1
2015 lLisa Najavits, PhD / Treatment lnnovations
PTSD
DSM-V definition: After a trauma (the experience, threat, or witnessing of physical harm, e.9., rape,
hurricane), the person has each of the following key symptoms for over a month, and they result in decreased
ability to function (e.9., work, social life): intrusion (e.9., flashbacks, nightmares); avoidance (not wanting to talk
about it or remember); neqative thouqhts and mood; and arousal (e.9., insomnia, anger).
Simple PTSD results from a sin gle event in adulthood (DSM-V symptoms); Complex PTSD is not a DSM
term but may result from multiple traumas, typically in childhood (broad symptoms, including personality
problems)
Rates: lOVo tor women, 5o/o for men (lifetime, U.S.). Up to 1/3 of people exposed to trauma develop
PTSD.
Treatment: if untreated , PTSD can last for decades; if treated, people can recover. Evidence-based
treatments include coqnitive-behavioral- coping skills training and exposure, i.e., processing the trauma story.
Substance Abuse
"The compulsion to use despite negative consequences" (e.9., legal, physical, social, psychological). Note
that neither amount of use nor physical dependence define substance abuse.
DSM-V term is "substance-related and addictive disorder", which can be mild, moderate, or severe.
Rates: 35% for men; 1 8o/o tor women (lifetime, U.S.)
It is treatable disorder and a "no-fault" disorder (i.e., not a moralweakness)
Two ways to oive it up: "cold turkey" (give up all substances forever; abstinence model) or "warm turkey"
(harm reduction, in which any reduction in use is a positive step); moderation managemenf, some people can
use in a controlled fashion- but only those not dependent on substances, and without co-occurring disorders).
The Link Between PTSD and Substance Abuse
About PTSD and substance abuse
Rates: Of clients in substance abuse treatment, 12o/o-34o/o have current PTSD. For women, rates are
33Yo-59o/o.
Gender. For women, typically a history of sexual or physical childhOod trauma; for men, combat or crime
Drug choice: No one drug of choice, but PTSD is associated with severe drugs (cocaine, opioids); in 213 of
cases the PTSD occurs first, then substance abuse.
Treatment issues
Other life problems are common: other Axis I disorders , personality disorders, interpersonal and medical
problems, inpatient admissions, low compliance with aftercare, homelessness, domestic violence.
PTSD does not qo awav with abstinence from substances; and, PTSD symptoms are widely reported to
become worse with initial abstinence.
Splits in treatm ent svstems (mental health versus substance abuse)
Fraqile treatment alliances and multiple crises are common.
Treatments helpful for either disorder alone may be problematic if someone has both disorders (e^9.,
emotionally intense exposure therapies, benzodiazepines), and should be evaluated carefully prior to use.
Recommended treatment strateg ies
Treat both disorders at the same time. Research supports this and clients prefer this.
Decide how to treat PTSD in context of active substance abuse. Options: (1) Focus on present onlv
(coping skills, psychoeducation, educate about symptoms) [safest approach, widely recommended]. (2) Focus
on past onlv (tell the trauma story) [high risk; works for some clients] (3) Focus on both present and past
Diversity lssues
ln the US, rates of PTSD do not differ by race (Kessler et al., 1995). Substance abuse: Hispanics and
African-Americans have lower rates than Caucasians; Native Americans have higher rates than Caucasians
(Kessler et al., 1995, 2005). Rates of abuse increase with acculturation. Some cultures have protective
factors (religion, kinship).
It is important to respect cultural differences and tailor treatment to be sensitive to historical prejudice. Also,
terms such as "trauma,"'PTSD," and "substance abuse" may be interpreted differently based on culture.
2
Seeking Safety
About Seeking Safety
*
*
A present-focused model to help clients (male and female) attain safetv from PTSD and substance abuse.
25 topics that can be conducted in anv order:
o lnterpersonal topics: Honesty, Asking for Help, Setting Boundaries in Relationships, Getting Others
to Support Your Recovery, Healthy Relationships, Community Resources
Coqnitive topics: PTSD: Taking Back Your Power, Compassion, When Substances Control You,
Creating Meaning, Discovery, lntegrating the Split Self, Recovery Thinking
o Behavioral topics: Taking Good Care of Yourself, Commitment, Respecting Your Time, Coping with
Triggers, Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding)
o Other topics: lntroduction/Case Management, Safety, Life Choices, Termination
Desiqned for flexible use: can be conducted in group or individual format; for women, men, or mixedgender; using all topics or fewer topics; in a variety of settings; and with a variety of providers.
¡
*
Key principles of Seeking Safety
cø Safetv as the goal for first-stage treatment (later stages are mourning and reconnection)
<ø lnteqrated treatment (treat both disorders at the same time)
cß Afocus on ideals to counteract the loss of ideals in both PTSD and substance abuse
<ø Four content areas: cognitive, behavioral, interpersonal, case management
cø Attention to clinician processes: balance praise and accountability; notice your own emotional
responses (fear, wish to control, joy in the work, disappointment); all-out effort; self-care
Additional features
x Trauma details not part of qroup therapy; in individual therapy, assess client's safety and monitor
carefully (particularly if has history of severe trauma, or if client is actively using substances)
* ldentifv meaninqs of substance use in context of PTSD (to remember, to forget, to numb, to feel, etc.)
* Optimistic: focus on strengths and future
x Help clients obtain more treatment and attend to daily life problems (housing, AIDS, jobs)
* Harm reduction model or abstinence
* 12-step qroups encouraqed. not required
* Empower clients whenever possible
* Make the treatment engaginq: quotations, everyday language
* Emphasize core concepts (e.9., "YorJ can get better")
Evidence Base
Seeking Safety is an evidence-based model, with over 20 studies and consistently positive results. For all
studies, go to www.seekinqsafety.org, section Evidence. Studies include pilots, randomized controlled trials,
multi-site trials.
Resources on Seekrng Safety. All below are available from www.seekingsafetv.org and/or from the order
form at the end of this packet of handouts.
* lmplementation / research articles: all articles related to Seeking Safety can be freely downloaded.
* Training: training calendar and information on setting up a training (section Training).
* Consultation: on clinical implementation, research studies, evaluation projects.
* Fidelity Scale: free download (section Assessment).
* Book: Seeking Safety: A Treatment Manualfor PTSD and Substance Abuse. Has the clinician guide and
all client handouts. Also available in Spanish, French, German, Swedish, Dutch, Polish, Chinese,
Vietnamese, Portuguese. By late 2015, Japanese and Greek will also be available.
+ DVD training series: four videos provide training on Seeking Safety. (1) Seeking Safety (two hour
training video by Lisa Najavits); (2) Asking for Help (one-hour demonstration of a group session with real
clients); (3) A Clienf's Sfory (26 minute unscripted life story by a male trauma survivor) and Teaching
Grounding (16 minute example of the grounding script from Seeking Safety with a male client): (4) Adherence
Session (one hour session that can be rated with the Seeking Safety Adherence Scale).
3
*
*
*
Online learning
Teaching Guide to lntroduce Seeking Safety to your agency
Poster: poster of over 80 safe coping skills, full-color, scenic background; large format (24 x 3O") or 1-page
format (in English or Spanish).
* Gard deck: all of the safe coping skills and quotations on cards, with ideas for games. English or Spanish.
* Magnets, key chain to remind clients of the skills.
