James Fitzgerald Therapy, PLLC

Seeking Safety (Lisa M. Najavits)



Introduction & Overview of the Program



The program 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 disorder (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.

Every session of Seeking Safety is structured with a check-in, an inspiring quotation, discussion, and check-out. The goal is to use time well to help you get the most from each session. Seeking Safety focuses on the present. This means you will not be asked to reveal upsetting stories of trauma or addiction. We focus on what you can do right now to create a better life for yourself.

It is relevant to all types of trauma and/or addiction. For example, you may have survived traumas such as child abuse, combat, natural disasters, accidents, or violence. You may have addiction to substances, gambling, food, or other behavior. If you have both trauma and addiction issues, we address the link between the two—how common it is for the two to go together.

Seeking Safety has been successfully used for over 20 years across genders and with people struggling with many different life issues including HIV/AIDS, homelessness, serious mental illness, and incarceration. It can be used for group or individual counseling and can also be delivered by peers.

Anyone can join Seeking Safety. You can get a lot from participating, especially if you are open to new coping skills to improve your life.

Seeking Safety works Seeking Safety is the most popular and scientifically studied counseling model for trauma and addiction. Research shows that it works for both trauma and addiction issues, is cost-effective, and very safe.

Seeking Safety is culturally sensitive Seeking Safety has been implemented with diverse cultural and ethnic groups, who have consistently expressed strong satisfaction with it. It has also been translated into over 12 languages. Seeking Safety emphasizes adaptation to each person’s needs.



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.



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 somewhere 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.



This treatment is based on 5 central ideas:

  1. Safety as the priority of this first stage treatment
  2. Integrated treatment of PTSD and substance use disorder
  3. A focus on ideals
  4. Four content areas: cognitive, behavioral, interpersonal, and case management
  5. Atention to therapist processes

These five principles are described in more detail here: Principles of Seeking Safety



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. See the complete list with short descriptions here: Seeking Safety Topics

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 psychotherapywas 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.



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 supplied a written sheet that summarizes the main points of the topic.
  3. Lesson. You will be asked to read the lesson (on the website) before the next session.
  4. Discussion/practice. Most of the session will be spent reviewing, discussing, and processing 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. Several topics 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.
  5. 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.



Yes, but the aim will be to talk about the impact of your trauma on your life today. Sometimes we want to talk a lot about the past, but then we are unable to regulate the overwhelming emotions and memories that come up. The goal of this program is to help you establish safety and connection first and to learn techniques and strategies to regulate those intense overwhelming emotions. Once you have mastered 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 participate in individual therapy at the same time so that you will have a place to talk about the past if you want to.



The treatment was developed by Lisa Najavits, PhD. She is Professor of Psychiatry, Boston University School of Medicine; 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 Psychological 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 therapy, a licensed psychologist in Massachusetts, a psychotherapy supervisor, and she conducts a psychotherapy practice.

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, development of new psychotherapies, and evaluation and outcome research.



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.


A Brief Description of the 25 Seeking Safety Treatment Topics

Citation: Downloaded from www.seekingsafety.org. Excerpt from: Najavits, L.M. (2002). Seeking Safety: A New Psychotherapy for Posttraumatic Stress Disorder and Substance Abuse. In Trauma and Substance Abuse: Causes, Consequences and Treatment of Comorbid Disorders (Eds. P. Ouimette & P. Brown). Washington, DC: American Psychological Association.

Domains (cognitive, behavioral, interpersonal, or a combination) are listed in parentheses.

(1) Introduction to treatment / Case management
This topic covers: (a) Introduction to the treatment; (b) Getting to know the patient; and (c) Assessment of case management needs.

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

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

(4) Detaching from Emotional Pain: Grounding (behavioral)
A powerful strategy, “grounding”, is offered to help patients detach from emotional pain. Three types of grounding are presented (mental, physical, and soothing), with an experiential exercise to demonstrate the techniques. The goal is to shift attention toward the external world, away from negative feelings.

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

(6) Asking for Help (interpersonal)
Both PTSD and substance abuse lead to problems in asking for help. This topic encourages patients to become aware of their need for help and provides guidance on how to obtain it.

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

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

(9) Red and Green Flags (behavioral)
Patients are guided to explore the up-and-down nature of recovery in both PTSD and substance abuse through discussion of “red and green flags” (signs of danger and safety). A Safety Plan is developed to identify what to do in situations of mild, moderate, and severe relapse danger.

(10) Honesty (interpersonal)
Patients are encouraged to explore the role of honesty in recovery and to role-play specific situations. Related issues include: What is the cost of dishonesty? When is it safe to be honest? What if the other person doesn’t accept honesty?

(11) Recovery Thinking (cognitive)
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 rethinking is demonstrated through think-aloud and rethinking exercises.

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

(13) Commitment (behavioral)
Making and keeping promises, both to self and others, are explored. Creative strategies for keeping commitments, and feelings that can get in the way, are described.

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

(15) Community Resources (interpersonal)
A lengthy list of national non-profit resources is offered to aid patients’ recovery (including advocacy organizations, self-help, and newsletters). Also, guidelines are offered to help patients take a consumer approach in evaluating treatments.

(16) Setting Boundaries in Relationships (interpersonal)
Boundary problems are described as either too much closeness (difficulty saying “no” in relationships) or too much distance (difficulty saying “yes” in relationships). Ways to set healthy boundaries are explored, and domestic violence information is provided.

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

(18) Getting Others to Support Your Recovery (interpersonal)
Patients are encouraged to identify which people in their lives are supportive, neutral, or destructive toward their recovery. Suggestions for eliciting support are provided, as well as a letter they can give to others to promote understanding of their PTSD and substance abuse. A safe family member or friend can be invited to attend the session.

(19) Coping with Triggers (behavioral)
Patients are encouraged to actively fight triggers of PTSD and substance abuse. A simple three-step model is offered: change who you are with, what you are doing, and where you are (similar to “change people, places, and things” in AA).

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

(21) Healthy Relationships (interpersonal)
Healthy and unhealthy relationship beliefs are contrasted. For example, the unhealthy belief “Bad relationships are all I can get” is contrasted with the healthy belief “Creating good relationships is a skill to learn.“ Patients are guided to notice how PTSD and substance abuse can lead to unhealthy relationships.

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

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

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

(25) Termination
Patients express their feelings about the ending of treatment, discuss what they liked and disliked about it, and finalize aftercare plans. An optional Termination Letter can be read aloud to patients as a way to validate the work they have done.