amount of structured time (e.g., work, Yes Sometimes No
school), neither too much nor too little?
7. Use time to take good care of your body (eating, sleeping, Yes Sometimes No
exercising)?
8. Spend little or no time in substance-abuse activities (buying, Yes Sometimes No
selling, using, recovering from substance use)?
9. Balance time alone versus time with others? Yes Sometimes No
10. Have enough time that is entirely your own to enjoy (at Yes Sometimes No
least 1 hour/day is recommended)?
11. Protect your time from being wasted by other people? Yes Sometimes No
12. Have a stable daily routine? Yes Sometimes No

« When you look at your use of time, what are your reactions?

« What does your schedule tell you about your priorities in life (e.g., what matters to you, how you take care of
yourself)?

« How would you would like to change your use of time (e.g., priorities, time alone versus time with others, bal-
ance of work and play, time wasted or used well)?

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

325
HANDOUT 2 (page 2 of 2) Respecting Your Time

« When you were growing up, what messages (positive and negative) did you get about spending time?

(+) Positive messages:

(–) Negative messages:

« Is how you spend time similar to how you spend money? For many people, these are similar and give clues about
deep assumptions. For example, do you balance your use of both time and money? Do you waste time and money
too freely? Are you too “tight” with time and money, so you can’t enjoy life?

326
 Respecting Your Time

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Interview two people in your life this week—one person who uses time well, and one who doesn’t.
Ask them questions such as “What is your schedule?”, “How do you feel about how you use time?”, “How
do you try to get yourself to use time well?” (If you can’t think of someone who uses time well, consider
your boss, your AA sponsor, or your therapist.)
ª Option 2: Create a schedule for the week ahead (using the blank schedule from today’s session). Focus on
how to use time to make recovery your top priority.
ª Option 3: Get a book on time management. Look through it until you find one new way to use your time
better. One outstanding book is The Seven Habits of Highly Effective People by Stephen J. Covey (1989). It
explores using your time to implement the values you care about.
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation I saw my brother at a family I saw my brother at a family
dinner last week. He seemed so dinner last week. He seemed so
“together”: has a great job, “together”: has a great job,
lots of money, two kids, and lots of money, two kids, and
seems happy. seems happy.

« Your Coping «
My life is a wreck. I haven’t There are some things I could
worked for years, don’t have a do to cope better. I could talk
family, and I spend my time in to my brother and ask how he
treatment. What the hell is makes such good use of his
wrong with me? When I got home, time. Also, I can work in
I did some coke to raise my therapy on putting together a
mood. I just needed to feel schedule that moves me forward
good for a little while. in life.

Consequence Nothing ever changes: I’m stuck Even though it still feels
in this pattern—I feel bad, I pretty hopeless, at least it
use coke; I feel bad, I use has a chance of getting me out
coke. Treatment isn’t helping of this rut. Even though my
and I can’t help myself. feelings are still negative,
trying to cope better may do
something.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

327
INTERPERSONAL

Healthy Relationships

SUMMARY

This topic explores healthy and unhealthy beliefs about relationships.

ORIENTATION

For people with PTSD and substance abuse, relationships often represent both a deeply
wished-for connection and a frightening experience fraught with potential for harm. In to-
day’s topic, patients are encouraged to explore their beliefs about relationships. Although
some of the healthy beliefs listed in the handouts appear simple, they may represent a pro-
found shift. For example, one patient, a professional with children, was incredulous at the
idea that it is possible to have a relationship in which “anything can be talked about.” She
thought that even in the best relationships there are always lies or secrets. Note too that
women may be especially prone to the relationship dilemmas described in the handouts. As
Lerner (1988) has written, “Irrespective of diagnostic category and severity of pathology,
women often learn to protect relationships at the expense of the self, to take responsibility for
the feelings and behaviors of others rather than putting their primary energy into identifying
their own personal goals and directions” (p. 153).
As with previous cognitive topics, it is important for patients not to feel that their ideas
are being attacked, but rather that their beliefs make sense in light of their histories. Also, try
to address specific rather than global beliefs. Sometimes a discussion of beliefs can result in a
philosophical debate rather than a concerted effort to work on here-and-now interpersonal
situations.
This topic is similar to Creating Meaning in exploring patients’ underlying assumptions.
It targets relationships in particular, however, as they are among the greatest sources of con-
flict for patients, as well as major triggers for substance use (Marlatt & Gordon, 1985).
If a patient has been maltreated in childhood, it should be emphasized that the beliefs in
the handouts relate only to relationships between adults. They do not apply to patients when

328
Healthy Relationships 329

they were growing up, but only to how they handle relationships in the present with other
adults.

Countertransference Issues
The therapist may feel pulled to take patients’ side when hearing about a relationship con-
flict. However, a key idea in today’s topic is that patients can control only themselves, not oth-
ers. The therapist can validate patients’ disappointment in others, but needs to direct atten-
tion largely to how patients can try to relate better. This often means listening for what
patients are not saying, or noticing what patients do not currently “see,” which can be a chal-
lenge for the therapist. If the session turns into just a “gripe session” about how others mis-
treat them, there will be little new growth. Thus the question for the therapist is “What does
this patient need to learn to relate better to others?”

Acknowledgments
The idea of core assumptions derives from Beck and colleagues (1979) and also the Dysfunc-
tional Attitudes Scale (Weissman, 1980).

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 331. Link the quotation to the session—for example,
“Today we’ll focus on healthy relationships. The quotation suggests that the ability to love
opens up life’s possibilities.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2.
Handout 1: Healthy Relationships
Handout 2: Changing Unhealthy Relationship Beliefs
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Help patients identify their beliefs about relationships (Handout 1).
¨ Help patients change beliefs that interfere with healthy relationships (Handout 2).
330 Treatment Topics

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Ask patients to check off the beliefs in Handout 1 they notice in
themselves, both healthy and unhealthy.
ê Discussion
• “Which beliefs do you agree or disagree with?”
• “Are there current relationship situations that you could handle better if you
changed your beliefs?”
• “How can you apply the healthy relationship beliefs to your life?”
• “What relationship skills do you need to learn, and how might you go about learning
them?”
• “How might your relationship beliefs relate to your PTSD and substance abuse?”
• “Why is it important to focus on changing yourself rather than others?”
• “Do you find yourself using substances more when you have relationship conflicts?”

Suggestions
✦ Note that each of the beliefs in Handout 1 is described in detail in Handout 2. A para-
graph explores how to change each unhealthy belief (marked by a black diamond) into its cor-
responding healthy belief (marked by an asterisk).
✦ Help patients explore their choices in relationships. For example, “I understand that
your boss is a very difficult person, but since we can’t change him, what do you need to do to
make your situation better?” Never invalidate patients’ view of other people or convey that
relationship problems are just patients’ fault; rather, help empower them to recognize what
they can do differently (which may mean ending some relationships that are not salvageable).
✦ In group therapy, you may want to ask people to raise their hands if they agree with a
particular belief, so that patients get a sense of how others view relationships.

Tough Cases
∗ “I drink so I can socialize. If I gave up drinking, I know I’d isolate.”
∗ “I want to believe the healthy relationship beliefs, but I just can’t.”
∗ “I can’t find anyone healthy.”
∗ “This healthy–unhealthy distinction sounds like black-and-white thinking.”
∗ “Should I tell my partner that I had an affair last year?”
∗ “Are you saying that when I was abused as a child, it was my fault?”
 Quotation

“If we change within,

our outer life will change also.”
—Jean Shinoda Bolen
(20th-century American writer)

From Seeking Safety by Lisa M. Najavits (2002).

331
HANDOUT 1 Healthy Relationships

Healthy Relationships

« Put a check mark (ü) next to any statement that you believe.

HEALTHY RELATIONSHIP BELIEFS

1. Seek understanding and solutions, not blame.

2. In a healthy close relationship, anything can be talked about.
3. The best way to change a relationship is by changing my behavior.
4. Creating good relationships is a skill to learn, just like playing a sport.
5. While losing a relationship may be painful, I can mourn and move on.
6. It is better to be alone than in a bad relationship.
7. A good relationship requires effort but is worth it.
8. I need relationships in which both people’s needs are respected.
9. I need to cultivate relationships with a few people who really matter.
10. With recovery, I can respect myself more and others will too.
11. Acceptance is the basis of healthy relationships.

UNHEALTHY RELATIONSHIP BELIEFS

1. I am always wrong; the other person is always right.

2. I should hide what I really think and feel.
3. The other person has to change.
4. Bad relationships are all I can get.
5. I cannot exist without .
6. It is better to be with someone destructive than to be alone.
7. Good relationships are easy.
8. I must take care of everyone else first; my needs come last.
9. I must be liked by everyone.
10. I have no value to other people.
11. I am not enough for a relationship.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

332
HANDOUT 2 Healthy Relationships

Changing Unhealthy Relationship Beliefs

u Relationship belief. “I am always wrong; the other person is always right.”

˜ Exploration. A common relationship problem for trauma survivors is the belief that all relationship problems are
their fault (or vice versa—that all relationship problems are the other person’s fault). There are two ways out of this
destructive view. First, try to view relationship problems between adults as having a 50–50 balance: Each person is
responsible for half. If you have a conflict with someone, ask yourself, “What are we each contributing to creating a
problem?” A second way out is to seek understanding and solutions, rather than focusing on “who is right and who
is wrong.” Each person has limitations, wants, and needs, however irrational these may seem to the other. In healthy
relationships, both people need to arrive at a solution together.
* A healthier view. “Seek understanding and solutions—not blame.”
2

u Relationship belief. “I should hide what I really think and feel.”

˜ Exploration. Honesty and communication are the core of a healthy relationship. This includes conflicts as well as
the full range of positive and negative feelings. A disagreement does not mean the end of a relationship. In fact, re-
solving conflicts is a normal part of healthy relationships. When conflicts are out in the open, there is a chance to re-
solve them. If you are hiding your reactions or isolating, there may be very good reasons for this based on your past,
but the goal now is to learn how to be honest with safe people. In a strong close relationship, anything can be talked
about, including vulnerable feelings, criticism, loving feelings, sex, and money.
* A healthier view. “In a healthy close relationship, anything can be talked about.”
3

u Relationship belief. “The other person has to change.”

˜ Exploration. When a relationship is not working, it is human nature to try to change the other person. But this
rarely works. What you can control is your part of the relationship. That means that you have choices. You can, for
example, accept the other person’s behavior, discontinue the relationship, change how you relate, or say what you
want (but without necessarily expecting the other person to give it to you). It is very freeing to let go of trying to
change other people and to turn your attention to what you can control, which is yourself.
* A healthier view. “The best way to change a relationship is by changing my behavior.”
4

u Relationship belief. “Bad relationships are all I can get.”

˜ Exploration. If you have PTSD and substance abuse you may have difficulty finding healthy relationships. You
may find yourself getting drawn over and over into relationships with people who have substance abuse or are de-
structive. But developing good relationships is a skill to learn, just like learning to play a sport. One good way to start
is to take the same approach as you would for any other skill: Read some books on the topic, take a class if you can,
and watch how others do it. Working on it in therapy is also helpful. Just as in learning tennis you would need to
learn how to serve the ball, how to hit a backhand, a forehand, and how to score the game, with relationships you
may need to learn how to recognize healthy and unhealthy relationships, how to converse, how to negotiate con-
flicts, how to assert yourself, how to give and accept compliments, and how to start and end relationships.
* A healthier view. “Creating good relationships is a skill to learn, just like playing a sport.”
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

333
HANDOUT 2 (page 2 of 3) Healthy Relationships

u Relationship belief. “I cannot exist without .“

˜ Exploration. While it is natural to be upset if you lose someone, loss and mourning are part of life. If you stay in
an unhealthy relationship because it is hard to face loss, you are paying a very high price for the relationship. Ways to
mourn the loss of a relationship include talking about it to others, crying about it, writing about it, recognizing that
time heals, and getting involved in activities to make the loss less prominent in your life.
* A healthier view. “While losing a relationship may be painful, I can mourn and move on.”
6

u Relationship belief. “It is better to be with someone destructive than to be alone.”

˜ Exploration. Destructive relationships damage your emotional health and your self-esteem. It may be difficult to
find healthy people, but it is worth the search. The more time spent in destructive relationships, the less likely you are
to find better ones. For some people in early recovery, their only trustworthy relationships are with treaters such as
therapists or counselors, and that is okay for now. Over time, you can build a safe support network.
* A healthier view. “It is better to be alone than in a bad relationship.”
7

u Relationship belief. “Good relationships are easy.”

˜ Exploration. All relationships require effort: to begin them, maintain them, resolve conflicts, be responsible to
each other, be supportive of each other, and end them if need be. It is realistic to expect a relationship to take work
at times.
* A healthier view. “A good relationship requires effort but is worth it.”
8

u Relationship belief. “I must take care of everyone else first; my needs come last.”
˜ Exploration. While taking care of others is admirable, if it is at your expense, it is an unhealthy pattern. Some
people make great efforts to take care of others, but no one takes care of them. If you are not feeling supported or
helped in return, you are likely to resent it over time and may compensate by “feeding” yourself through excesses of
alcohol, drugs, food, or other addictions. In good relationships, caring goes both ways.
* A healthier view. “I need relationships in which both people’s needs are respected.”
9

u Relationship belief. “I must be liked by everyone.”