Gontact lnformation
Contact: Lisa Najavits, PhD, Treatment lnnovations, 28 Westbourne Road, Newton Centre, MA02478;617299-1610 [phone]; [email protected] [email]; www.seekinosafetv.orq or www. www.treatmenþ
innovations.org [web]
Would you like to be added to the Seeking Safetv website to list that you conduct Seekino Safety? If so, please
email [email protected] your basic information OR fill out the online entry on the website. Example:
Boston, MA: Karen Smith, LICSW; group and individual Seeking Safety; private practice with sliding scale.
6 1 7-300-1 234. Karensm ith@netzero. com.
Resources on Substance Abuse and Trauma
a) Substance abuse
National Clearinqhouse for Alcohol and Druq lnformation
National Drug lnformation, Treatment & Referral Hotline
Alcoholics Anonvmous
SMART Recovery (alternative to AA)
Addiction Technoloqv Transfer Centers
Harm Reduction Coalition
b) Trauma / PTSD
lnternational Society for Traumatic Stress Studies
lnternational Society for the Study of Dissociation
National Centers for PTSD (extensive literature on PTSD)
National Child Traumatic Stress Network
National Center for Trauma-lnformed Care
National Resource Center on Domestic Violence
Department of Veterans Affairs
EM DR I nternational Association
Communitv screening for PTSD and other disorders
Sidran Foundation (trauma information, support)
800-729-6686 ; www. health. ors
800-662-H ELP, http://csat.samsha.qov
800-637-6237 ; wr¡vw. aa. org
www.smartrecovery.org
www.nattc.orq
21 2-21 3-6376 ; www. harmreduction. org
708-480-9028; www. istss. orq
847 -480-9282 ; www. issd. org
802-296-5 1 32; www. ptsd.va. gov
31 0-235-2633; www. nctsn. org
866-254-481 9 ; m ental health. sam hsa. g ov/ncti c
800-537 -2238; www. n rcdv. org
800-827 -1000; www. ptsd.va. gov
866-45 1 -5200; www.emdria.org
www. m ental healthscreen nq. orq
41 0-825-8888 ; www. si d ra n. org
i
4
Educational Materials
Books on PTSD
1.
2.
Herman J. L. (1992). Trauma and Recoverv. New York, Basic Books.
Pearlman, L.4., & Saakvitne, K. W. (1995). Trauma and the Therapist: Countertransference and Vicarious
Traumatization in Psvchotherapv with lncest Survivors. New York: \AAff Norton.
3. Briere, J.N. & Scott, C. (2006). Principles of Trauma Therapv: A Guide to Svmptoms, Evaluation, and Treatment.
Thousand Oaks, CA: Sage.
4. Fallot, R.D. & Harris, M. (200f ). Usinq Trauma Theorv to Desiqn Service Svstems. San Francisco: Jossey-Bass.
5. Hoge, C. C. (2010). Once a Warrior--Always a Warrior: Navigating the Transition from Combat to Home--lncluding
Combat Stress, PTSD, and mTBl. GPP Life Press.
Books on Substance Abuse
1. Beck A. T., Wright J., et al. (1993). Coonitive Therapv of Substance Abuse. New York: Guilford.
2. Marlatt G., Gordon J. (1985). Relapse Prevention. NewYork: Guilford.
3. Fletcher, A. (2001). SoberforGood. Boston: Houghton Mifflin.
4. Najavits L. M. (2002). A Woman's Addiction Workbook. Oakland, CA: New Harbinger.
5. Miller, W. R., Zweben, 4., et al. (1995). Motivational Enhancement Therapv Manual (Vol. 2). Rockville, MD: U.S.
Department of Health and Human Services. Free from www.health.org.
Books on PTSD and Substance Abuse
1. Najavits L. M. (2002). Seekino Safetv: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford
Spanr'sh and I other translations also available (vwvw.seekingsafety.org)
2. Ouimette, P. & Read, J. (2013) Trauma and Substance Abuse: Causes. Consequences, and Treatment of
Comorbid Disorders (2nd edition). Washington, DC: American PsychologicalAssociation Press.
Videos
a) Najavits, L.M. (2006). Video training series on Seeking Safety; www.treatment-innovations.org.
b) Najavits, L.M., Abueg F, Brown PJ, et al. (1998). Nevada City, CA: Cavalcade [800-345-5530]. Trauma and substance
abuse. Part l: Therapeutic approaches lFor professionalsl;Part ll: Special treatment issues lFor professionalsl; Numbinq
the Pain: Substance abuse and psvcholoqical trauma lFor clientsl
Clinicallv-Relevant Articles start h
1. Seal, KH, Bertenthal, D, Miner, CR, Sen, S, Marmar, C (2007). Bringing thewar back home: mental health disorders
among 103 788 us veterans returning from lraq and Afghanistan seen at Department of Veterans Affairs facilities. Arcfi
I nte m Med. 2007 ;1 67 (Q:a7 6-482.
2. Golier, J.A., Yehuda, R. et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder
and traumatic events. American J PsvchiatrvJ60, 2018-24.
3. Najavits, LM, Schmitz, M, Johnson, KM, Smith, C, North, T et al. (2009). Seeking Safety therapy for men: Clinical and
research experiences. ln Men and Addictions. Nova Science Publishers, Hauppauge, NY.
4. Brady, K.T., Dansky, B.S. et al. (2001). Exposure therapy in the treatment of PTSD among cocaine-dependent
individuals: Preliminary fìndings. J Substance Abuse Treatment. 21 ,47-54.
5. Bradley, R., Greene J., et al. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of
Psychiatry, 162, 214-227 .
6. Kessler, R.C., Sonnegâ, A., et al. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of
General Psvchiatrv, 52, 1048-1 060. [Provides rafes/
7. Najavits, L.M. (2004). Assessment of trauma, PTSD, and substance use disorder: A practicalguide. ln J. P. Wilson & T.
M. Keane (Eds.), Assessment of PsychologicalTrauma and PTSD (pp. 466-491). New York: Guilford.
L Ougrin D. (201 1). Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and metaanalysis. BMC Psychiatry. 1 1(1):200.
9. Vogelmann-Sine, S., Sine, L., et al. (f 998). EMDR: Chemical Dependencv Treatment Manual. Unpublished manuscript,
Honolulu, Hawaii.
10. Najavits, L., Highley, J., Dolan, S., & Fee, F. (2012). Substance use disorder, PTSD, and traumatic brain injury. ln J.
Vasterling, R. Bryant & T. Keane (Eds.), PISD and Mild Traumatic Brain lnjury. New York: Guilford Press
1 1. Najavits LM (2007). Psychosocial treatments for posttraumatic stress disorder. ln P. E. Nathan & J. Gorman, A Guide to
Treatments that Work (3rd ed.). Oxford Press: New York.
12. Brown et al. (2O07). lmplementing an evidence-based practice: Seeking Safety group. Journal of Psychoactive Drugs,
39,231-240.
Pubmed lmedical
literature):
http://www.ncbi.nlm.nih.govlenlrezl
5
Safe C oping Skills
(Part 1)
from "Seeking Safety: Cognitive- Behavioral Therapy for PTSD and Substance Abuse"
by Lisa M. Najavits, Ph.D.
l.
Ask for help'Reach
safe 2. Inspire yourself- Carry something positive (e.g., poem), or
negative (photo of friend who overdosed) 3. Leave a bad scene- When things go \ilrong, get out 4. PersistNever, never, never, never, never, never, never, never, never give up 5. Honesty- Secrets and lying are at the core of
out tosomeone
PTSD and substance abuse; honesty heals
respect-
Choose whatever
them 6. Gry. Let yourself cry; it will not last forever 7. Choose self-
will make you like yourself tomorrow 8. Take good care of your body- Eat right,
sex 9. List your options-
choices 10. Greate meaningRemind yourself what you are living for: your children? Love? Truth? Justice? God? 11. Do the best you can
with what you have- Make the most of available opportunities 12. Set a boundary- Say ,.no,, to protect
yourself 13. Compassion- Listento yourself withrespectandcare 14. When in doubt, do what's
hardest'The most difficult path is invariably the right one 15. Tatk yourself through it- Self-talk helps in
difficult times 16, lmaginê- Create a mental picture that helps you feel different (e.g., remember a safe place)
exercise, sleep, safe
In any.situation, you have
17. Notice the choice point- In slow motion, notice the exact moment when you chose a substance 18. Pace
yourself- If overwhelmed, go slower; if stagnant, go faster lg. Stay safe- Do whatever you need to do to put your
safety above
all
20. Seek understanding, not blame- Listen to your behavior; blaming prevents growth
21-lf onewaydoesn'twork, tryanothef-Asif in aÍnaze,turnacornerandtryanewparh 22.LinkPTSD
and substance abusê- Recognize substances as an attempt ro self- medicate 23. Alone is better than a bad
relationship- If onty treaters are safe for now, that's okay 24. Create a new story- you are the author of your
life: be the hero who overcomes adversity 25. Avoid avoidable suffering- Prevent bad situations in advance
26. Ask others' Ask others if your belief is accurate 27 . Get organized- You'll feel more in control with lists,
"to do's" and a clean house 28. Watch for danger signs- Face a problem before it becomes huge; notice red flags
29. Healing above allthan a perfect one
Focus on what
matters 30. Try something, an¡rthing- A good plan today is better
tomonow 31. Discovery-
head' 32' Attend treatment33. Create a buffer-
Find out whether your assumption is hue rather than staying "in your
AA, self-help, therapy, medications, groups- anything that keeps you going
distance) 34. Say what you realty
think- You'll feel closer to others (but only do this with safe people) 35. Listen to your needs- No more neglectreallyhear what youneed 36. Move toward your opposite- E.g.,if youaretoo dependent,trybeing more
independent 37. Replay the scene- Review a negative event: what can you do differently next time?
38. Notice the cost- What is the price of substance abuse in your life? 39. Structure your day- e productive
Put something between you and danger (e.g., time,
schedule keeps you on track and connected to the
world 40. Set an action plan-
othersknowaboutit 4l . Protect yourself-
Be specific, set a deadline, and let
Put upa shieldagainstdestructivepeople,badenvironments,
substances 42. Soothing talk- Talk to yourself very gently
(as
if to
and
a friend or small child)
With appreciation to the Allies Program (Sacramento, CA) for formatting this Safe Coping List.
@ Guilford Press, New York. From: Najavits, L.M. Seekrng Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <[email protected]> or <[email protected]>
6
Safe Gop rn g Skills
(Parr2)
from "Seeking Safety: Cognitive- Behavioral Therapy for PTSD and Substance Abuse"
by Lisa M. Najavits, Ph.D.
43. Think of the consequencês- Really see the impact for tomorrow, next weeh next year 44. Trust the
process- Just keep moving forward; the only way out is through 45. Work the material- The more you practice
healing 46. lntegrate the split self- Accept all sides of yourself; they are there for a
r€ason 47. Expect growth to feel uncomfortable- trit feels awkwa¡d or difficult you,re doing it right
andparticipate, the quicker the
48. Replace destructive activitieshow different the day
past or
futüe
Eat candy instead of gening
feels 50. Focus on now-
high 49. Pretend you tike yourself-
See
Do what you can to make today beuer; don't get overwhelmed by the
51. Praise yourself- Notice what you did right; this is the most powerful method of growth
52. Observe repeating patterns- Try to notice
and understand
your re-enactmenrs 53. Self- nurture- Do
movie) 54. Practice delay- If you can't totally prevent a selÊ
destructive act, at least delay it as long as possible 55. Let go of destructive relationshlps- If it can't be fixed,
detach 56. Take responsibility- fak an active, not a passive approach 57.Set a deadline- Make it happen
something that you enjoy (e.g., take
by setting a date 58. Make a
a walk,
see a
commitment-
Promise yourself to do what's right to help your recovery
59. Rethink- Think in a way that helps you feel bener 60. Detach from emotional pain (grounding)Distract walk away, change the channel 61. Learn
from experience-
Seek wisdom that can help you next time
62' Solve the problem- Don't take it personally when things go wrong- rry to just seek a solution 63. Use
kinder language- Make your language less ha¡sh 64. Examine the evidence- Evaluats both sides of the
picture 65. Plan it out-
Take the time to think ahead-it's the opposite of
For example, shoulds, deprivation reasoning 67.
right
Reward yourself- Find
68. Greate new "tapes" Literally! Take
69. Find rules to live by' Remember
failures- A setback is just
a phrase
impulsiviry 66. ldentify the beliefa
healthy way to celebrate anything you do
a tape recorder and record a new
way of thinking to play back
tlat works for you (e.g., "Stay real') 70. Setbacks are not
more 71. Tolerate the feeling- '1.{o feeling is final',, just get through
it safely 72. Actions first and feelings will follow- Don't wait until you feel motivared; jusr start now
a setback, nothing
73. Greate positive addictions- Sports, hobbies,
stay
away 75. Fight the trigger-
don't feel like
it
74. When in doubt, don't- If you suspec
Take an active approach to protect
you accept criticism or advice, notice who's telling it to
best solution you can right now; don't
4,l...
wait
you
danger,
yourself 76. Notice the source-
Before
77. Make a decision- If you're stuck, try choosing
the
78. Do the right thing- Do what you know will help you, even if you
79. Go to a meeting- Feet fust; just get there and let rhe rest happen 80. Proteet your body
from HIV' This is truly a life-or-death issue 81. Prioritize healing- Make healing your most urgent and important
goal, above all else 82. Reach for community resourcês- Lean on them! They can be a source of great support
83. Get others to support your recover!- Tetl people what you need 84. Notice what you can
cOntrOl- List the aspects
of your life you do control (e.g., job, friends...)
@ Gu¡lforO Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <[email protected]>
(2OO2).
7
Lisa Na
PhD
Deta
From Emotional Pain Groundi
WHAT IS GROUNDING?
Grounding is a set of simple strategies lo detach from emotional pain (for example, drug cravings, self-harm
impulses, anger, sadness). Distraction works by focusing outward on the external world-- rather than
inward toward the self. You can also think of it as "distraction," "centering," "a safe place," "looking outward,"
or "healthv detachment."
WHY DO GROUNDING?
When you are ovenruhelmed with emotional pain, you need a way to detach so that you can gain control
over your feelings and stay safe. As long as you are grounding, you cannot possibly use substances or hurt
yourself! Grounding "anchors" you to the present and to reality.
Many people with PTSD and substance abuse struggle with either feeling too much (overwhelming
emotions and memories) or too little (numbing and dissociation). ln grounding, you attain balance between the
two-- conscious of reality and able to tolerate it.
Guidelines
t Grounding can be done any time, any place. anywhere and no one has to know.
t Use grounding when you are: faced with a triqqer, havino a flashback, dissociatino, havinq a substance
cravino, or when vour emotional pain ooes above 6 (on a 0-10 scale). Grounding puts healthy distance
between you and these negative feelings.
t Keep your eves open. scan the room, and turn the liqht on to stay in touch with the present.
I Rate vour mood before and after to test whether it worked. Before grounding, rate your level of emotional
pain (0-10, where means "extreme pain"). Then re-rate it aftenruards. Has it gone down?
r No talkinq about neqative feelinqs or iournalwritinq. You want to distract away from negative feelings, not
get in touch with them.
a Stav neutral- no judgments of "good" and "bad". For example, "The walls are blue; I dislike blue because it
reminds me of depression." Simply say "The walls are blue" and move on.