˜ Exploration. If you have felt isolated, rejected, or neglected, it is understandable that you may want to compen-
sate by seeking everyone’s approval. But in trying to please others too much, you can lose yourself. A healthier ap-
proach is to cultivate a few good relationships with safe people whom you genuinely like. A more selective approach
allows you to focus your energy on strengthening who you are and caring for a small number of relationships that
truly matter. No one can be liked by everyone anyway!
* A healthier view. “I need to cultivate relationships with a few people who really matter.”

(cont.)

334
HANDOUT 2 (page 3 of 3) Healthy Relationships

10
u Relationship belief. “I have no value to other people.”
˜ Exploration. If you have been stuck in PTSD and substance abuse, you may view yourself as not worth very
much. Developing a sense of yourself as desirable and valuable may take time. The best strategy is to keep progress-
ing in your recovery. Both PTSD and substance abuse lower your self-esteem; recovery improves it. You can come to
respect who you are, and, almost like magic, you will find that other people do too.
* A healthier view. “With recovery, I can respect myself more, and others will too.”
11
u Relationship belief. “I am not enough for a relationship.”
˜ Exploration. Some people believe they are not good enough for a relationship because they need to be more at-
tractive, thin, smart, funny, confident, clean and sober, recovered from PTSD . . . and so forth. But acceptance is the
key to good relationships—acceptance of who you are right now, and acceptance of the other person. Acceptance in
a relationship is like sunlight to a plant; it allows it to grow.
* A healthier view. “Acceptance is the basis of healthy relationships.”

335
 Healthy Relationships

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Identify one way in which you can be different in a current relationship. Try being that new way
this week and observe what happens.
ª Option 2: Your relationship with yourself is the basis of your relationships with others. Go through Handout 1
and circle any healthy beliefs that could help improve your relationship with yourself. For example, could you
learn to seek understanding and solutions rather than blaming yourself? If you want, you could also write a
paragraph on this topic.
ª Option 3: Change the script. Take a piece of paper and draw a line down the middle. On the left side, write a
script of current conflict with someone in your life (what you say, what the other person says). On the right
side, write how you could respond differently.
ª Option 4: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation Every time I try to be Every time I try to be
honest with my father, he honest with my father, he
criticizes me. criticizes me.

« Your Coping «
I get scared and shut up. I I need to remember that he
want to be able to be honest is who he is. I’ve told him
with him without getting many times what I want, and
criticized. This makes me he has not changed. It is
want to get high. probably healthier for me to
not talk to him honestly at
this point, as he can’t
handle that. I need to focus
on other people.

Consequence I feel stuck and depressed. I would feel less depressed,

and wouldn’t feel like I
need to get high.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

336
BEHAVIORAL

Self-Nurturing

SUMMARY

Today’s topic seeks to inspire patients to increase pleasurable activities. Safe self-nurturing is
distinguished from unsafe self-nurturing (e.g., use of substances and other “cheap thrills”).

ORIENTATION

The issue of pleasure is central for this population. Frequently, there is an impulsive and ex-
cessive search for pleasure that is ultimately self-destructive. Substance abuse is the most ob-
vious example, but co-occurring areas may include binge eating, gambling, overspending,
sexual addiction, and other impulse control problems. Simultaneously, there is often a lack of
healthy pleasures, such as hobbies, sports, or outdoor activities. Thus today’s topic asks pa-
tients to evaluate their current levels of both safe and unsafe pleasurable activities. The goal
is to increase the former and decrease the latter.
In doing this work, many complex meanings of pleasure may arise. Substance abuse ini-
tially appears to be associated with seeking pleasure (albeit in a misguided way), while PTSD
is associated with pain, and the two disorders become causally linked in an attempt to offset
the pain with substances. This is the classic self-medication model, and it appears to hold true
for the development of these disorders in many patients with this dual diagnosis. After a
while, however, if the disorders are chronic, they may reverse their meaning. The substance
abuse may become fraught with suffering (with the “high” no longer enjoyable but merely a
desperate attempt to feel normal), and the suffering in PTSD may become so familiar that it is
difficult to give up—there may be attachment to the identity of suffering, repeated re-
enactments, and a sense of deep familiarity with it. This does not mean that patients want to
suffer, but just that suffering takes on a life of its own. Many other meanings are possible as
well. Some patients with PTSD may have an aversion to pleasure, as it may be associated
with someone’s seeking pleasure at their expense (e.g., in sexual abuse or sadistic physical or
emotional abuse). Some seemingly pleasurable events may also be triggers for them, such as a

337
338 Treatment Topics

warm bath, certain seasons of the year, or being alone in the outdoors. They may report that
nothing at all gives them pleasure, or that they feel guilty taking care of their own needs be-
cause trauma taught them that their needs do not matter. Even adults with PTSD who are
survivors of war or natural disasters may have difficulty seeking pleasure in their lives if they
feel “survivor guilt” that others died while they did not. If patients with PTSD and substance
abuse grew up without family members to teach healthy self-nurturing, they may have simply
never learned it.
In working to improve such patients’ self-nurturing in treatment, therefore, a variety of
approaches may be helpful. Such approaches include helping to increase awareness of self-
nurturing patterns by assessing what patients are currently doing and not doing; discussing
how self-nurturing deficits relate to PTSD and substance abuse; exploring feelings that may
arise when patients try to improve their self-nurturing; providing a simple behavioral con-
tract for self-nurturing activities (called A Gift to Yourself); and finding ways to give them-
selves permission to make changes in these areas.
In short, a relatively simple behavioral task—to increase safe daily pleasurable activities
and to decrease those that are unsafe—may require concerted work by the therapist, and also
the discovery of complex belief systems inherent in PTSD and substance abuse. The reward
can be significant forward movement toward recovery.

Countertransference Issues
Exploring one’s own issues with self-nurturing may be helpful for today’s topic. For many
people, it is an ongoing challenge to balance safe self-nurturing with other parts of their lives,
and to fully avoid unsafe self-nurturing. Indeed, depending on where the therapist “lands” at
the moment on these issues, there may be judgment or negative feelings toward patients’ ex-
cesses; jealousy of patients who have a lot of time or other resources for self-nurturing that
may not be available to oneself; or arousal of the therapist’s own childhood deprivations, fam-
ily excesses, or other family-of-origin issues. And, as with all of the behavioral topics in the
treatment, developing a concrete plan with patients and following up on it in an organized
way require notable therapist effort.

Acknowledgments
This topic draws from a module in Lewinsohn’s (1984) treatment manual for depression,
which lists a variety of self-nurturing activities. Linehan’s (1993) skills training manual for
borderline personality disorder has an extensive list as well.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 341. Link the quotation to the session—for example,
“Today we’ll focus on self-nurturing. Sometimes simple pleasures can bring much-needed
perspective.”
Self-Nurturing 339

3. Relate the topic to patients’ lives (in-depth, most of session).

a. Ask patients to look through the handouts, which can be used separately or to-
gether. Consider covering them in multiple sessions if you have the time. See “Ses-
sion Content” (below) and Chapter 2 for suggestions.
Handout 1: Safe and Unsafe Self-Nurturing
Handout 2: A Gift to Yourself
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2 for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Explore the concept of safe and unsafe self-nurturing (Handout 1).
¨ Help patients increase safe self-nurturing and decrease unsafe self-nurturing (Hand-
out 2).

Ways to Relate the Material to Patients’ Lives

ê Create a behavioral plan. The recommended exercise for the topic is to help patients
commit to increasing their safe self-nurturing and decrease their unsafe self-nurturing
(Handout 2). Try doing a walk-through to explore what feelings may arise, obstacles that may
get in the way (both emotional and practical), and ways to learn from the experience.
ê Discussion
• “What does ‘self-nurturing’ mean?”
• “What are your safe and unsafe self-nurturing activities?”
• “What happens when you don’t have enough safe self-nurturing?”
• “How do PTSD and substance abuse lead to problems in self-nurturing?”
• “If you give yourself more safe self-nurturing, will that make it easier to give up sub-
stances?”

Suggestions
✦ Notice “addiction to pain.” People who have suffered a lot may tend to keep expecting
and even unconsciously seeking out pain. Although they may not want to do this, they may be
so familiar with it that they keep reenacting it. Be careful in discussing this issue, however, so
that patients do not feel that you are minimizing their suffering or blaming them for their
trauma.
✦ Encourage re-parenting. Patients can try to treat themselves as children who need
healthy fun and pleasure to make up for the deprivations associated with PTSD and sub-
stance abuse. For patients who were abused as children, they can give themselves what they
didn’t get while growing up.
340 Treatment Topics

✦ Daily safe self-nurturing activities are recommended. Many patients will report infre-
quent safe self-nurturing activities (e.g., once per month). Consider asking them to commit to
at least one per day.
✦ Note that activities that are safe for one patient may be unsafe for another. For exam-
ple, gambling may be fine for one patient, but may be extremely self-destructive for another.
Thus, patients should be aware that the type of activity is not a problem per se, but rather the
degree of excess and harm that it causes.
✦ Explore emotional obstacles to self-nurturing. For example, “What would it feel like to
do something healthy and nice every day?” or “What would it feel like to give up an unsafe
activity that you do?” Patients may feel sad, angry, guilty, or deprived as they try to make such
changes.
✦ Explore practical obstacles to safe self-nurturing. For example, “What practical arrange-
ments do you need to make to allow 2 hours a day just for fun?” Note that sometimes patients
truly need to find practical solutions. However, practical excuses can also be “smoke screens”
for larger defenses. Help patients recognize that all people—even the President or the head of
IBM—can take some time for themselves. Time is usually not the issue; rather, it’s fear.
✦ Explore how patients can give themselves permission to do more safe self-nurturing.
What might they need to say to themselves? What beliefs get in the way? Especially if they
grew up being abused, it may take a leap of faith for them to embark on safe, enjoyable activi-
ties.
✦ Initially, patients may need to do safe self-nurturing as a task until it becomes a natu-
ral part of their lives. This is particularly true for patients who feel guilty about or afraid of
self-nurturing. An effective way to overcome such feelings is to commit to fun activities even
if it’s uncomfortable; eventually it will feel easier (a behavioral exposure model).
✦ If patients report that nothing feels pleasurable, normalize this. You can validate the
experience (e.g., “That is very common in survivors of trauma”), while also getting them to
start identifying small ways to find activities they like.
✦ Explore why patients might have difficulty with pleasure. It may remind them of an
abuser’s seeking pleasure by abusing them; it may raise anxiety because it wasn’t allowed
when they were growing up; it may be associated with “survivor guilt” (e.g., for survivors of
accidents, combat, or natural disasters).
✦ To reduce unsafe self-nurturing, make sure the behavioral plan is extremely clear. Cre-
ate an “airtight” plan so that it will be clear whether or not patients were able to reduce the
unsafe activity when they come to the next session.

Tough Cases
∗ “I can’t experience pleasure—nothing feels good to me.”
∗ “All of the people I know drink to have a good time.”
∗ “I have three kids and a full-time job. I don’t have any time for myself.”
∗ “My partner doesn’t want me to go out of the house.”
∗ “Nothing can make up for the trauma I’ve been through.”
∗ “What’s wrong with exercising 5 hours a day?”
∗ “Whenever I try to do something pleasurable, I feel guilty.”
 Quotation

“Perhaps the truth depends on a

walk around the lake.”
—Wallace Stevens
(20th-century American poet)

From Seeking Safety by Lisa M. Najavits (2002).

341
HANDOUT 1 Self-Nurturing

Safe and Unsafe Self-Nurturing

v Safe self-nurturing means seeking fun, joy, and pleasure in healthy ways and without excess.
ö Unsafe self-nurturing means seeking pleasure in an activity that causes you harm (legal, financial, social, per-
sonal, or physical) and/or doing the activity to excess.

EXAMPLES OF SAFE SELF-NURTURING

« (a) Circle any that you currently do. (b) Check (ü) any that you’d like to add to your life.

v Taking walks v Socializing with safe friends v Reading v Travel

v Movies v Crafts or hobbies (e.g., painting, woodworking, puzzles) v Sports
v Enjoying pets v Participating in a club or organization v Music v Exercise
v Eating out v Local trips (day trips, weekends away) v Baking or cooking
v Dance v Visiting museums v Playing games v Taking an interesting class
v Volunteering v Learning a new skill v Enjoying the outdoors v Writing
v Religious services v Meditation v Enjoying computers v Warm baths
v Playing with children v Going to events (concerts, comedy clubs, lectures, etc.)
v Others:

EXAMPLES OF ACTIVITIES THAT MAY BE UNSAFE FOR SOME PEOPLE (WHEN EXCESSIVE)
« Circle any that are unsafe for you.

ö Shopping ö Food ö Watching TV ö Gambling ö Partying ö Work

ö Pornography ö Exercise ö Video or computer games ö Internet ö Sex
ö Others:

HOW DO PTSD AND SUBSTANCE ABUSE RELATE TO PROBLEMS IN SELF-NURTURING?

PTSD. You may be more familiar with pain than with pleasure. You may feel guilty about nurturing yourself (es-
pecially if you grew up without much love). To cope with trauma, you may have turned to unhealthy addictions
rather than healthy activities to feel better.
Substance abuse. Substance abuse and other addictions are “cheap thrills.” They may work in the short run,
but in the long run they cause tragedy. They are misguided attempts to give yourself pleasure, and they keep you
from finding healthy ways to feel good.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

342
HANDOUT 2 Self-Nurturing

A Gift to Yourself

v Give yourself a gift by . . . increasing safe self-nurturing.

ö Give yourself a gift by . . . decreasing unsafe self-nurturing.