I Focus on the present, not the past or future.
o Note that qroundinq is nof the same as relaxation traininq. Ground ing is much more active, focuses on
distraction strategies, and is intended to help extreme negative feelings. lt is believed to be more effective for
PTSD than relaxation training.
WAYS TO GROUND
Mental Groundinq
<ø Describe vour 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: "l'm on
the subway. l'll see the river soon. Those are the windows. This is the bench. The metal bar is silver. The
subway map has four colors..."
<¡6 Plav a "cateqories" qame with yourself. Try to think of "types of dogs", "jazz musidans", "states that begin
with '4"', "cars", "TV shows", "writers", "sports", "songs", "ELlropean cities."
rø Do an age progression. lf you have regressed to a younger age (e.9., I years old), you can slowly work
your way back up (e.9., "l'm now g"; "l'm now 10"; "l'm now 11"...) until you are back to your current age.
<ø Describe an everydav activity in great detail. For example, describe a meal that you cook (e.9., "First I peel
the potatoes and cut them into quarters, then I boil the water, I make an herb marinade of oregano, basil,
gadic, and olive oil...").
<ø lmagine. Use an image: Glide along on skafes away from your pain; change the TV channelto get to a
better show; think of a wall as a buffer between you and your pain.
u 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 _."
<ø Read something, saying each word to yourself. Or read each letter backwards so that you focus on the
letters and not on the meaning of words.
<ø Use humor. Think of something funny to jolt yourself out of your mood.
<ø Count to 10 or say the alphabet, very s..1..o..w..1..y.
<¡s Repeat a favorite savinq to yourself over and over (e.9., the Serenity Prayer).
I
Phvsical Groundinq
a
a
a
a
a
a
a
o
a
a
o
Run cool or warm water over vour hands.
Grab tiqhtly onto your chair as hard as you can.
Touch various obiects around vou: a pen, keys, your clothing, the table, the walls. Notice textures, colors,
materials, weight, temperature. Compare objects you touch: ls 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.
Carrv a qroundinq obiect in vour pockel-- a small object (a small rock, clay, ring, piece of cloth or yarn) that
you can touch whenever you feel triggered.
Jump up and down.
Notice your bodv: The weight of your body in the chair; wiggling your toes in your socks; the feel of your
back against the chair. You are connected to the world.
Stretch. Extend your fingers, arms or legs as far as you can; roll your head around.
Walk slowlv, noticinq each footstep, saying "left","right" with each step.
Eat somethino.
binq the flavors in detailto yourself
Focus on
r breathino , noticing each inhale and exhale. Repeat a pleasant word to yourself on each
inhale (for example, a favorite color or a soothing word such as "safe," or "easy").
Soothinq Groundinq
Sav kind statements, as if you were talking to a small child. E.9., "You are a good person going through a
hard time. You'll get through this."
, Think of favorites Think of your favorite color, animal, season, food, time of day, TV show
Picture people you care about (e.9., your children; and look at photographs of them).
Remember the words to an inspirinq sono, quotation, or poem that makes you feel better (e.9., the Serenity
Prayer).
Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or
a favorite room); focus on everything about that place-- the sounds, colors, shapes, objects, textures.
Say a copino statement. "l can handle this", "This feeling will pass."
.f. Plan out a safe treat for vourself, such as a piece of candy, a nice dinner, or a warm bath.
.¡. Think of things vou are lookinq foruvard to in the next week, perhaps time with a friend or going to a movie.
WHAT IF GROUNDING DOES NOT WORK?
Practice as often as possible, even when you don't "rìeed" it, so that you'll know it by heart.
Practice faster. Speeding up the pace gets you focused on the outside world quickly.
Trv orounding for a looooooonnnnngggg time (20-30 minutes). And, repeat, repeat, repeat.
Try to notice whether vou do better with "Þhvsical" or "mental" qroundinq.
Create your own methods of groundinq. Any method you make up may be worth much more than those
you read here because it is yours.
Start qrounding early in a neqative mood cycle. Start when the substance craving just starts or when
you have just started having a flashback.
.t
*
*
*
*
.
o
.
.
o
o
@ Gu¡ltord Press, New York. From: Najavits, L.M. Seeklng Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <[email protected]>
I
Lisa Najavits, PhD
Taking Good Gare of Yourself
Answer each question below "yes" or "no."; if a question does not apply, leøve it blønk.
DO YOU...
lAssociate only with safe people who do not abuse or hurt you?
vHave annual medical check-ups with a:
oDoctor? YES_NO _
oEye doctor? YES _No _
oDentist?
YES_ NO_
YES_
No
_
¡Gynecologist (women only)? YES _ No _
çEaÍ. a healthful diet? (healthful foods and not under- or over-eating) YES _ NO _
vHave safe sex? YES _
NO _
lTravel in safe areas, avoiding risky situations (e.g., being alone in deserted areas)? YES _ NO _
vGet enough sleep? YES _
NO _
vKeep up with daily hygiene (clean clothes, showers, brushing teeth, etc.)? YES _
NO _
(not
NO _
vGet adequate exercise
too much nor too little)? YES _
vTake all medications as prescribed? YES _NO_
vMaintain your car so it is not in danger of breaking down? YES _NO _
vAvoid walking or jogging alone at night? YES_ NO
vSpend within your financial means? YES_ NO _ -rPay your bills on time? YES_NO _
vKnow who to call if you are facing domestic violence? YES NO
vHave safe housing? YES_NO _
vAlways drive substance-free? YES_NO _
vDrive safely (within 5 miles of the speed limit)? YES_NO_
vRefrain from bringing strangers home to your place? YES_ NO _
vCarry cash, ID, and a health insurance card in case of danger? YES_ NO _
rCurrently have at least two drug-free friendships? YES _
NO _
vHave health insurance? YES_ NO _
vGo to the doctor/dentist for problems that need medical attention? YES_NO_
vAvoid hiking or biking alone in deserted areas? YE,S_ NO _
TUse drugs or alcohol in moderation or not at all? YES _
NO _
TNot smoke cigarettes? YES _ NO _
rl-imit caffeine to fewer than 4 cups of coffee per day or 7 colas? YES _ NO _
vHave at least one hour of free time to yourself per day? YES _
NO _
lDo something pleasurable every day (e.g., go for a walk)? YE,S_ NO_
vHave at least three recreational activities that you enjoy (e.g., sports, hobbies- but not substance use!)
?
YES_ NO_
vTake vitamins dally? YES_NO_
vHave at least one person in your life that you can truly talk to (therapist, friend, sponsor, spouse)?
lUse contraceptives as needed? YES_NO_
lHave at least one social contact every week? YES_NO_
vAttend treatment regularly (e.g., therapy, group, self-help groups)? YES_NO_
vHave at least 10 hours per week of structured time? YES _ NO _
lHave a daily schedule and "to do" list to help you stay organized? YES_NO_
vAffend religious services (if you like them)? YES_ NO_ N/A_
YES NO
vOther:
YES_NO_
10
YOUR SCORE: (total # of "no's)
Notes on self-care:
Self-Care and PTSD. People with PTSD often need to learn to take good care of themselves. For example, if
you think about suicide a lot, you may not feel that it's worthwhile to take good care of yourself and may need
to make special efforts to do so. If you were abused as a child you got the message that your needs were not
important. You may think, "If no one else cares about me, why should I?" Now is the time to start treating
yourself with respect and dignity.