Some ways to do this:

 Replace unsafe activities with safe activities.
 Set a structure (e.g., at least 2 hours a day of safe self-nurturing).
 “Play around”—try a variety of safe new activities to see what you like.
 Work on it in therapy or with someone else who can help.
 Write yourself a letter giving yourself “permission” to improve self-nurturing.
 Explore the emotions that arise when you change your self-nurturing.
 Listen to your deepest needs.
 Get back to activities that you enjoyed “way back when” but gave up along the way.

YOUR SELF-NURTURING PLAN

« Create your plan below, focusing on the week ahead. Be very specific to really make it work! Include any details
that are important for you—for example, what activities, how often, during what time frame, how you will make it
happen, who you will get help from, how you will remember to do it, and how you will feel if you do it. Continue on
the back of the page if you need more space.

My “gift to myself” to increase safe self-nurturing activities:

My “gift to myself” to decrease unsafe self-nurturing activities:

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

343
 Self-Nurturing

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.

ª Option 1: Carry out the “gift to yourself” plan that you wrote in today’s session.
ª Option 2: Try one new self-nurturing activity before the next session.
ª Option 3: Make a life plan: What self-nurturing activities do you want to do every day? Every week? Every
year? What would it take for you to give yourself these?
ª Option 4: Write a letter giving yourself permission for self-nurturing activities.
ª Option 5: Remember yourself as a child: What activities did you used to enjoy that you’ve lost along the
way? Can you get back to any of those activities now?
ª Option 6: Fill out the Safe Coping Sheet. (See below for an example applied to this topic.)

EXAMPLE OF THE SAFE COPING SHEET APPLIED TO THIS TOPIC

Old Way New Way

Situation Had a conflict with my boss Had a conflict with my boss
today at work. today at work.

« Your Coping «
Went home, felt depressed. Get a video to take my mind
My thoughts were “Why can’t off work, make myself a nice
I function like everyone dinner, and take my dog out
else? This is my third job for a run (all self-
in 2 years. I can’t keep my nurturing activities).
mouth shut, and I get mad at
the slightest thing.” I
smoked some pot.

Consequence Went to sleep early. Woke up Feel calmer; have more

the next day and felt worse. perspective.

How safe is your old way of coping? How safe is your new way of coping?

Rate from 0 (not at all safe) to 10 (totally safe)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

344
INTERPERSONAL

Healing from Anger

SUMMARY

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

ORIENTATION

“There’s a side of me that’s very young and hurt—that’s the side that needs protection from
my angry side.”

“It takes everything I’ve got not to take a gun and start shooting.”

“I want to cut my arms until I’ve cut out the bad part of me.”

A major premise of today’s topic is that anger is a necessary part of recovery from PTSD and
substance abuse: There is no way for the patient to get better and for therapy to truly help un-
less there are points when anger is part of the work. The main question is how to use the an-
ger constructively toward healing, rather than destructively toward harm (of self, others, or
the therapy). Thus it is not whether anger is part of the work, but rather whether therapist
and patient can use it, own it, manage it, and get through it safely.
Anger is intimately bound up with PTSD and substance abuse because it is a natural hu-
man response when situations are out of a person’s control. By definition, both PTSD and
substance abuse are disorders of control (see the “Process” section of Chapter 2 for more on
this). In PTSD, the random unfairness of trauma leads to anger that may be projected in all
directions—at oneself, others, life, God, existence. In substance abuse, the inability to control
its downward spiral can similarly lead to frustration and rage. Indeed, substances are often a

345
346 Treatment Topics

way to try to manage anger (and other feelings) that cannot be managed through healthier
coping. Some subpopulations with PTSD and substance abuse (e.g., war veterans and prison-
ers) are particularly known for high levels of anger (McFall, Wright, Donovan, & Raskind,
1999).
Anger is a very difficult emotion in treatment, for several reasons. First, when not pro-
cessed successfully, it manifests itself through action: both acting out toward others (e.g., do-
mestic violence, child abuse, fighting, verbal eruptions) as well as acting in toward the self
(e.g., self-harm, suicidal actions). These serious behavioral dangers are stressful for the thera-
pist as well as for the patient. Second, anger is typically a shield for other emotions that may
be more painful to feel, most notably vulnerable feelings such as sadness, disappointment,
and feelings of failure. Helping the patient see through the anger to face such feelings is a
challenging task. Finally, when anger is present, it may become a threat to the therapeutic re-
lationship. Anger will at some point become part of the therapy, in any number of forms: di-
rect anger with the therapist, unacknowledged anger that gets expressed through action, or
anger that gets played out with other patients (in group treatment). If the therapist is unable
to work effectively with the anger, the patient may be at high risk of poor outcome or early
dropout from treatment.
It is also notable that much old-style anger management does not appear to work for
many patients. Strategies that emphasize “getting the anger out,” such as hitting pillows,
throwing rocks into a pond, or writing about angry feelings, may escalate rather than defuse
anger. Thus it is important to make sure that whatever strategies are attempted actually bring
angry feelings into the safe-zone range (i.e., 5 or lower on a 0–10 scale, where 10 is angriest).
The goal is for patients to be aware of their anger, yet within sufficient control of it to commu-
nicate effectively with others and avoid dangerous behaviors.
The title of this topic, Healing from Anger, thus has two meanings: “constructive anger”
and “destructive anger.” Constructive anger is the idea that healing can derive from anger if it
is addressed therapeutically (i.e., anger as a source of important learning that leads to
growth). For example, a patient may come to see that anger is a cue that her needs are not be-
ing met adequately in a relationship and she needs to speak up about it. Or a patient may find
that his anger represents a younger side of himself who “throws tantrums” when he doesn’t
get what he wants, and he needs to soothe this side of himself. The second meaning, destruc-
tive anger, is the idea that there are times when it is important to heal by moving away from
anger. When anger is extreme or chronic, it tends to be unproductive—it creates bitterness,
leads to behavioral problems, and perpetuates blaming others or oneself rather than taking
mature responsibility. Thus an important second goal of today’s topic is helping patients learn
ways to move away from anger when it becomes too intense. The handouts attempt to ad-
dress both meanings of healing from anger.
Note that other topics in this treatment provide ways to cope with anger as well, particu-
larly the topics Honesty, Setting Boundaries in Relationships, Detaching from Emotional Pain
(Grounding), and Recovery Thinking. Finally, if there is any serious risk that a patient’s anger
will become expressed in action that poses a significant danger to either self or others, all
emergency clinical procedures must be applied (see the section “Problem Situations and
Emergencies” in Chapter 2 for specifics).
Healing from Anger 347

Countertransference Issues

Just as anger is part of recovery from PTSD and substance abuse for the patient, so will it
likely be part of the therapist’s experience as well. Anger (or its subsidiaries, frustration
and annoyance) is a natural response when a patient does not seem to get better, keeps us-
ing substances or doing other self-harm, acts out toward others, or disrupts treatment
through no-shows or lack of follow-through on commitments. When the therapist feels an-
ger, the least helpful way of managing—for both therapist and patient—is to do what many
treaters are inclined to do: ignore it and keep focusing on being supportive and kind, or
continue trying to conduct cognitive-behavioral interventions without acknowledging the
underlying feelings. People who go into human services work generally like to be warm
and helpful; “owning” one’s annoyance with a patient and using it productively may be dif-
ficult. Yet if the therapist uses anger well, it can be of great service to the patient. The
therapist may be the only one to give the patient honest feedback; letting the patient “walk
all over” the therapist does not help the patient or the treatment. Also, if the therapist can
own angry feelings in a therapeutic way, it will provide a healthy model for the patient,
who may never have learned how anger can be addressed effectively within a relationship.
If a therapist has trouble giving the patient direct negative but constructive messages, set-
ting limits, or keeping the frame of treatment (e.g., “indulging” the patient), these may be
signs of anger.
Although the dynamics of anger in therapy are too broad a subject to cover in detail here,
a few guidelines may be useful. First, if the patient becomes angry with you, it is important to
respond by trying to hear the patient without defensiveness or blame (see “Process” in Chap-
ter 2 for more on this). Second, if the patient’s or your own anger becomes long-lasting,
strongly consider seeking consultation from a supervisor or expert therapist. Allowing an an-
gry transference–countertransference dynamic to continue can be dangerous for both sides.
Third, be aware of the very common pattern that when patients cannot face their own anger,
you may end up feeling it for them. Fourth, if you are angry, it may be important to give the
patient constructive negative feedback at times. As long as it is done with the goal of helping
the patient rather than simply venting frustration, it can be therapeutic. For example: “Mark,
I’m beginning to lose trust in your commitments when you make them every week but then
keep forgetting to do them. Can I help you come up with a way to remember them? I want to
be able to regain trust in your word.” As with any delicate intervention, check in with the pa-
tient to make sure how the patient is interpreting what is being said. Finally, one of the best
articles on therapists’ angry countertransference is by Maltsberger and Buie (1973); another
excellent article is by Gunderson (1996).

Acknowledgments

Readings that were helpful in the development of this topic included Chemtob, Novaco, Ha-
mada, and Gross (1997), Maltsberger and Buie (1973), Gunderson (1996), Potter-Efron and
Potter-Efron (1995), and McKay, Rogers, and McKay (1989). The “Change ‘shoulds’ to ‘I
wants’ ” recommendation in Handout 3 is based on Burns (1980).
348 Treatment Topics

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 350. Link the quotation to the session—for example,
“Today we’ll be talking about anger. A loving stance can help you use your anger toward posi-
tive purposes rather than letting it destroy you.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether. Cover them in multiple sessions if you have the time. See “Session Con-
tent” (below) and Chapter 2.
Handout 1: Exploring Anger
Handout 2: Understanding Anger
Handout 3: Before, During, and After: Three Ways to Heal Anger
Handout 4: Safety Contract: Protecting Yourself and Others
b. Help patients relate the skill to current and specific problems in their lives. See
“Session Content” (below) and Chapter 2.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Help patients explore whether they have an anger problem, and how anger can be
both helpful and harmful for recovery (Handout 1).
¨ Discuss typical destructive and constructive beliefs associated with anger (Handout 2).
¨ Use a three-step model, “Motivate, Contain, and Listen,” to manage anger before,
during, and after it occurs (Handout 3).
¨ Develop a Safety Contract (Handout 4).

Ways to Relate the Material to Patients’ Lives

ê Self-exploration. Help patients determine whether they have a problem with anger by
taking the brief self-test at the top of Handout 1.
ê Role plays. Identify specific situations in which patients have problems with anger.
Some examples of role plays are listed in Handout 3, but it’s best to use patients’ real-life ex-
amples if possible. Try to guide patients to (1) express anger appropriately (assertively,
calmly); and (2) identify the feelings behind the anger (e.g., vulnerable feelings such as sad-
ness).
ê Develop an anger plan. Using the three-step model in Handout 3, try to have patients
circle the points that they might be able to use.
ê Fill out the Safety Contract. Encourage patients to be realistic in identifying risks, and
thoughtful about ways to keep safe from acting out anger.
Healing from Anger 349

ê Discussion
• “Do you believe you have a problem with anger?”
• “How is your anger connected to your PTSD and/or substance abuse?”
• “What do you think of the idea that anger is inevitable in recovery from PTSD and
substance abuse?”
• “What coping strategies work best to help you control your anger?”

Suggestions
✦ Help patients recognize both constructive and destructive anger. If just a positive
view of anger is emphasized, patients’ dangerous behavior may not be sufficiently managed.
If just a negative view of anger is emphasized, patients may feel demoralized.
✦ Be careful about not getting into power struggles about ideas on the handouts. Dis-
cussions of anger tend to bring out very strong feelings in patients. If the session becomes an
argument about anger, it will ironically just reinforce rather than defuse anger. Focus on areas
that patients can agree with or want to work on.
✦ If a patient gets overly angry during the session (e.g., threatens harm to self or others),
implement crisis intervention strategies. These might include helping ground the patient,
working on the Safety Contract, or asking the patient to go to an emergency room. See Chap-
ter 2.
✦ In filling out the Safety Contract, try to go with patients’ ideas first. Encourage pa-
tients to suggest how to fill in the blanks on the contract, with the therapist adding in ideas as
needed. This makes it more likely that patients will abide by the contract.

Tough Cases
∗ “I don’t care who I hurt; I feel like I’m going to explode.”
∗ “Okay—so behind my anger is sadness. What do I do with that?”
∗ “I don’t feel safe unless I keep weapons at home.”
∗ “I want to die.”
∗ “I’m angry with you—this treatment isn’t helping me.”
∗ “I want to kill my partner.”
 Quotation

“A loving heart
is the truest wisdom.”
—Charles Dickens
(19th-century British author)

From Seeking Safety by Lisa M. Najavits (2002).

350
HANDOUT 1 Healing from Anger

Exploring Anger

DO YOU HAVE A PROBLEM WITH ANGER?

Do you think you have a problem with anger? Yes / No / Unsure

« If you circled “Yes,” you may want to go directly to the next section. If you are unsure, check (ü) below any that
are true for you—these are typical signs of an anger problem.

r You “blow up” at others. r You hate yourself.

r You often criticize others. r You often isolate.
r You feel anger but can’t express it. r You feel bitter.
r You have impulses to harm others. r You have impulses to harm yourself.
r You “never feel angry.” r Others have said you have an anger problem.

TWO TYPES OF ANGER

It is important to know that anger is not bad or wrong. Rather, it is information that can be used either to help or to
harm your recovery. It can be used constructively to help you heal, to be honest with others, to face your pain. Or it
can be used destructively to act out against yourself or others, to give up, to become bitter. Anger itself is not a prob-
lem—it’s all in what you do with it.

Constructive Anger: Anger that Heals

“Constructive anger” means anger that is . . .

• Moderate or lower (e.g., up to 5 on a 0–10 scale, where 0 = no anger and 10 = intense anger).
• Explored to understand yourself and others better.
• Conscious (you are aware of it).
• Handled well (e.g., not acted out in dangerous behavior).
• Respectful of your own and others’ needs.
For example, if you go out on a date and the other person acts selfish, you may rightly feel angry. If you listen
to your anger, you can use it as a sign to protect yourself; perhaps you can talk to the person about what bothers
you, or you can calmly end the date early. You can feel good about using your anger constructively.
There are great benefits to constructive anger. It can help protect you from danger . . . convey insights
about yourself and others . . . give you real power. « Any other benefits you notice?

Destructive Anger: Anger that Harms

“Destructive anger” means anger that is . . .

• Acted out in dangerous behavior (hurting yourself or others).
• Too intense and/or frequent (e.g., often above a 5 on a 0–10 scale).
• “Underground” (quietly seething or feeling bitter).
• Unconscious.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 1 (page 2 of 2) Healing from Anger

There are great costs to destructive anger. It can destroy your relationships . . . cause physical harm . . .
weaken you . . . become an addiction. « Any other costs you notice?
Destructive anger can be directed toward yourself and/or directed toward others. Both represent a lack
of balance between your own and others’ needs. For some people, both are present.
Destructive anger toward self (e.g., self-harm, suicidal feelings): Putting others’ needs too much
ahead of yours.
Destructive anger toward others (e.g., verbal abuse, assault): Putting your needs too much ahead of
others’.
With destructive anger toward yourself, you may not be aware of anger. For example, if you physically
hurt yourself you may not notice anger at the time. However, such acting out does indeed represent anger—typically
anger toward others that you have difficulty “owning.”

« How do you tend to handle anger? Circle one: Constructively / Destructively / Both
Circle one: Toward self / Toward others / Both

DID YOU KNOW . . . ?

« Check (ü) any points below that you understand. Circle any that you have questions about.
Anger is normal in recovery from PTSD and substance abuse. If you have been through the terrible experi-
ences of trauma and substance abuse, anger is inevitable. You may feel angry at people who hurt you, at the world,
at God, at yourself, at life, at treaters, at family, at strangers. Your anger is valid and real. In recovery, the goal is to
use your anger as a way to learn about yourself and grow. The task is to face your anger without letting it destroy
you or others.
Behind all anger are unmet needs. Anger is a signal that something is wrong. It may mean that you are not
taking enough care of yourself, or that you have a lot of sadness to work through, or that you are in a harmful rela-
tionship. Listening to your anger and caring for the underlying needs can resolve anger.
Constructive anger can be learned. It is never too late, no matter how long you’ve had a problem with an-
ger. Mainly, it requires really listening to others’ feedback about your anger, “owning” your feelings rather than act-
ing them out, expressing anger in healthy ways, and learning to tolerate the painful feelings behind the anger.
Destructive anger can become an addiction. Can you see similarities between destructive anger and sub-
stance abuse? For example, the more you engage in it, the more it increases. Also, with destructive anger you may
feel “high” on it in the moment. Have you “hit bottom” with destructive anger—has it caused serious problems in
your life?
Venting anger does not work. An old-style view of anger was the idea of venting—that the solution to anger
is to “get it out” (e.g., punch a pillow, write an angry letter, throw rocks at a tree). However, these actually tend to in-
crease rather than decrease anger. Currently, it is understood that anger needs to be handled constructively, not sim-
ply vented.
Destructive anger never works in the long term. You may get results in the short term. People may do what
you want; you may feel powerful in the moment. It is only later that you can see that these are an illusion. Destruc-
tive anger spins you out of control and weakens your bonds with others.

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HANDOUT 2 Healing from Anger

Understanding Anger

Notice how each constructive view on the right side of the list below softens the anger. Destructive anger is rigid and
harsh. You may want to think of it as ice that needs to melt. The goal is to keep perspective, balance your own and
others’ needs, and understand yourself better. Also, don’t feel you have to agree with each view below—just use the
ones that work for you.
« Check (ü) any below that might help you.

Anger toward Others

Destructive View Constructive View
“Others should put my needs first.” “Among adults, one’s ultimate duty in life is to put
one’s own growth first.”
“If I yell at people, they’ll treat me better.” “Yelling alienates people and makes them dislike me. I
need to ask for what I want in calm ways.”
“I know what’s right.” “There are many perspectives on truth. I need to listen
fully before I judge a situation.”
“The only way people hear me is if I yell.” “People will want to help me more if I talk to them
respectfully.”
“Other people screw up.” “If other people make mistakes, I need to gently guide
them. And I make mistakes too.”
“Anger shows how strong I am.” “Strong anger makes me weak. I become out of
control.”
“Others have to make my life better.” “It’s up to me, more than anyone else, to make my
life better.”
“I can only deal with anger by acting out.” “Everyone can learn to deal with anger safely.”
“I’m right to be angry.” “I have a right to be angry, but how I express it is
what counts.”
“I’m better than other people.” “Everyone in life has a purpose, even if I can’t see it.
Respect is the basis of all relationships.”
“I know I need to stop blowing up, but I can’t.” “I need to listen to my emotional pain—that’s what’s
behind my anger.”
“If others threaten me, I have to hurt them.” “In a case of serious physical danger, self-defense is
appropriate. Other than that, violence is
unacceptable.”

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 2 (page 2 of 2) Healing from Anger

Anger toward Self

Destructive View Constructive View
“I should put others’ needs ahead of mine.” “My needs are just as important as anyone else’s. It’s
time for me to treat myself well.”
“I should never get angry.” “It is normal to get angry at times. I need to listen to
my anger and respond to it safely.”
“If I hurt myself, I’ll feel better.” “I need to find long-term solutions to my pain.”
“I’m a failure.” “Deep inside, I know that life is about personal
progress—not about ‘winning’ and ‘losing.’ ”
“I can’t say what I really think.” “It’s how I say it that matters.”
“I need to be punished.” “That is a PTSD thought. It reflects my inner pain, but
it’s not true.”
“I want to die.” “I’m in a lot of distress. But I deserve to live.”
“This will show people how I feel.” “I need to put it in words, not action.”

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HANDOUT 3 Healing from Anger

Before, During, and After: Three Ways to Heal Anger

To transform anger from destruction to healing, three key strategies are helpful: “Motivate,” “Contain, and “Listen.”
These correspond, generally, to “before,” “during,” and “after” destructive anger episodes. If you want, you can re-
member the acronym “MCL” or “More Caring Life” to represent the idea that handling anger well can help you take
better care of yourself and others.
« Note: If you tend to harm yourself, you may not be aware of your anger. In reading the material below, you can
substitute the term “self-harm” where it says “anger.”

BEFORE ANGER EPISODES . . . MOTIVATE

“Motivate” means searching your heart for compelling reasons to stop destructive anger. This can free you to handle
the anger constructively. Prepare now, before the next anger episode.
Why? When you are in the midst of destructive anger, it may feel “right” to do something you will later regret.
Whether it’s hurting yourself or someone else, the feelings are so strong that you may feel you have no choice ex-
cept to go with them. They are like a tidal wave. Think of all the times you’ve sworn “things will be different next
time”—but then they aren’t. The only way to make them different is to establish strong motivation and then work at
it. It will not happen on its own. A key question: Why is it in your best interest to solve your anger problem?

How? « Check off any ideas below that might help you.

n Observe the cost of your anger. Has it isolated you? Kept you from feeling at peace? Hurt your job perfor-
mance? Left scars on your body (from self-harm)?
n Get feedback about your anger. Hearing how others view your anger problem can give you important in-
formation. Becoming defensive or dismissing feedback keeps you stuck. You do not have to agree with others, but
listen very carefully before you decide what’s true.
n Feel the impact of anger on your body. People who get angry a lot are more likely to have physical prob-
lems and to die younger. Do you notice the intense stress that anger puts on your body? Can you feel the tension it
creates?
n Notice whom your anger has hurt. Yourself? Your partner? Your children? Your therapy relationship? An-
ger scares people, even if they cannot tell you that. See the other’s pain—the hurt look on a child’s face, the partner
who becomes quiet. If you are feeling empathy for someone, you cannot simultaneously harm that person. (That in-
cludes yourself too!) Remember that you cannot “unstab” someone once the damage is done.
n Develop a policy on anger. Make a commitment to yourself (and your therapist or sponsor) that no matter
what happens, you will not act on your anger. Handout 4 is a Safety Contract you can fill out.
n Imagine how it would feel to control your anger. Picture how extraordinary it would be—freeing, truthful
at the deepest level, caring, in control. In the long run, it will feel like a new life. It is “intoxicating” in the best sense.
n Learn more about anger. This is one of the best ways to motivate yourself. Take a class on anger manage-
ment or assertiveness—local adult education programs and/or mental health clinics offer such courses. Or read a
book on it (two are listed in Handout 5). Learn when and how to express anger, and what to do if the other person
does not respond well. You can also ask others how they handle angry situations. Find out what is realistic to expect
from people and from yourself (often your anger derives from unrealistic expectations).

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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HANDOUT 3 (page 2 of 5) Healing from Anger

n Create an image to help you. A horse being reined in? A child being raised? An athlete in training? Really
picture the process that’s required to learn how to control your anger—the ups and downs.
n Carry an “anger reminder.” Carry a physical reminder of how destructive your anger can be—for example,
a photo of someone you’ve hurt with your anger, or a list of the hospitalizations you’ve had for suicidal behavior.
n Get rid of weapons until you are safe to keep them. Keeping weapons that can be used against oneself
or others is dangerous (e.g., guns, ropes). Until you can express anger in constructive ways without acting out, it is
essential to keep your environment as free as possible of weapons. They are disasters waiting to happen.

« On the back of the page, write out your motivation for working on anger. Make it clear, compelling, and realistic.
“Own your anger!”

DURING ANGER EPISODES . . . CONTAIN

Once destructive anger has begun, the only goal is to bring it back to the “safe zone”—aware of it, but keeping it
within a manageable level (no higher than a 5 on a 0–10 scale).
Why? Destructive anger can blind you. It makes you unable to get perspective or improve the situation. Only
once you are in control of anger can you put it to positive use. Thus, when you are feeling the impulse to act on an-
ger—to say something you’ll later regret, to hurt someone—the only priority is to regain safety. Do not try to explore
the anger, understand it, or express it (all that’s for later). Think of an “emergency response system” or “damage con-
trol.” For example, when there is a toxic industrial spill, the goal is to contain it, get people to safety, clear the area,
and only figure out why later on. Remember that controlling your anger does not mean your anger is wrong. Your
anger is a valid, important feeling that comes from somewhere important. But how it gets addressed—not hurting
yourself or others—is just as important. Each time you are able to contain your anger, you are building strength. It will
get easier over time!

How? « Check off any ideas below that might help you.

 Delay or “time out.” This is one of the most effective strategies. No matter what, force yourself to delay
any anger expression or action until you’re back in the safe zone. Delay for at least a half hour—it has been found
that it takes the body at least 20–30 minutes to return to normal once anger has been activated.
 Do soothing activities. These might be music, meditation, relaxation, sports, reading, TV, praying, ground-
ing, sex, or hobbies.
 Do activities that help you feel in control. These counteract the out-of-control feeling of destructive an-
ger. They include cleaning your room, writing a list of things to do, going shopping, searching the Web, or any other
productive activity that is not too stressful for you.
 Notice what you’re grateful for. Notice what you do have in life, and what others have done for you. For
example, think, “I have a job, a car, my health.” Or “I am lucky I have enough to eat every day.” Or “I am seeing im-
provements in my life, such as more days clean.”
 Apply the twelve steps of AA to your destructive anger. Give yourself up to your Higher Power for help.
Think of destructive anger as an addiction.
 Remember “clear thinking.” Clear thinking means saying statements to yourself that remind you to keep
perspective. See Understanding Anger (Handout 2).
 See the good in people. For anger toward others: Try to identify—right now—anything you can that is good
about the person you are angry at; if you can do this, notice whether your anger goes down a little. For anger to-
ward yourself: Try to identify anything that is good about you.

(cont.)

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HANDOUT 3 (page 3 of 5) Healing from Anger

 Ask for help. Try to identify someone you can call when you feel like hurting yourself or others. It may take
others’ help before you can stop yourself, once the feeling builds (just as with cravings for substances). If you have
no one to call, try using a hotline.
 If you are unaware of your anger, try to become conscious. Sometimes people physically hurt them-
selves but are not aware of any anger. It has gone “underground.” Your goal in such situations is to notice your an-
ger. This too is a form of containment— conscious anger is much safer than unconscious anger. Ways to do this in-
clude, Ask yourself, “Who am I angry with?” and “What am I afraid will happen if I express anger?”
 Remember the bottom line: It is not okay to act out anger. It is never okay to physically hurt someone
(unless you or others are in life-threatening danger). Never attack someone weaker than yourself (e.g., a child, an an-
imal, an elderly person). No matter what someone says or does to you, it is your responsibility to manage your anger.
Do not justify angry outbursts—they harm others and degrade you. And never leave a trail of anger, such as an angry
voice mail or an angry letter. Wait until you’re calmer to express your anger (see the next section, “Listen”).
 Remember your rights. You have a right to feel angry, but you do not have a right to abuse others or your-
self. You have a right to leave a relationship, but you do not have a right to stay and hurt someone. If you cannot ac-
cept the other person, consider detaching from the relationship.
 Stay humble. Much of what fuels anger is a feeling of righteousness. Notice that everyone, including you,
makes mistakes in life. Make a list of the mistakes you’ve made toward others, and read it the next time you feel like
blowing up at someone.