Self-Care and Substance Abuse. Excessive substance use is one of the most extreme forms of self-neglect
because it directly harms your body. And, the more you abuse substances the more you are likely to neglect
yourself in other ways too (e.g., poor diet, lack of sleep).
Try to do a little more sel.f-care each day. No one is perfect in doing everything on the list at all times.
However, the goal is to take care of the most urgent priorities first and to work on improving your self-care
through daily efforts. "Progress, not perfection."
@ Gu¡ltord Press, New York. From: Najavits, L.M. Seek'ing Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <[email protected]>
11
Najavits, LM (2002)
Creati
Meanin in PTSD and Substance Abuse
MEANINGS THAT DEFINITION
HARM
Because you have
Deprivation
Reasoning
l'm Crazy
Time Warp
Actions Speak
Louder than Words
Beating Yourself
Up
The Past ís the
Present
EXAMPLES
MEANINGS THAT
HEAL
Live Well. A happy,
functional life will make
--I've had a hard time, so
suffered a lot, you deserve I'm entitled to get high.
substances (or other
-If you went through what I up for your suffering far
did, you'd cut your srm too. more than will hurting
destructive behavior).
yourself. Focus on
positive steps to make
your life better.
Honor Your Feelings.
--I must be crazy to be
You believe that you
You are not crazy. Your
shouldn't feel the way
feeling this upset.
you do
feelings make sense in
-I shouldn't have this
light of what you have
craving.
been through. You can
get over them by talking
about them and learning
to cope.
Observe Real Time.
--This craving won't stop.
It feels like a negative
Take a clock and time
feeling will go on forever --If I were to cry, I would
how long it really lasts.
never stop.
Negative feelings will
usually subside after a
while; often they will go
away sooner if you
distract with activities.
Break Through the
Show distress by actions, --Scratches on my arml
Silence. Put feelings
show what I.feel
or people won't see the
into words. Language is
pain.
--An overdose will show
the most powerful
them.
communication for
people to know you.
In your mind, you yell at
yourself and put yourself
down.
--I'm a loser.
--I'm a no-good piece of
Because you were a
victim in the past, you are
a victim in the present.
--I can't trust anyone.
--I'm trapped.
dirt.
Love-Not Hate-Creates Change.
Beating yourself up does
not change your
behavior. Care and
understanding promote
real change.
Notice Your Power.
Stay in the present: I am
an adult (no longer a
child); I have choices (I
am not trapped); I am
getting help (I am not
alone).
12
The Escape
An escape is needed (e.g., --I'll never get over this; I
food, cutting) because
have to cut mysel.f,
feelings are too painful
--I can't stand cravings; I
have to smoke a joint.
Ignoring Cues
If you don't notice a
problem it will go away.
--If I just ignore this
You give yourself
permission for selfdestructive behavior.
--Just one won't hurt.
-I'll just buy a bottle of
wine for a new recipe
Dangerous
Permission
toothache it will go awoy
-I don't abuse substances.
The Squeaþ \ilheel If you get better you will
Gets the Grease
not get as much attention
from people
--If I do well, my therapist
won't notice me.
--No one will listen to me
unless I'm in distress.
It's All My Fault
Everything that goes
wrong is due to you.
--The trauma was my fault
-If I have a disagreement
with someone, it means I'm
wrong.
I am My Trauma
Your trauma is your
identity; it is more
important than anything
-My lfe
else
is pain.
--I am what I have
suffered..
Keep Growing.
Emotional growth and
learning are the only real
escape from pain. You
can learn to tolerate
feelings and solve
problems.
Attend to Your Needs.
Listen to what you're
hearing; notice what
you're seeing; believe
your gut feeline.
Seek Safety.
Acknowledge your urges
and feelings and then
find a safe way to cope
with them.
Get Attention from
Success. People love to
pay affention to success.
If you don't believe this,
try doing better and
notice how people
respond to vou.
Give Yourself a Break
Don't carry the world on
your shoulders. When
you have conflicts with
others, try taking a 50-50
approach (50% is their
responsibility, 50% is
yours).
Create a Broad
Identity. You are more
than what you have
suffered. Think of your
different roles in life,
your varied interests,
your goals and hopes.
@ Cu¡ltorO Press, New York. From: Najavits, L.M. Seekrng Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <[email protected]>
13
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15
"Tough Cases"
--
Rehearsing Difficult Client Scenarios
Below are examples of "tough cases" in the treatment of PTSD and substance abuse. They are organized by
themes related to this dual diagnosis.
Trauma/PTSD.
'l'll never recover from PTSD."
"Reading about trauma makes me want to burn myself."
"How can I give up substances when I still have such severe PTSD?'
x
*
*
Substance Abuse:
"Using cocaine makes my PTSD better-l can't give it up."
"lt's my alter who drinks and she's not here now" (dissociative identity disordered client)
"l definitely think I can do controlled drinking."
"Do I have to get clean before working on my PTSD?'
"ln AA they said to me, 'You don't drink because you were molested as a child, you drink because you're
an alcoholic.'
x
*
*
x
*
Self-Nurturing:
"ljust can't experience pleasure-nothing feels fun to me."
"All of the people I know drink to have a good time."
"Whenever I try to do something pleasurable I feel guilty."
'My partner doesn't want me to go out of the house."
*
*
x
*
Safety:
"l don't want to stay safe; I want to die."
"Safe coping skills are a nice idea, but when I get triggered it's so fast that I don't even have time to think
about what I'm doing."
* "l feel like I need mourn my trauma now, not wait until later."
*
*
Boundaries in Relationships:
x "l can't say 'no'. lt makes me feel l'm being mean, like my abuser."
x "When I say 'no'to my partner I get hit."
* "l want to set a boundary with you- stop telling me to get off substances! I'm not ready."
* "You tell me to reach out to others, but I feel safer alone."
* 'My cousin keeps offering me crack no matter how much I say not to."
Honesty:
"But it will hurt the other person if l'm honest."
"l can be honest in the role-play, but in real life I could never do it."
"l won't tell my doctor that I abuse alcohol."
"Should I tell everyone at work that l'm an addict?"
"Are you telling me l'm aliar?"
"When I was growing up, I told my mother that my brother molested me and she said I was lying."
x
*
*
x
*
x
Creating Meaning:
* "My thoughts are bad, just like l'm bad."
* "But my negative thoughts really are true!"
x "Positive thinking never works for me."
@ Guiltord Press, New York. From: Najavits, L.M. Seekrng Safety: A Treatment Manual for PTSD and Substance Abuse (2002).
Only for personal use (with clients); for any other use contact <infoseekingsafety.org> or <[email protected]>
16
Trauma Svmptom Checklist-40
How often have you experienced each of the following in the last month? Please circle one number, 0 through 3.
1
2.
Headaches
lnsomnia
4.
Stomach n ro b lems
Never
0123
0123
0123
6 Feelinn isnlatecl frnm ntherc,
7.