« On the back of the page, write out your plan for containing destructive anger. Make sure it fits who you are and
what most helps you.

AFTER ANGER EPISODES . . . LISTEN

The next major step in healing from anger is listening to it. This means respecting that your anger comes from some-
where important; it signifies a message that needs to be heard.
Why? Behind all anger are unmet needs. Hear the “whisper” behind the anger. If you try to push it away with-
out looking at it, it will keep coming back. Note that listening is meant broadly; it means both listening to yourself
and getting others to listen to you. The key step is for you to hear it clearly—if you can hear it, you can learn to ex-
press it clearly to others too. And if you can hear it clearly, you can then work to get your needs met in effective
ways.

How? « Check off any ideas below that might help you.

u Listen to the most vulnerable sides of yourself. Destructive anger is like a small child throwing a tan-
trum—a vulnerable child who feels scared, sad, alone, guilty or powerless, for example. Indeed, it is said that anger is
often a defense against feelings that are more painful. An essential task of recovery is to respect these feelings and
soothe yourself through them.
u Listen to your anger messages. Some typical messages that anger conveys include, “Others are not hear-
ing me,” “I have suffered too much,” “I want the world to be a better place,” “I don’t have enough support,” “I feel
hopeless,” “I feel like a failure,” “Other people have it easier.”
u Notice patterns. Does your anger occur when you feel hurt? When you are tired or hungry? When others
are incompetent? When you have been working too hard? When you feel rejected? When others place demands on
you? Some people keep an anger journal to better identify their patterns. For self-harm, too, it is important to notice
what triggers you.

(cont.)

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HANDOUT 3 (page 4 of 5) Healing from Anger

u Express your anger calmly. Be gentle, centered, caring. Get others to listen to your anger by expressing it
in appropriate ways. Always try to express anger face to face and really “see” the other person. Also, get help from
others before expressing it: Ask your therapist, friend, or sponsor how to express the anger. If you start to escalate
(yelling, anger above a 5 on a 0–10 scale), leave until you can come back and try again calmly
u Strive to get your needs met through your own efforts. Once you have heard your needs, you can take
care of them. If you are tired or hungry, get sleep or something to eat. If you feel disappointed that your partner doesn’t
want to spend more time with you, consider couple therapy or find other people to do more activities with. Remember
that ultimately you are responsible for your own happiness. There are always ways to improve your situation.
u Explore how anger relates to your PTSD and substance abuse. How did each of these contribute to
your anger?
u If you want to change others, use methods that work. Anger and criticism never change people in the
long run. People just feel afraid of you and avoid you. Methods that do work include negotiation, empathy, praise,
and teaching.
u Take good care of yourself. People who hurt others are typically not getting their needs met in healthy
ways. People who harm themselves typically put others’ needs before theirs too much. If you hear the needs behind
your anger you may notice, for example, “I need someone to listen to me,” “I need to say ‘no,’ ” “I need to take
more time for myself.”
u Change “shoulds” to “wants.” All anger has a “should” statement in it—for example, “My partner should do
what I ask.” A very helpful strategy is to change the “should” statement to a statement beginning with “I want”: “I want
my partner to do what I ask.” Do you notice your feelings shift when you do this? Usually it makes you aware of limita-
tions that are important to accept. Much anger is a way to gain control in situations where you do not have it.
u Create “win–win” solutions. Take into account both your needs and the other person’s. Take turns mak-
ing decisions. Take turns listening and speaking.
u Notice why you did what you did. Much anger (especially self-harm) comes from self-criticism. If you be-
come angry with yourself because of something you did or didn’t do, try to see why you made that choice. Being
compassionate allows you to take responsibility for your actions and move forward.
u Notice low-level anger. People who act out anger often have trouble expressing it as it builds up. They bot-
tle it up and then blow up, often triggered by some small event. Notice your anger in its low-level forms (e.g., annoy-
ance, irritation), and try to get your needs met then so it won’t build up.
u Protect yourself from angry influences. Observe how you are affected by violent movies, watching televi-
sion news, or being around angry people. There is often a connection between larger cultural forces and your anger.
But remember that anger is a habit that you can change.
u Notice how anger gets misdirected. Anger often gets directed at people who do not deserve it or who do
not deserve it so intensely. For example, perhaps you get very angry over some “small” thing—such as a clerk at a
store who gives you wrong information. You might say to yourself, “I’m furious, but it doesn’t make sense to be so
angry about this. I think I’m really angry, deep down, about feeling like no one ever helps me out. I need to start get-
ting more support, rather than blowing up at a store clerk.”
u Notice whose point of view is being neglected. If you are angry at others, try to listen to others’ point of
view more. If you are angry at yourself, try to listen to your point of view (or the various sides of yourself) more. The
goal is to hear both your own and others’ point of view at the same time.
u Apologize to people you’ve hurt with your anger. This does not fully take it away, but it may help. If
you can, try to explain the painful feelings that drive your anger.
u Recognize that you may need to mourn things you cannot change. Ultimately, after doing whatever
you can to get your needs met, there may be some that can never be fulfilled. Perhaps you have a medical illness that
will never go away. Perhaps you are too old to have a child or to have the career you want. Perhaps your partner can-
not be the person you want. With situations that you cannot change, you will need to mourn and accept them. This
is emotional work that you can and should do, but that may need a therapist’s help.
(cont.)

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HANDOUT 3 (page 5 of 5) Healing from Anger

« On the back of the page, write out your plan for listening to your anger. Use it as important knowledge that can
help you grow.

AN EXAMPLE OF THE THREE STEPS

Situation: Your boss gives a promotion to someone who deserves it less than you.
1. Motivate: You say to yourself that blowing up at your boss will not help anything. You need to keep your
job. Yelling at people has lost you jobs in the past.
2. Contain: You decide to wait at least 24 hours before going in to see your boss. During those 24 hours, you
try to stay calm and distract yourself with activities. You say to yourself, “No matter what, I am going to deal with
this in a constructive way.”
3. Listen: You recognize that all your life it has felt as though you get less than others. It is extremely painful to
be disappointed by your boss. But you recognize that your intense feelings are partly due to feeling neglected when
you were growing up. You remind yourself that in the working world politics often wins out, and you’re not the first
to have this happen to you. You decide to talk to your therapist to role-play how to discuss the issue with your boss.
After doing this, you go into your boss’s office. You say to your boss, “I’d like to understand better why the promo-
tion went to someone else rather than me. Please explain it to me.” Your boss gives you a vague answer and seems
uncomfortable. You realize that he’s not going to tell you the truth. You calmly leave the office. You say to yourself,
“I have two options: I can either stay in this job and recognize that there are some major limitations here. Or I can
apply for a new job. But either way, I did not blow up at anyone, and that is a major victory.”

ROLE PLAYS

« Rehearse how you can work on your anger constructively. If you want, try one of the role plays below:

• You have PTSD and you’re angry at feeling miserable so much of the time.
• You help out a “friend” who then won’t help you in return.
• Your partner keeps refusing to pay child support.
• Your insurance company cancels your policy by mistake, then gives you the “run-around.”
• Someone cuts you off in traffic.
• Someone betrays a confidence.
• Someone makes a nasty comment.
• You think about how much of your life you’ve lost due to your substance abuse and PTSD.
• You feel furious at yourself for using substances.
• You feel like killing yourself.
• There is a long line at the post office, and you have very little time to wait.
• You find out your partner is cheating on you.

Acknowledgments: Readings that were helpful in the development of this topic included Potter-Efron and Potter-Efron (1995) and McKay, Rogers,
and McKay (1989). The “Change ‘shoulds’ to ‘wants’ ” recommendation in Handout 3 is based on Burns (1980). Ask your therapist for guidance if
you would like to locate any of these sources.

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HANDOUT 4 Healing from Anger

Safety Contract: Protecting Yourself and Others

1. I am aware that I am in danger of hurting myself others both myself and others
2. I recognize that wanting to hurt myself and/or others is a common feeling in recovery from PTSD and sub-
stance abuse. I understand that this is not “bad” or “wrong,” but that it does need to be dealt with in healthier ways.
3. “Hurting myself” means all methods of harm. Circle those that apply: cutting, burning, suicidal action,
bingeing–purging on food, gambling, using a substance, driving too fast. Additional ones for me are:

4. “Hurting others” means any emotional or physical attack on others. Circle those that apply: physical attack
(hitting, punching, using a weapon against someone); emotional attack (yelling at someone, saying cruel words).
Additional ones for me are:

5. I recognize that hurting myself or others comes from emotional pain. There are real reasons for it, and I need
to listen to myself very closely to explore those. I’m aware of the following main issues behind my hurting myself
and/or others (circle those that apply): wanting people to see how upset I feel; wanting to be taken care of; feeling
hopeless; feeling like a failure. Additional ones for me are:
6. Whatever the reasons for my impulses, I still must learn to stay safe. I promise—to myself, to my recovery,
and to my therapist—that I will carry out the following:
a. Before hurting myself or others, I will attempt to reach out for help from

b. Before hurting myself or others, I will use the following safe coping skills:

c. If I hurt myself or others in any way, I will be fully honest with my therapist and talk about it at the next
possible opportunity (e.g., at my next session or by leaving a phone message).
d. If my life or serious physical harm is at risk, I will do whatever it takes to protect myself (e.g., going to an
emergency room). My specific plan will be:

7. This contract will remain in effect until I and my therapist agree to revise it.
8. Optional: if I violate this contract, the following will occur (circle any that apply):
a. I will agree to obtain more care (e.g., go into the hospital, sober house, join AA).
b. I will agree to get rid of my weapon (e.g., rope, knife).
c. I will agree to write about why I violated my contract and whom I have hurt.
d. I will agree to
9. Optional: I will give a copy of this contract to (circle any that apply): my partner, my doctor, my AA sponsor,
my

Patient signature: Therapist signature: Date:

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

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 Healing from Anger

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Write a script (or record a tape) of what you can say to yourself the next time you have the impulse
to hurt yourself or someone else. If you want, ask your therapist to add to it as well.

ª Option 2: Imagine that you are teaching a child how to express anger. What would you say?
ª Option 3: Take one of the following situations and rewrite it in a healthier way.
a. Jim tries hard to control his anger, but every few weeks he screams at his wife when she “screws up.” To-
day she forgets to pick up his prescription from the pharmacy. He gets enraged and yells at her.
b. Martha hates herself. Everyone seems smarter and more attractive than she is. Today her boyfriend tells
her he wants to break up. She goes home and cuts herself with a razor.
ª Option 4: Read a book about anger. For example, two recommended books on anger are When Anger
Hurts: Quieting the Storm Within (McKay et al., 1989) and Letting Go of Anger (Potter-Efron & Potter-Efron,
1995).

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

361
COMBINATION

The Life Choices Game (Review)

SUMMARY

The Life Choices Game is provided as an entertaining way to review the treatment.

ORIENTATION

Many different skills and concepts have been covered in the treatment. As part of the process
of termination, patients are invited to play a game as a way of reviewing the material. The
game is structured so that patients are presented with challenging life situations (e.g., “You
get laid off from your job”) and asked to respond with how they would cope, using game rules
that keep the focus on constructive coping. Guidelines are provided to help deepen the thera-
peutic process so that the game does not feel superficial or irrelevant to patients’ real con-
cerns.

Countertransference Issues
Although today’s game is designed to be fun, the process of termination is typically very diffi-
cult for patients. Staying attuned to their (and your) underlying feelings about ending is im-
portant, as well as expressing and empathizing with those feelings.

PREPARING FOR THE SESSION

♦ You will need only one copy of the Life Choices Game, but read the instructions to de-
cide how you will conduct the game (see “Session Content,” below). You may need scissors
and a small box or hat, depending on the method you choose.

362
The Life Choices Game (Review) 363

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2. Also, as termination is near, ask
patients if they have any feelings about treatment ending, and allow some opportunity for dis-
cussion. When reviewing community resources, continue to help patients develop a firm
aftercare plan.
2. Quotation (briefly). See page 367. Link the quotation to the session—for example,
“Today we’ll focus on reviewing material we’ve covered in this treatment. The quotation sug-
gests that in every situation, you can choose how to respond.”
3. Relate the topic to patients’ lives (in-depth, most of session). See the Therapist Sheet,
The Life Choices Game. Note that because of the game format, this session is conducted dif-
ferently from other sessions. See “Session Content,” below.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Remind patients of termination, and keep working on aftercare plans.
¨ Conduct the Life Choices Game as a way to review the concepts covered in the treat-
ment.

Ways to Relate the Material to Patients’ Lives

ê Play the Life Choices Game. Using the Therapist Sheet, read the game rules out loud.
Conduct the game using either of the following methods. The first is recommended for group
therapy and the second for individual therapy, but either is fine.
a. Drawing slips from a box. Cut the Life Choices Game into strips as indicated. Put
the strips into a container (e.g., box, hat), and place the container in the middle of
the table. Ask the first patient to draw a slip of paper from the box.
b. Pick a number. Ask the patient to randomly pick a number from 1 to 37; the thera-
pist can read that item out loud for the patient to answer.
For each situation, ask, “How could you cope best with this situation?” Patients will under-
stand the task quickly, but may need help to identify positive methods of coping. Guide them
to use the list of Safe Coping Skills (Handout 2 in the topic Safety) for ideas if needed.
ê Discussion
• “How would you cope with that situation if there was no one around to help you?”
• “How could you apply [grounding, asking for help, honesty . . . ] to that situation?”
364 Treatment Topics

Suggestions
✦ Hold patients to a high standard. Not all answers are “fine”; some may need more
elaboration, some may need constructive feedback, and some may not be realistic. Give pa-
tients accurate feedback after each response, and for group treatment, encourage other pa-
tients to offer feedback as well. Unless high standards are sought, the game can become triv-
ial. Push patients to the bounds of their knowledge so that something new can be learned.
✦ Create a dialogue with the patient to encourage deeper responses. For example, if the
patient says, “I would do grounding to cope with that situation,” you could say, “Good—can
you say aloud how you would do the grounding?” or “Good, but what would you do if you
tried grounding and it didn’t work?”
✦ The therapist can make up situations not on the sheet to customize it for patients.
✦ Note that there is no scoring for the game, although if you want, you could assign
points (e.g., 1 point for each solid coping strategy, ½ point for an attempt that does not go far
enough). In group therapy, you could have two teams and ask them to write as many positive
coping methods within 3 minutes as they can think of, giving a point for each valid method
(and then processing them aloud so that the game is not simplistic). If you are considering
scoring the game, be sure to ask patients first, and only do so if they agree. Some patients do
not like to be evaluated.

Tough Cases
∗ “I can’t remember any coping skills.”
∗ “I’d just use substances if that situation happened to me.”
∗ “I feel triggered reading the situation listed on this slip of paper.”
∗ “I hate games. They remind me of being an unhappy child.”
THERAPIST SHEET The Life Choices Game (Review)

The Life Choices Game

Read the rules of the game aloud to patients before the game begins.
Rules for the Life Choices Game

1. Just as life brings many different situations, this game will present random events for you to cope with.
2. Answer each situation with the best coping you can think of. Use any of the strategies you learned in this
treatment, or any others that you know.
3. Good coping means no use of substances, and all solutions are realistic and safe.
4. [Group treatment only:] Only one person selects a slip of paper at a time, so that we can all pay attention to
that person and give helpful feedback.
Let the game begin!

1. You are feeling numb. You say to yourself, “It doesn’t matter if I live or die.”
2. In the newspaper, you read an article that reminds you of your trauma. You feel enraged that so much suf-
fering occurs.
3. You are with your family, and your father puts you down in front of everyone.
4. The weekend is coming, and you have no plans. You think, “I’m a loser.”
5. You want to take Valium that wasn’t prescribed for you. You say to yourself, “This isn’t really substance
abuse.”
6. You wake up and think, “I don’t want to go to work. I’ll just lie in bed.”
7. You look in the mirror. You feel old and fat.
8. You just got an “A” on your exam. You think, “I want to celebrate. I’ll have a hit of coke.”
9. You are not eating well or exercising. How could you get yourself to do those?
10. There is a relationship that you know is bad for you, but you keep feeling drawn back in. How could you
stay away?
11. You are preparing a recipe that calls for red wine. You say to yourself, “I need to buy wine for the recipe.”
12. You are laid off from your job.
13. It is late at night. You are feeling lonely. You are thinking, “No one loves me.”
14. You see an ad for a course at the local college that you want to take, but you think, “I’ll never pass that
course. Everyone will be smarter than me.”
15. While in individual therapy, you remember a painful trauma. You feel very upset, but you don’t want to cry
because you think you would look “weak.”

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

365
THERAPIST SHEET (page 2 of 2) The Life Choices Game (Review)

16. You yell at your children more than you should. You feel guilty.
17. You have a habit of hiding in the closet when you feel upset. You don’t want to tell your therapist about
this, as you think it will sound crazy.
18. You have had a hard day. You say to yourself, “I need a drink.”
19. You used substances yesterday even after promising yourself, your family, and your therapist you wouldn’t.
You feel ashamed and disgusted with yourself.
20. You find out that your daughter is being sexually abused by your cousin.
21. You run into your ex-partner on the street who looked very happy with someone new. You think, “I’ll never
have a successful relationship.”
22. You try an AA meeting. You get there, look around the room, and think, “No one here can understand
what I’ve been through.”
23. Your mother is criticizing you again. You think, “I am sick of everyone. I need a drink.”
24. Your partner says, “Why can’t you get over your trauma? I want to live a normal life.”
25. You are at a work party and someone offers you a drink.
26. Your son says to you, “Why can’t you get off substances? That’s all I want.”
27. You go to a medical doctor who is very rude to you.
28. Your ex-partner violates the court’s custody agreement and won’t let you see your children.
29. You find out that your partner is having an affair.
30. You keep promising yourself that you’ll make an appointment for an annual physical exam, but you keep
putting it off, week after week.
31. Your parents say, “Why can’t you hold a job like regular people? If you just worked full-time, everything
would work out.”
32. You pick up someone at a bar who wants to have sex without a condom.
33. You pass by your dealer and think, “I’ll just have one.”
34. You feel triggered by a movie that reminds you of your trauma.
35. Someone cuts you off in traffic. You feel enraged.
36. Someone says a remark in front of you that is offensive to you (e.g., about your race, ethnicity, heritage, or
sexual preference).
37. Everyone you know gets invited to a party except you.

366
 Quotation

“Each of us is two selves, and the

great challenge of life is to try to
keep that higher self in command.”
—Martin Luther King, Jr.
(20th-century American leader)

From Seeking Safety by Lisa M. Najavits (2002).

367
 The Life Choices Game (Review)

Ideas for a Commitment

Commit to one action that will move your life forward!

It can be anything you feel will help you, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
ª Option 1: Make a plan to do something nice during the same time that you were coming to this treatment.
For example, if you were here Mondays at 6:00–7:00 P.M., find something to do on Mondays from 6:00–
7:00 P.M. Ideas: Treat yourself to something special during that time (no substances!), take a walk in a beauti-
ful part of town, or read an inspiring book.
ª Option 2: Write a letter describing thoughts and feelings you have about the treatment ending.
ª Option 3: Find a way to express how you have grown during this treatment. You could use writing, painting,
photography, poetry, crafts, or any other method you choose.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

368
COMBINATION

Termination

SUMMARY

The final topic encourages patients to express their feelings about the ending of treatment,
discuss what they liked and disliked about it, and finalize their aftercare plans.

ORIENTATION

In termination, the tone changes from an educational, structured format to a more quiet ret-
rospection. It provides patients the opportunity to say goodbye and to express how they feel.
For the therapist, it is also an important process; it is likely that you will hear some surprising
views about the impact of treatment and about what patients liked and disliked.
A termination letter is provided, which you may want to edit to fit your style. Such a
“transitional object” can make it easier for patients to move on as well as validate their con-
nection to you and the treatment. A treat such as cake and soda at the last session is also a way
to commemorate the treatment ending. Finally, consider offering a limited number of
“booster sessions”; this is a device used in CBT to promote reinforcement of gains and a
healthy transition. (See “Suggestions,” below, for ways to conduct booster sessions.)
Patients and therapists are also offered a Seeking Safety Feedback Questionnaire to rate
what they specifically liked and disliked about the treatment. This may be helpful to the ther-
apist conducting the treatment; if you want to send it, see the end of the questionnaire for in-
formation on this.

Countertransference Issues

There is sometimes a tendency for therapists to elicit only positive feedback during termina-
tion; yet exploring criticisms is just as important.

369
370 Treatment Topics

PREPARING FOR THE SESSION

♦ Optional: Bring in a cake or make some other “goodbye” gesture.

SESSION FORMAT

1. Check-in (up to 5 minutes per patient). See Chapter 2.

2. Quotation (briefly). See page 372. Link the quotation to the session—for example,
“Today we’ll focus on termination. I hope you will keep striving for the best that life has to
offer.”
3. Relate the topic to patients’ lives (in-depth, most of session).
a. Ask patients to look through the handouts, which can be used separately or to-
gether.
Handout 1: Termination (you can read the letter out loud or have patients read it to
themselves)
Handout 2: Seeking Safety Feedback Questionnaire (optional for both therapist
and patients)
b. Encourage open-ended discussion. See “Session Content” (below) and Chapter 2
for suggestions.
4. Check-out (briefly). See Chapter 2.

SESSION CONTENT
Goals
¨ Promote a discussion of feelings and thoughts about the treatment ending.
¨ Elicit views on what patients liked and disliked about the treatment.
¨ Read the Termination Letter (Handout 1).
¨ Ask patients to report their aftercare plans.
¨ Fill out the Seeking Safety Feedback Questionnaire (Handout 2), if desired.

Ways to Relate the Material to Patients’ Lives

ê Discussion
• “Do you have any feelings about the treatment ending?”
• “What did you like and dislike about the treatment?”
• “What will you most remember?”
• “How will it feel not to come back to sessions after this week?”
• “Did you get what you expected from the treatment?”
• “What were your favorite and least favorite topics?”
• “How will your life be different as a result of this treatment?”
Termination 371

• “What would you suggest I do differently next time?”

• “Was there anything harmful about the treatment?”
• “Do you think that your aftercare plan is sufficient?”

Suggestions
✦ Patients who are especially upset about termination either may not show up or may
express their distress indirectly, such as being silent or laughing a lot in the session. Allow pa-
tients to terminate in whatever way they need to, as long as it is safe.
✦ If few patients show up for the final session of a group therapy, try to normalize this.
For example, “Sometimes people have trouble saying ‘goodbye’—it is too painful, or they are
angry. Even with only a few of us today, we can enjoy our final session as planned.”
✦ To ease the transition, you may want to suggest that patients can write or leave mes-
sages for you in the future to let you know how they are doing.
✦ It can be very moving for patients to hear your views on the progress they have made.
Be specific and positive. For example, “John, I have been really impressed by your ability to
start a job during this treatment—I know how hard that was for you.”
✦ If a patient has insufficient aftercare, you may want to offer one final individual meet-
ing to explore options.
✦ If you are offering booster sessions, you can still conduct this termination session. In
the booster sessions, no new material is introduced, but patients can report how they are do-
ing, obtain additional referrals if needed, and review any material from the treatment they
might wish to. Boosters are typically offered on a low-dose schedule, such as four sessions
over 2 months, or two sessions over 2 months.

Tough Cases
∗ “Can we keep the treatment going for another month?”
∗ “I’d like to call you every week to check in.”
∗ “This treatment didn’t help me.”
∗ “I don’t have any aftercare set up.”
∗ “I get suicidal when treatment ends.”
∗ “I don’t like filling out questionnaires.”
 Quotation

“In the time of your life, live.”

—William Saroyan
(20th-century American playwright)

From Seeking Safety by Lisa M. Najavits (2002).

372
HANDOUT 1 Termination

Termination
Dear ,

A few last words before we end.

First, my enduring appreciation for what we have experienced together, for offer-
ing your wisdom and honesty, for trusting me with your feelings, and for staying in
treatment. You deserve great recognition for surviving thus far in your life and for
your persistence in recovery.

Second, I hope that you will continue to remember this treatment as you go for-
ward in your life: staying substance-free, healing from trauma (yes, both are possi-
ble!), attaining safety, trusting good people, reaching out, taking risks, attending
treatments that work for you, honoring yourself, striving for healthy coping day to
day, and using whatever aspects of this treatment you have found most helpful.

I wish you the best that life can offer.

Sincerely,

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

373
HANDOUT 2 Termination

Seeking Safety Feedback Questionnaire

Your honest feedback about the Seeking Safety treatment would be greatly appreciated, so that possible future revi-
sions of it can be as helpful as possible. Both patients and clinicians can fill out the first part of this question-
naire; the last part is for clinicians only. Return the form by mail, fax, or email (see information below), and an-
swer only the questions you choose to. Thank you!

How many sessions of Seeking Safety have you done?

For questions below, please use the following scale:

–3 –2 –1 0 +1 +2 +3
Greatly Somewhat A little Neutral A little Somewhat Greatly
harmful harmful harmful helpful helpful helpful

« How helpful is the treatment? «

How helpful is the treatment overall?
How helpful is the treatment for PTSD and substance abuse?
How helpful is the treatment for PTSD alone?
How helpful is the treatment for substance abuse alone?
« How helpful are each of the topics? «

Safety Commitment
PTSD: Taking Back Your Power Red and Green Flags
Detaching from Emotional Pain (Grounding) When Substances Control You
Asking for Help Community Resources
Compassion Recovery Thinking
Taking Good Care of Yourself Healthy Relationships
Setting Boundaries in Relationships Getting Others to Support Your Recovery
Honesty Healing from Anger
Discovery Self-Nurturing
Coping with Triggers Integrating the Split Self
Respecting Your Time The Life Choices Game (Review)
Creating Meaning Termination
« How helpful are the parts of the treatment? «
Safety as the priority of treatment
The integrated treatment (the focus on both PTSD and substance abuse)
The focus on abstinence from all substances
The focus on ideals (e.g., honesty, compassion)
The focus on learning coping skills
The focus on cognitive skills
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

374
HANDOUT 2 (page 2 of 4) Termination

The focus on behavioral skills

The focus on interpersonal skills
The focus on community resources
The use of quotations
The check-in/check-out (if there were any parts you didn’t like, write on back of page)
The patient handouts
The commitments (“homework”)
The list of Safe Coping Skills (e.g., “persistence”)
The Safe Coping Sheet (i.e., “old way ” vs. “new way”)
The Core Concepts of Treatment
The national resources outside this treatment
The length of treatment (25 topics)
The amount of written material provided
The structured approach (the organized plan for each session)
The empirical basis of the treatment (i.e., it has been scientifically evaluated)
Other: (add more on back of page if needed)

The next four questions are for clinicians only:

The therapist guide for each topic
The suggestions for further reading
The “Tough Cases” sections
The emphasis on therapy process (e.g., countertransference)

Please rate the next four questions 0% (not at all) to 100% (totally):

• How frequently will you use what you learned in this treatment in the future? %
• How easy to understand is this treatment? %
• How innovative (creative, different from other treatments) is this treatment? %
• To what extent would you recommend this treatment to someone else? %
• How long did it take you to feel comfortable with this treatment? (Please answer using a time
frame—e.g., 1 week, 6 months, etc.)
• Your age: Your gender: Female Male
• Have you experienced (clinicians, please answer this question too):
Trauma? No/Yes PTSD? No/Yes Substance abuse? No/Yes

In your own words (write answers on back of page):

• What do you consider the best/worst aspects of the treatment program?