"Flashbacks"(sudden, vivid, distractinq memories)
0
0
Often
1
1
23
2
Dizziness
17. Not feelinq satisfied with vour sex life
18. Trouble controllino vour temoer
19. Wakino uo earlv in the mornino
20. Uncontrollable crvinq
21 Fear of men
22. Not feelinq rested in the morninq
0123
0
123
0123
0123
0123
0123
0123
0
1 2
0
123
0123
0123
0
123
0123
0123
0123
24 lrouble oeftino
0
8. Restless sleep
I
I ow sex clrive
10. Anxietv attacks
1l Sexual overactivitv
12. Loneliness
13. Niohtmares
14. "Soacino out" (ooino awav in vour mind )
l5.Sadness
l6
al on ct with others
problems
25. Memorv
26 Desire fo nhrrs,inallv hr rrt vnr rrqclf
27. Fear of women
28. Wakinq up in the middle of the niqht
29 Bad thouohts or feelino s duri no SEX
30. Passinq out
31. Feelino that thinos ere "unreal"
32. Unnecessary or over-freouent washin q
0123
0
0123
0123
0123
0123
0123
0
3
3
123
1
23
1
23
0123
0123
0123
37F eelin sof uilt
0
123
38. Feefinq that vou are not alwavs in vour bodv 0
1 2
39" Havino trouble breathino
0123
40. Sexual feelinqs when vou shouldn't have them 0
1 2
34 Feelino tense
all the time
35. Beinq confused about vour sexual feelinqs
36. Desire to phvsicallv hurt others
ct
ct
3
3
lmportant note: this measure assesses trauma-related problems in several categories. According to John Briere, PhD "The TSC-40 is
a research instrument only. Use of this scale is limited to professional researchers. lt is not intended as, nor should it be used
as, a self-test under any circumstances." For a more current version of the measure, which can be used for clinical purposes (and for
which there is a fee), consider the Trauma Symptom lnventory, contact Psychological Assessment Resources, 800-331-8378. The
TSC-40 is freely available to researchers. No additional permission is required for use or reproduction of this measure, although the
following citation is needed: Briere, J. N., & Runtz, M. G. (1989). The Trauma Symptom Checklist (l-SC-33): Early data on a new scale
Journal of lnterpersonal Violence, 4, 151-163. For further information on the measure, go to www.johnbriere.com.
17
PToQOL R-lV
PROFESSIONAL QUALITY OF LIFE SCALE
Compassion Satisfaction and Fatigue Subscales-Revision lV
Helping people puts you in direct contact with their lives. As you probably have experienced, your compassion
for those you help has both positive and negative aspects. V/e would like to ask you questions about your
experiences, both positive and negative, as a helper. Consider each of the following questions about you and
your cwrent situation. Select the number that honestly reflects how frequently you experienced these
characteristics in the last 30 davs.
O=Never 'l=Rarely
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22
23
24.
25.
26.
27.
28.
29.
30.
2=A Few
Times
3=Somewhat
Often 4=Often
5=Very Often
I am happy.
I am preoccupied with more than one person I help.
I get satisfaction from being able to help people.
lfeel connected to others.
ljump or am startled by unexpected sounds.
feel invigorated after working with those I help.
find it difficult to separate my personal life from my life as a helper.
I am losing sleep over traumatic experiences of a person I help.
I think that I might have been "infected" by the traumatic stress of those I help.
I feel trapped by my work as a helper.
Because of my helping, I have felt "on edge" about various things.
I like my work as a helper.
I feel depressed as a result of my work as a helper.
I feel as though I am experiencing the trauma of someone I have helped .
I have beliefs that sustain me.
I am pleased with how I am able to keep up with helping techniques and protocols.
I am the person I always wanted to be.
My work makes me feel satisfied.
Because of my work as a helper, I feel exhausted.
I have happy thoughts and feelings about those I help and how I could help them.
I feel ovenuhelmed by the amount of work or the size of my casework load I have to
deal with.
I believe I can make a difference through my work.
I avoid certain activities or situations because they remind me of frightening
experiences of the people I help.
I am proud of what I can do to help.
As a result of my helping , I have intrusive, frightening thoughts.
I feel "bogged down" by the system.
I have thoughts that I am a "success" as a helper.
I can't recall important parts of my work with trauma victims.
I am a very sensitive person.
I am happy that I chose to do this work.
I
I
Copyright lnformation
Stamm, 1997-2005. Professional Quality of Life: Compassion Satisfaction and Fatigue
Subsca/es, R-lV (ProQOL). http://www.isu.edu/-bhstamm. This test may be freely copied as long as (a) author
is credited, (b) no changes are made other than those authorized below, and (c) it is not sold. You may
substitute the appropriate target group tor helper if that is not the best term. For example, if you are working
with teachers, replace helperwifh teacher.
@ B. Hudnall
18
Disclaimer
This information is presented for educational purposes only. lt is not a substitute for informed medical advice or
training. Do not use this information to diagnose or treat a health problem without consulting a qualified health
or mental health care provider. lf you have concerns, contact your health care provider, mental health
professional, or your community health center.
Self-scoring directions, if used as self-test
1.
2.
3.
Be certain you respond to all items.
On some items the scores need to be reversed. Next to your response write the reverse of that score (i.e. 0:0, 1:5,
2:4,3=3). Reverse the scores on these 5 items: 1,4,15,17 and 29. Please note that the value 0 is not reversed, as
its value is always null.
Mark the items for scoring:
a.
Put an X by the I 0 items that form the Compassion Satisfaction Scale: 3, 6, 12, I 6, 1 8, 20, 22, 24,
27 ,
30.
b.
c.
4.
Putacheckbythe l0itemsontheBurnoutScale:7,4,8,10, 15, 17,19,21,26,29.
Circle the 10 items on the Trauma/Compassion X'atigue Scale: 2,5,'7,9,17,13,74,23,25,28.
Add the numbers you wrote next to the items for each set of items and compare with the average scores below.
Compassion Satisfaction Scale. The average score is 37 (SD 7;
alpha scale reliability .87). About25Yo of people score
higher lhan42 and about 25Yo ofpeople score below 33. Ifyou are in the higher range, you probably derive a good deal of
professional satisfaction from your position. If your scores are below 33, you may either find problems with your job, or
there may be some other reason-for example, you might derive your satisfaction from activities other than your job.
Burnout Scale. The
average score on the burnout scale is 22 (SD 6.0; alpha scale reliability .72). About25Yo of people score
above 27 and about 25Yo of people score below I 8. Ifyour score is below I 8, this probably reflects positive feelings about
your ability to be effective in your work. If you score above 27 you may wish to think about what at work makes you feel like
you are not effective in your position. Your score may reflect your mood; perhaps you were having a "bad day" or are in need
of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.
Trauma/Compassion Fatigue Scale. The average score on this scale is 13 (SD 6; alpha scale reliability .80). About25Yo of
people score below I and about 25o/o of people score above 17. If your score is above 17, you may want to take some time to
think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher
scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your
work and your work environment. You may wish to discuss this with your supelisor, a colleague, or a health care
professional.
If you have any concems, you should drscuss them with a health care professional.
LEC.5
Listed below are a number of difficult or stressful things that sometimes happen to people. For each event
check one or more of the boxes to the right to indicate that: (a) it happened to vou personally; (b) you
witnessed it happen to someone else; (c) you learned about it happening to a close family member or close
friend; (d) you were exposed to it as Ørt_gÍ_voul_joþ(for example, paramedic, police, military, or other first
responder); or (e) you're not sure if it fits.
Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.
1.
Event
Naturaldisaster (for example, flood,
hurricane, tornado, earthquake)
Happened
to me
Witnessed
it
Learned
about
it
2. Fire or explosion
3. Transportation accident (for example, car
accident, boat accident, train wreck, plane
crash)
4.
Serious accident at work, home, or during
recreational activity
5.
Exposure to toxic substance (for example,
dangerous chemicals, radiation)
6.
Physical assault (for example, being
attacked, hit, slapped, kicked, beaten up)
7.
Assault with a weapon (for example, being
shot, stabbed, threatened with a knife, gun,
bomb)
Sexual assault (rape, attempted rape, made
to perform any type of sexual act through
force or threat of harm)
8.
9.
Other unwanted or uncomfortable sexual
experience
10.
Combat or exposure to a war-zone (in the
military or as a civilian)
11.