• What modifications would you like to see made to the program? For example, should it be longer? Shorter?
Topics to add? Topics to delete?
• Are there particular types of people you feel the program is especially helpful/unhelpful for?
• Any other comments?

(cont.)

375
HANDOUT 2 (page 3 of 4) Termination

Thank you! Please return this survey in any of the following ways:
Mail: Lisa Najavits, McLean Hospital, 115 Mill St., Belmont, MA 02478
Fax: 617-855-3605

FOR CLINICIANS ONLY

Your professional background:

• Theoretical orientation (please fill in percentages to total 100%):

(Note: If you are eclectic, please identify the percentage of each orientation you use, or else fill in “no model” if
you do not follow any orientation.)
Cognitive-behavioral
Twelve-step
Psychodynamic/psychoanalytic
Systems
No model
Other:
Total (above should total 100%)

• Primary diagnoses of your patient population (please total to 100%):

Substance abuse
Trauma/PTSD
Mood disorders (e.g., depression, bipolar disorder)
Psychosis
Personality disorders
Other:
Total (above should total 100%)

• Your work setting (check all that apply):

Outpatient clinic Private practice Inpatient Detox Residential Prison VA
Other:

• Primary populations that you work with (check all that apply):
Geriatric Adults Adolescents Children
Males Females Veterans Prisoners Other:

• How many hours per week do you currently spend directly treating patients?
• Years experience: (only include years after training). If you are in training now, how many years of
training have you had thus far?
• Your professional training (check all that apply). (If you are currently in training, check off the training
program you are in.)
Social worker (MSW, LICSW) Certified alcohol/drug counselor (CAC)
Doctoral-level psychologist (PhD, PsyD, EdD) Master’s-level psychologist (MA/MS)
Psychiatrist (MD) Pastoral counselor AA (or other twelve-step) sponsor
No professional training Other:

• How many treatment manuals have you read?

(cont.)

376
HANDOUT 2 (page 4 of 4) Termination

Please answer each question below 0% (not at all) to 100% (totally):

• How much do you enjoy conducting clinical work? %

• How “burned out” do you feel by your clinical work? %
• How likely is it that you would choose a career as a clinician again? %
• How effective a clinician do you believe you are in general? %
• How would you rate your current ability to conduct this treatment? %
• How helpful would it be to have a videotape to accompany the manual, demonstrating actual in-session
techniques/procedures? %
• What kind of training or experience do you think is necessary for a clinician to successfully use this treatment
program? (Write on back of page)

377
 Termination

Idea for a Commitment

ª Practice, in your life: Staying substance-free, healing from trauma (yes, both are possible!), attaining safety,
trusting good people, reaching out, taking risks, attending treatments that work for you, honoring yourself,
striving for healthy coping day to day, and using whatever aspects of this treatment you have found most
helpful.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

378
 References

See references with asterisks for information on PTSD and substance abuse that may be es-
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Back, S. E., Dansky, B. S., Carroll, K. M., Foa, E. B., & Brady, K. T. (2001). Exposure therapy in the
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Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. New York:
Guilford Press.
*Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive Therapy of Substance
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*Bollerud, K. (1990). A model for the treatment of trauma-related syndromes among chemically de-
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Movies that convey the experiences of PTSD or substance abuse include:

Movies relevant to PTSD: Beloved (1998); Streetwise (1998); The Great Santini (1980);
This Boy’s Life (1993); Ponette (1996); The Celebration (1998)

Movies relevant to substance abuse: When a Man Loves a Woman (1994); Leaving Las
Vegas (1995); The Lost Weekend (1945); Trainspotting (1996); Clean and Sober (1988);
28 Days (2000)
 Index

Abstinence Boundaries
PTSD and, 1, 3–4 healthy, 272–273
in substance abuse treatment, 94–95 setting. See Setting Boundaries in Relationships topic
Accountability, 30–31
Addiction. See also Substance abuse Case management
community resources for, 255, 304 assessing patient needs for, 76–80
AIDS, community resources for, 256–257, 305–306 introduction to, 65–86
Alcoholics Anonymous, therapist familiarity with, 29. orientation in, 65–67
See also Twelve-step programs session content in, 67–68
Alliance building, 11 strategies for, 73–86
Alternative health care, assessing patient need for, 80 therapist checklist for, 86
Anger rationale for in treatment model, 10–11
constructive versus destructive, 346, 351–354 CBT. See Cognitive-behavioral therapy
healing from. See Healing from Anger topic Certificate of Achievement, 61
old-style management of, 346 Check-in, 33–35
Anxiety disorders, community resources for, 256, 305 format for, 55
Asking for Help topic, 164–173 limits on, 34–35
case study of, 169 therapist feedback in, 35
commitment ideas, 173 Check-In and Check-Out, 55
content of, 165–168 Checklist, before beginning treatment, 52
countertransference in, 165 Check-out
format for, 165 format for, 55
handouts for, 171–172 procedure for, 41–44
main points in, 171 Cognitive distortion, 9–10. See also Creating
orientation to, 164–165 Meaning topic
quotation for, 170 Cognitive-behavioral therapy
role-plays in, 166 characteristics of, 9
suggestions for therapist, 167–168 misconceptions about, 209
tough cases in, 168 versus Seeking Safety, 19
Autobiography, of substance abuse/PTSD, 17 in therapy model, 4–5

391
392 Index

Commitment topic, 231–239 Coping skills

commitment idea, 239 good, function of, 33
content of, 232–233 safe, 103–107
countertransference in, 232 therapist, 11
format for, 232 Coping with Triggers topic, 308–316
handouts for, 235–238 commitment ideas, 316
orientation to, 231–232 content of, 310–313
quotation for, 234 countertransference in, 309
tough cases in, 233 format for, 310
Commitment to Recovery, 59–60 handouts for, 314–315
Community Resources topic, 250–264 orientation to, 308–309
commitment ideas, 264 quotation for, 313
content of, 252–253 tough cases in, 312
countertransference in, 251 Core Concepts of Treatment, 56
format for, 251–252 Countertransference, 67, 96
handouts for, 255–263 Creating Meaning topic, 240–249
orientation to, 250–251 commitment ideas, 249
quotation for, 254 content of, 242–243
therapist preparation for, 251 countertransference in, 241
tough cases in, 253 format for, 241–242
Compassion topic, 182–188 handout for, 245–248
commitment ideas, 188 orientation to, 240–241
content of, 183–184 quotation for, 244
countertransference in, 183 tough cases in, 243
format for, 183 Cross-training, therapist, 4, 28
handouts for, 186–187
orientation to, 182–183 Detaching. See Grounding
quotation for, 185 Detaching from Emotional Pain (Grounding) topic,
therapist preparation for, 183 125–136
tough cases in, 184 commitment ideas, 136
Conducting sessions. See also specific treatment content of, 127–129
topics countertransference in, 126
check-in, 33–35 demonstration in, 130–131
check-out, 41–43 format for, 126–127
choosing problems, 37–38 handouts for, 133–135
community resources and, 43 orientation for, 125–126
handouts in, 36–37 quotation for, 132
mentioning dual diagnosis in, 40 therapist preparation for, 126
pages copied for, 53 tough cases in, 129
quotation for, 35 Detox, assessing patient needs for, 78
relating material to patient’s life, 37 Dialectical behavior therapy, versus Seeking Safety, 19–20
relating topic to patient’s life, 35–36 Discovery topic, 282–292
suggested exercises in, 38–39 commitment ideas, 291–292
trauma discussion during, 46–49 content of, 284–286
Confidentiality, limits to, 50–51 countertransference in, 283
Consultation, seeking out, 51 format for, 284
Consumer guidelines, 260–261 handouts for, 287–290
Control orientation to, 282–284
need for, 303 quotation for, 286
patient, 11 tough cases in, 285
Index 393

Dishonesty. See also Honesty topic Goal setting, 73

psychic cost of, 200 case management, 82–85
as self-protection, 202 patient, 17
Domestic violence Grounding
assessing potential for, 79 mental, 134
community resources for, 256 physical, 134
organizations helping with, 305 problems with, 135
substance abuse and, 2 soothing, 134–135
Dual diagnosis of PTSD and substance abuse Group therapy, trauma discussion in, 46–49
case history of, 21–22
downward spiral in, 2 Handouts
emphasizing during topic, 40 Asking for Help topic
integrated model of, 3, 6–8 Approach Sheet, 171
problem situations/emergencies in, 49–51 Asking for Help, 171
Seeking Safety approach to, versus other Commitment topic
treatments, 20–21 Action Plan, 238
stages of healing from, 101–102 Creative Solutions, 236
treatment dilemmas in, 3 Overcoming Emotional Blocks, 237
Responsibility and Promises, 235
Emergencies, management of, 49–51 Compassion topic
intoxication, handling, 50 Harshness versus Compassion, 186
suicidality, 50 Ways to Increase Compassion, 187
Emotional blocks, overcoming, 237 Community Resources topic
Emotional issues, detaching from. See Grounding Consumer Guidelines for Treatment, 260–
Empathy, therapist use of, 30 263
Empirical results of Seeking Safety, 17–19 National Resources, 255–259
End-of-Session Questionnaire, 60 Coping with Triggers topic
Exercises, conducting, 38–39 Coping with Triggers, 314–315
Exposure therapy, versus Seeking Safety, 20 Creating Meaning topic
Eye movement desensitization reprocessing, 14 Creating Meaning, 245–248
Detaching from Emotional Pain (Grounding)
Financial assistance, assessing patients’ need for, 79 topic
Format of treatment Using Grounding to Detach from Emotional
application of, 25 Pain, 133–135
length of, 24, 26–27 Discovery topic
list of, 57 Discovery Sheet, 290
order of, 23–24 Discovery versus Staying Stuck, 287
structure of, 25 How to Find Out If Your Belief Is True..., 288–
289
Getting Others to Support Your Recovery topic, 293– Getting Others to Support Your Recovery topic
307 A Letter to People in Your Life, 302–306
commitment ideas, 307 Three Types of People Who Can Influence Your
content of, 295–298 Recovery, 300–301
countertransference in, 294 Healing from Anger topic
format for, 294–295 Before, During, and After: Three Ways to Heal
handouts for, 300–306 Anger, 355–359
orientation to, 293–294 Exploring Anger, 351–352
quotation for, 299 Safety Contract: Protecting Yourself and Others,
therapist preparation for, 294 360
tough cases in, 298 Understanding Anger, 353–354
394 Index

Handouts (cont.) Taking Good Care of Yourself topic

Healthy Relationships topic Self-Care Questionnaire, 179–180
Changing Unhealthy Relationship Beliefs, 333– Termination topic
335 Seeking Safety Feedback Questionnaire, 374–
Healthy Relationships, 332 377
Honesty topic Termination, 373
Honesty, 205–206 When Substances Control You topic
Integrating the Split Self topic Choose a Way to Give Up Substances, 153–
The Split Self, 228–229 154
Introduction to Treatment/Case Management Climbing Mount Recovery, 155–156
topic How Substance Abuse Prevents Healing from
About the Seeking Safety Treatment, 88–90 PTSD, 152
How to Get the Most from This Treatment, 92 Mixed Feelings, 157
Practical Information about Your Treatment, 91 Self-Help Groups, 160
Seeking Safety Treatment Agreement, 93 Self-Understanding of Substance Use, 158–
PTSD: Taking Back Your Power topic 159
The Link between PTSD and Substance Abuse, Substance Abuse and PTSD: Common
119 Questions, 161–162
Long-Term PTSD Problems, 122–123 What Is Substance Abuse?, 151
Using Compassion to Take Back Your Power, Healing from Anger topic, 345–361
120–121 commitment ideas, 361
What Is PTSD?, 118 content of, 348–349
Recovery Thinking topic countertransference in, 347
About Rethinking, 220–221 format for, 348
Notice What You Say to Yourself!, 215–216 handouts for, 351–360
Rethinking Tools, 217–219 orientation to, 345–347
Red and Green Flags topic quotation for, 350
Create a Safety Plan, 196 tough cases in, 349
Key Points about Red and Green Flags, 197 Health care, consumer guidelines for, 260–261
Signs of Danger versus Safety, 194–195 Health problems, community resources for, 257–
Respecting Your Time topic 259
Are You Respecting Your Time?, 325–326 Healthy Relationships topic, 328–336
Respecting Your Time, 323–324 commitment ideas, 336
Safety topic content of, 329–330
Safe Coping Skills, 103–108 countertransference in, 329
Safety Is the Most Important Priority Right format for, 329
Now, 101–102 handouts for, 332–335
Self-Nurturing topic orientation to, 328–329
A Gift to Yourself, 343 quotation for, 331
Safe and Unsafe Self-Nurturing, 342 tough cases in, 330
Setting Boundaries in Relationships topic Help, asking for. See Asking for Help topic
Boundary Problems Associated with PTSD Hepatitis shots, for staff, 51
and Substance Abuse, 280 HIV, community resources for, 256, 305
Getting Out of Abusive Relationships, 278– HIV testing
279 assessing patient needs for, 77
Healthy Boundaries, 272–273 encouraging, 45
Too Much Closeness: Learning to Say “No” Honesty topic, 199–207
in Relationships, 274–275 commitment ideas, 207
Too Much Distance: Learning to Say “Yes” content of, 202–203
in Relationships, 276–277 countertransference in, 201
Index 395