Captivity (for example, being kidnapped,
abducted, held hostage, prisoner of war)
12.
Life-threatening illness or injury
13.
Severe human suffering
14.
Sudden violent death (for example,
homicide, suicide)
15.
Sudden accidental death
16.
Serious injury, harm, or death you caused
to someone else
17
.
Any other very stressful event or experience
PLEASE COMPLETE PART 2 ON THE FOLLOWING PAGE
Part
of
mv iob
IVof Sure
PART 2:
A. lf you checked anything fo¡ #17 in PART 1, briefly identify the event you were thinking of:
B. lf you have experienced more than one of the events in PART l, think about the event you consider
the u¡orsf event, which for this questionnaire means the event that currently bothers you the most. lf
you have experienced only one of the events in PART 1, use that one as the worst event. Please
answer the following questions about the worst event (check all options that apply):
1. Briefly describe the worst event (for example, what happened, who was involved, etc.).
(please estimate il you are not sure)
2. How long ago d¡d ¡t happen?
3. How did you experience it?
_
_
_
_
_
lt happened to me directly
I witnessed it
I learned about it happening to
a close family member or close friend
I was repeatedly exposed to details about it as part of my job (for example, paramedic, police, military, or other
first responder)
Other, p/ease describe:
4. Was someone's life in danger?
_ Yes, my life
_Yeg someone e/se's /ife
5. Was
someone seriously injured or killed?
-No
_
_
Yeg lwas seriously injured
Yeg someone e/se was seriously injured or killed
it involve sexualviolence?
6. D¡d-No
_Yes _No
7. lf the event involved the death of a close family member or close friend, was it due to some kind of
accident or violence, or was it due to natural causes?
_
_
_
Accident or violence
Natural causes
Nof applicable (The event did not involve the death of a close family member or close friend)
8. How many times altogether have you experienced a similar event as stressful or nearly as stressful
as the worst event?
_
_
Just once
More than once (please spectfy or estimate the total# of times you have had this
experience
PLEASE COMPLETE PART 3 ON THE FOLLOWING PAGE
)
Part 3: Below is a list of problems that people sometimes have in response to a very stressful experience.
Keeping your worst event in mind, please read each problem carefully and then circle one of the numbers to the
right to indicate how much you have been bothered by that problem in the past month.
at all
A little
bit
Moderately
a bit
Extremely
0
1
2
3
4
Repeated, disturbing dreams of the stressful experience?
0
1
2
3
4
Suddenly feeling or acting as if the stressful exper¡ence were
actually happening aga¡n (as if you were actually backthere
reliving it)?
0
,
2
3
4
0
1
2
3
4
Having strong physical react¡ons when something reminded
you of the stressfut experience (for example, heart pounding,
tro ubl e breath i ng, sweati n g)?
0
1
2
3
4
6.
Avoiding memories, thoughts, or feelings related to the
stressful experience?
0
I
2
3
4
7.
Avoiding external rem¡nders of the stressful exper¡ence for
example, people, places, conversations, activities, obiects, or
situations)?
0
1
2
3
4
8.
Trouble remembering important parts of the stressful
experience?
0
1
2
3
4
9.
Having strong negative beliefs about yourself, other people,
or the world (for example, having thoughts such as: I am
bad, there is something seriously wrong with me, no one can
be trusted, the world is completely dangerous)?
0
1
2
3
4
10. Blaming yourself or someone else for the stressful
experience or what happened after it?
0
1
2
3
4
11. Having strong negative feelings such as fear, horror, anger,
guilt, or shame?
0
1
2
3
4
12. Loss of interest in activities that you used to enioy?
0
1
2
3
4
13. Feeling distant or cut off from other people?
0
I
2
3
4
1
2
3
4
Nof
In the past month, how much were you bothered by:
1. Repeated, disturbing, and unwanted memories of the
stressful experience?
2.
3.
4.
Feeling very upset when something reminded you of the
stressful experience?
5.
14. Trouble experiencing positive feelings (for example, being
unable to feel happiness or have loving feelings for people
close úo you)?
Quite
15. lrritable behavior, angry outbursts, or acting aggressively?
0
1
2
3
4
16. Taking too many risks or doing things that could cause you
harm?
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
9. Having difficulty concentrating?
0
I
2
3
4
20. Trouble falling or staying asleep?
0
1
2
3
4
17. Being "superalert" or watchful or on guard?
18. Feeling jumpy or easily startled?
I
LEC-5 (10/1 112013) Weathers, Blake, Schnurr, Kaloupek, Max, & Keane -- National Center for PTSD
PCL-ï (101312013) Weathers, Litz, Keane, Palmieri, Max, & Schnurr
For scoring instructions, please go
-
National Center for PTS
to www.ptsd.va.gov/professional/assessmenUadult-sr/ptsd-checklist.asp
From: Najavits, LM (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford
IÀIÍEBPERSONAL
Asking for Help
aru
SUlvll'lARY
Each of the disorders-PTsD and substance abuse-leads to problems in asking for help' Today's topic encourages patients to become aware of their need for help, and provides guidance in how to do so effectivelY.
ORIENTATION
"lt føels Hke the tetnph,one wøiglw ø thotnanå' pounds-"
"l lose whether I get hetp or not. If I get halp, I feel guàItg; lf I dont, I feel lnnn¡løt¿d and
alnnß."
'Hor¡) haril ís ìt to
a.sk
for tntp? I tlxínk
ít's easíer to gìnse up cocaårw
-Eoeryone in my
W lrns lurt me onÊ u)ag or anothnr.
rnt easy-l cø¡ít tøke anV fiwre lutrt."
than to øskfor hul\.-
I guess ITI lmne to tr! to tnnt. lt's
"The power of
both PTSD and substance abuse, others'help is essential. It has been said,
drugs equals the need for help. . . . They are as closely related as supply and demand in economics, as inseparable as pressure and volume in behavior of gasses. . . . The gun is poínted
at my head: g"i h"lp 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 someone "strong"; th"y may have learned that ashng for help evokes punishment. For many patients with PTSD sufficient help was not available at the time of the trauma, and they may
Fìor
164
Asking for
Help
1ó5
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 systems that faited them, such as treatment systems ignorant about PISD or substance abuse, or
legal systems that may have punished them rather than providing treatrnent. Fbr a descripdon of one patient's dilemmas in asking for help, see 'A Patient's Story: Why lt'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 effectively, toward others. Thís 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 learning to move on to others who can, even if only to treaters. See also the topic Setting Bunã'
aríøs in Relat¡onships for more on getting patients to say "yes" to help from others.
coun tertronsference Issues
if they grew up in a supportive environment, underestimate patients' obstacles in seeking help. They may believe that the problem is mostly in patients'pereeptions rather than in reality, and they may be unawÍue of some real dangers in reaching out
for help. See "suggestions" þelow) for more on this issue.
Some therapists, particularly
SESSION FORT{AT
l.
Clwck-ön þry tn 5 tninutps per pøtimt). See Chapter 2.
2. Quotøtíon (briefl¡¡). See page I70. Link the quotation to the 5sssi6¡-fsr 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. Reløte tt e topiô to pøtíents' líoes (ìn-d,epth, most of session).
a. Asft pøtients ø look tbm'gh tlæ handou'ts:
Handout l: Asking for Help
Handout 2: Approach Sheet
patìents rel.ate the skill to ctnrent and specífic problents
"session Content" (b"lo*) and Chapter 2 for suggestions.