format for, 201 Nutrition, community resources for, 257

handouts for, 205–206
orientation to, 199–201 Overview of treatment, 1–22
quotation for, 204 Orientation, 65–67
therapist preparation for, 201
tough cases in, 203 Parenting, community resources for, 257, 306
Housing, assessing patient needs for, 76 Parenting skills, assessing patient needs for, 78
Human immunodeficiency virus (HIV). See HIV Pathology, reframing of, 16–17
Patient
Ideals, focus on, 8–9 assessing needs of, 73
Integrating the Split Self topic, 223–239 case management needs of, 76–80
commitment ideas, 230 continued substance abuse by, 49
content of, 225–229 control by, 11, 31
countertransference in, 224 empowerment of, 120
format for, 225 establishing boundaries of, 46
handouts for, 228–229 getting to know, 70
orientation to, 223–224 goal setting by, 17
quotation for, 227 identifying of good coping by, 33
tough cases in, 226 intoxicated, 51
Integration, goal of, 229 protection of, 32
removing from treatment, 49
Leisure time, assessing patient needs for, 79 and return to treatment, 49
Life Choices Game topic, 362–368 suitability for Seeking Safety, 25–26
commitment ideas, 368 treatment stages of, 95
content of, 363–364 validation of, 30–32, 69
countertransference in, 362 Perpetrators, substance abuse in, 2
format for, 363 Posttraumatic stress disorder. See PTSD
orientation to, 362 Power, taking back, 120
quotation for, 367 Praise, therapist use of, 30–31
therapist preparation for, 362 Problems. See also Emergencies, management
tough cases in, 364 of approach to, 38–39
List of Treatment Topics, 57 patient selection of, 37–38
Promises. See also Commitment topic
Materials for all sessions, 52–53 keeping, 235
Meaning Psychodynamic therapy, in treatment model, 14–1
Creating. See Creating Meaning topic 5
harmful versus healing, 240–241, 245–248 Psychotherapy
Medical care, assessing patient needs for, 78 assessing patient needs for, 76
Medical problems, community resources for, 257–259 evaluating, 261–263
Medications, psychiatric, assessing patient needs for, PTSD
76 anger and, 345–346, 352. See also Healing from
Mental health Anger topic
community resources for, 256 boundary problems associated with, 269–270,
organizations helping with, 305 280
Motivational enhancement therapy, versus Seeking community resources for, 256
Safety, 20 definition of, 110–111
Mourning, 14 link with substance abuse, 114
patient stage of, 95 long-term problems with, 115–116, 122–123
in PTSD and substance abuse treatment, 94 and loss of ideals, 8
therapist stage of, 96 organizations helping with, 305
396 Index

PTSD (cont.) Recovery

patient information on, 113–114 community resources for, 304–306
safety needs and, 94 signs of, 102
substance abuse and. See also Dual diagnosis Recovery Thinking topic, 208–222
patient’s perspective on, 1–2 commitment ideas, 222
therapist’s perspective on, 3–4 content of, 211–214
types of, 118 countertransference in, 209–210
PTSD/substance abuse format for, 210–211
other treatments for, 19–21 handouts for, 215–221
patients’ view of, 1–2, 21–22 orientation to, 208–210
relationship between, 4 quotation for, 214
therapists’ view of, 3–4 tough cases in, 213
PTSD: Taking Back Your Power topic, 110–124 Red and Green Flag topic, 189–198
commitment ideas, 124 commitment ideas, 198
content of, 113 content of, 191–192
countertransference in, 111–112 countertransference in, 190
format for, 112 format for, 190–191
handouts for, 113–123 handouts for, 194–197
orientation to, 110–112 key points in, 197
quotation for, 117 orientation to, 189–190
therapist preparation for, 112 quotation for, 193
tough cases in, 116 therapist preparation for, 190
tough cases in, 192
Quotations, 87 Rehearsals, out-loud, 167
Audre Lorde, 204 Relationships
Baruch Spinoza, 150 abusive, 268–269, 278–279
Buddha, 185 beliefs about, 333–335
Charles Dickens, 350 community resources for, 257
Ellen Glasgow, 286 healthy. See Healthy Relationships topic
Erica Jong, 170 organizations helping with, 306
Frank Outlaw, 244 saying no in, 274–275
function of, 35 saying yes in, 276–277
George Eliot, 87 setting boundaries in. See Setting Boundaries
Helen Keller, 100 in Relationships topic
Henry David Thoreau, 299 Re-parenting, encouraging, 339
introduction of, 67 Resource book, developing, 73
Janis Joplin, 178 Respecting Your Time topic, 317–327
Jean Shinoda Bolen, 331 commitment ideas, 327
Jesse Jackson, 117 content of, 319–322
Martin Luther King, Jr., 367 countertransference in, 318
Mohandas K. Gandhi, 322 format for, 318–319
Molly Goode, 271 handouts for, 323–326
Portia Nelson, 193 orientation to, 317–318
Rainer Maria Rilke, 132, 227 quotation for, 322
Ralph Waldo Emerson, 313 therapist preparation for, 318
Theodore Roosevelt, 254 tough cases in, 321
Wallace Stevens, 341 Responsibility. See also Commitment topic
Watty Piper, 214 handout on, 235
William Saroyan, 372 Rethinking. See also Recovery Thinking topic
Winston Churchill, 234 characteristics of, 220–221
Index 397

pitfalls with, 210 practical solutions in, 12–13

tools for, 212–213, 217–219 principles of, 5–12
Role models, identifying, 39 process for, 29–32
Role plays, 39 reframing pathology in, 16–17
in Asking for Help topic, 166 research on, 17–19
research strategies in, 12
Safe Coping Sheet, 58 for specific populations, 27–28
guidelines for, 40–41 strategies in, 23–62
Safety structure of, 25
in first-stage treatment, 5–6 substance abuse focus in, 14
staff, 51 therapist checklist for, 52
Safety contract, in Healing from Anger topic, 360 therapist preparation for, 28–29
Safety plan, creating, 196 therapist processes in, 11–12
Safety topic, 94–109 treatment topics for, 57
commitment ideas, 109 Self-Nurturing topic, 337–344
content of, 97–98 commitment ideas, 344
countertransference in, 96 content of, 339–341
format for, 97 countertransference in, 338
handouts for, 98–99, 101–108 format for, 338–339
orientation to, 94–96 handouts for, 342–343
quotation for, 100 orientation to, 337–338
therapist preparation for, 97 quotation for, 341
tough cases in, 99 tough cases in, 340
Secrecy, need for, 303 Setting Boundaries in Relationships topic, 265–281
Seeking Safety commitment ideas, 281
accessibility of, 13 content of, 267–270
adaptation of, 26–28 countertransference in, 266
attention to language in, 12 format for, 267
case management component of, 10–11 handouts for, 272–280
content areas of, 9–11 orientation to, 265–267
core concepts of, 5–14 quotation for, 271
development of, 15–17 tough cases in, 270
duration of sessions, 24 Sexually transmitted diseases (STDs), community
empirical results of, 17–19 resources for, 256–257, 305
versus existing treatments, 19–21 Significant others, support from, 10
focus on potential in, 12 Skills
format for, 23–26, 54 safe coping, 103–107
guidelines for, 44–49 teaching, 38–39
handouts for explaining, 88–93 Split self, integrating. See Integrating the Split Self
homework in, 17 topic
ideals in, 8–9 Substance abuse
integrated approach in, 6–8 anger and, 345–346, 352. See also Healing from
integration with other treatments, 24 Anger topic
language in, 12 boundary problems associated with, 269–270, 280
length of, 24, 26–27 community resources for, 255, 304
materials for, 52–53 and loss of ideals, 8
omissions in, 14–15 priority of, 14
order of topics in, 23–24 PTSD and, 119. See also Dual diagnosis
patient control and validation in, 30–32 patient’s perspective on, 1–2
patient suitability for, 25–26 therapist’s perspective on, 3–4
398 Index

Substance abuse (cont.) Therapist Assessment of Patient’s Case

safety needs and, 94 Management Needs (in the topic Introduction
types of, 2 to Treatment/Case Management), 76–81
Suicide risk, assessing, 79 Therapist Checklist for Case Management (in the
Support network, involving, 39 topic Introduction to Treatment/Case
Management), 73
Taking Good Care of Yourself topic, 174–181 Time, scheduling. See Respecting Your Time topic
commitment ideas, 181 Trauma
content of, 176 assessment of, 48–49
countertransference in, 175 community resources for, 256
format for, 175 organizations helping with, 305
handout for, 179–180 past
orientation to, 174–175 patient discussion of, 46–49
questionnaire for, 179–180 in treatment model, 14
quotation for, 178 in substance abuse clients, 3
tough cases in, 177 Treatment model. See Seeking Safety
Termination topic, 369–378 Treatment outcomes, 17–19
commitment ideas, 378 Treatment topics
content of, 370–371 Asking for Help, 164–173
countertransference in, 369 Commitment, 231–239
format for, 370 Compassion, 182–188
handouts for, 373–377 Community Resources, 250–264
orientation to, 369 Coping with Triggers, 308–316
quotation for, 372 Creating Meaning, 240–249
therapist preparation for, 370 Detaching from Emotional Pain (Grounding), 125–
tough cases in, 371 136
Therapist Discovery, 282–292
and countertransference issues, 96 Getting Others to Support Your Recovery, 293–307
cross-training of, 4 Healing from Anger, 345–361
difficulties of, 32 Healthy Relationships, 328–336
establishing boundaries for, 44 Honesty, 199–207
issues of, 74–75 Integrating the Split Self, 223–230
preferences of, 11–12 Introduction to Treatment/Case Management, 65–
preparation of, 28–29 93
processes of, 11–12 Life Choices Game (Review), The, 362–368
setting boundaries for, 69–70 PTSD: Taking Back Your Power, 110–124
suggestions for, 69–71 Recovery Thinking, 208–222
support for, 29, 50 Red and Green Flags, 189–198
Therapist Sheets Respecting Your Time, 317–327
Case Management Goal Sheet (in the topic Safety, 94–109
Introduction to Treatment/Case Management), Self-Nurturing, 337–344
82–85 Setting Boundaries in Relationships, 265–281
Life Choices Game, The (in the topic The Life Taking Good Care of Yourself, 174–181
Choices Game [Review]), 365–366 Termination, 369–378
Making It Happen: Management Strategies (in the When Substances Control You, 137–163
topic Introduction to Treatment/Case Triggers
Management), 73 coping with. See Coping with Triggers topic
Script for a 10-Minute In-Session Grounding definitions and examples, 314
Demonstration (in the topic Detaching from Twelve-step programs
Emotional Pain [Grounding]), 130–131 versus Seeking Safety, 20
Session Format (Chapter 2), 54 therapist familiarity with, 29
Index 399

Urinalysis, obtaining, 44–45 format for, 141

Walk-throughs, 39
When Substances Control You topic, 137–173
choosing healing method in, 143–144, 153–154
Climbing Mount Recovery exercise in, 145–146,
155–156
commitment ideas, 163
common questions in, 148–149, 161–162
content of, 141–149
countertransference in, 139–140
definitions in, 141–142, 151
handouts for, 151–162
mixed feelings and, 146, 157
orientation to, 137–139
and prevention of healing from PTSD, 142–143,
152
quotation for, 150
self-help groups and, 147–148, 160
self-understanding in, 146–147, 158–159
therapist preparation for, 140
tough cases in, 149
Women’s health, community resources for, 259
 About the Author


Lisa M. Najavits, PhD, is Adjunct Professor at the University of Massachusetts Medical

School and previously was on faculty at Harvard Medical School for 25 years and Boston Uni-
versity School of Medicine and the Veterans Affairs Boston Healthcare System for 12 years.
She is author of over 180 publications, including books for both professionals and general
readers. She is Director of Treatment Innovations, which conducts research and training re-
lated to mental health and addiction. Dr. Najavits serves on the boards of numerous journals,
including the Journal of Traumatic Stress, Journal of Gambling Studies, Journal of Dual Diag-
nosis, and Psychological Trauma, and has received awards including the Betty Ford Award
from the Association for Medical Education and Research in Substance Abuse, the Emerging
Leadership Award from the Committee on Women in Psychology of the American Psycholog-
ical Association, the Early Career Contribution Award from the Society for Psychotherapy
Research, and the Young Professional Award from the International Society for Traumatic
Stress Studies. She also served as president of the Society of Addiction Psychology of the
American Psychological Association. Her major clinical and research interests include addic-
tion, trauma, co-occurring disorders, community-based care, veterans’ mental health, devel-
opment of new counseling models, and clinical trials research. She has a private psychother-
apy practice in Massachusetts. Her website is www.treatment-innovations.org.

401