4. Check-out (brteÍlù.See Chapter 2.
b. Hetp
SESSION CONTENT
Gools
s Discuss effective ways to ask for help.
o Rehearse how to ask for help.
o Explore patients' experiences in asking for help.
in tlwir lio¿s. See
Treatment Topics
1óó
Wogs to Relote the /"foteriol to futients'Lives
*
role-play are current, real-lifu 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 ffght, 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 dont feel safe," "Call a friend when you are
feeling lonely," 'Ask someone to go with you to a self-help meeting," 'i{sk your partner to help
you review the material in this treatment," or "Call someone if you feel like hurting yourself
or someone else."
* Work on tlw Ayproæh Shee, (Hffidaut 2). Help patients identiS a current situation
that would benefft from asking for help, and process how to go about it. The goal is to get pa*in
their heads" and into ffnding out "what's real." Thus, guide
tients out of the assumptions
them to fill out the ffrst 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 session, they can try actually asking for the help specifted and observe whether their prediction
was accurate (filling out the fourth box in the sheet).
To help create å success experience, make sure that patients are truly tn ing 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 r&)t explicitly discuss how to prepare if a request for help
doesn't go well; explore practical and emotional obstacles to following through on the assignment; and, when patients come to the next session, process what happened. If it didnt go
well, the idea is to help patients learn somethíng 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, ffnd
out hou they asked for help, and give honest feedback and instructions on more effective
Rol,e pla¡s, The best situations to
ways.
*
Discussåon
o "What do you most want help with?"
¡ "Why is asking for help such a crucial coping skill?"
o "\{'as there a time recently when you needed to call someone for help, but didnt?"
o "Is it harder to ask for help with your PTSD, your substance abuse, or both equaþ?"
. 'Why might PTSD and substance abuse make it hard for you to ask for heþ?"
r "'What happens when you do not ask for help?"
o 'hre there any successes you ve had in asking for help? What made those possible?"
I "Do you think you can learn to ask for more help?"
o "Ho\M can you cope if the other person refuses to help?"
o "Ifyou feel an impulse toward a destructive behavior, do you lcnow whom you would
call and what you would saY?"
o "Why would asking for help make you more índ,øpender¿f in the long run?"
o "Can you 'coach' the other person in advance on what you want him or her to say?"
Asking for Help
167
Suggestíons
You mag uønt to íntrod,uce the topìc udth a úmpln, forcffi úøtement: *I ¿m 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 patÍents
+
to respond to this, and praise any positive examples they provide of asking for help.
+ Out-loud reh¿arsal ís tgp¡uøUy nwst effectir¡¿. 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.
I Note that sutw pøtöents hanse no one søfe to øsk heþ from. This is a very real situation for some people. In this case, the goal becomes practicing ashng help from treaters
(u.9., a hotline, an AA member or sponsorr a therapÍst). It is usually less helpful to 'lebate"
with patients whether particular füends or family members really would be there for
them-patients' instincts may be accurate, arrd the goal of the session is to have them locate help anywhere they can. Tieaters are an excellent source for mastering the skill of asking for help, and over time, patients may then be able to move on to developing a safe support 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 activities, 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 patients resources from Handout I in the topic Conmr"míty Resources, which provides many
toll-free numbers for obtaining informational help. Here too, just practicing reaching out is
the goal.
* Be sure to tøke oery seråouslg that thcre nwg be oølíd reøsons uhy askíngfor læþ h
gerwínelg dnngerous for sanle patöents at thÅs poônt. Sometimes patients have abusive partners who will hurt them if they seek help; at other times, emotional obstacles may be dangerous (e.g., "If I dodt get the help I ask fon 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 offìce) 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 partneç" or "You can do it!"
i Encowage pøtôents to íwtruct people ín t\wír lùoes øbout tlra kínd of fub üreg nøed.
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 advance what they want the other person to say-for example, "f cannot stpp you from using,
but I am wonied about you," or "I will just listen to anytùing you want to say." See the topic
Getting Others to Support Your Recooery for more on this.
+ It mag be søþst to start øåth conerete, phgsôcøl heþ røtller thøn emntùonal heþ, For
example, asking a füend 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 difftculty of the task (not too hard, not
too easy) is key. AIso, patients should select someone who truly has the potential to help, not a
Treatment Topics
1ó8
"hopeless case," such as a family member who has abused them or a füend who has refused to
help in the past.
+ AnV tfune åsbetter tløntw tí,me, Sometimes patients believe that they can only ask for
help before usíng (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:
Beþre:'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."
*Call
After:
a friend the next day to discuss what happened"'
+ Iilcntìf,y u)ags to cope uåth røjectíanbefore ít lwpperæ. 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 isrit as generous as I had thought," "I can learn from this and try againlater with someone else," "I need to
give myself credit for trying, even if it didrt't work out as I had hoped."
* Persåstente ma,tters. Patients should not give up easily. Offer suggestions, such es "You
rnay have to ask twice for someone to 'hear'you," or
"If one person can t help you, try ånother
person immediately."
* Patíents mag be ofroid of becomíng too dependent íf th,eg æk for lwþ. lt is often a
surprise that in fact it makes them more indcpendcnt in the long run. Learning to r€cognize and priorÍtize one's needs, knowing how to put a request for help into words, tolerating the vulnerability of such a request-all of these empower patients and increase
strength and self-esteem. Asking for help meåns that one is not afraid of people and can
join with others safely.
* Notíce lwu pøtúents askfor lr*lp, p*töcularly ún tlw rolc plags. You may need to give
honest feedbacl< and instructions on more effective ways to ask for help. For example, one patient 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.
+ Sonæ pøtåents møg røtund¿rstandthe quotatioæ. You may want to emphasize that it suggests 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 Coses
t "I'm always helping others, but no one helps me."
* "I can ask for help in role plays, but not in real life."
* "I dorft have anyone in my life to ask heþ from."
x "\ühenever I ask for help, I get rejeeted."
x "I cart't ask for help when I feel like using-I dont want to be talked
out of it."
"f'm calling you from â 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 \ryas beaten if I asked for help."
*' 'fu a Latino in this society, I can only ask for heþ from other Latinos."
*
*
*
Asking for Help
A
169
PATIENT'S STORY:
WHY lT'S HARD TO ASK FOR HEIP
"My trøurna started arund,thø timø I usas about 5 or so. Aluøgs arumil nighttimn, when
tlw li.ghts went ufi, ùt was a scary time. Bad, things happerwd ìn th¿ dnrk. I uutld pretend
to bø aslcep but that d¡dn't matter If I clnsed mV eyes> ít woul.d go aua7. But tha.t wasn't
truø I wouldhold, onto my ilollfor cornfort. Sonwtim,es I uouli.lnld, on so tígþt I thought
her læad, wutld, pop off,
"So why didn't I askforlnle? lf onlg I wentforlnlp,I curld,hone stoppedthe wholn
thíng. But I díùít, I did nothing; I l.et ¿t all happen, Was I sryid,? Or magbe I kked it?
Please gíoe me tlw answers-,l iloríthaoe thøm. I feel dírtA, ølways feelìng dùty. Grouíng
up, ani, et)en now when I think øbout ít, it was always my fault, I didn't stop any of ít.
Eoøn øfter the ra.pø at 77 gews old, I stíll didn't tøll angorc. Eoen os an øilult, I lßt it go on
in mg mørríage. An adult! I sfuuld, hane stopped it then. But I didn't. I'm just a lluln glrl
cryíngfor hølp but rct dní,ng angthíng about åt.
*Well,
Aes, mV trun¡tn ilidlwppen os alinln girl That's jwt it---a little grl This rnøn
tuo.s Dery powedul. There u)ut no waE I could, stop this perstn wlw was terifgðngmn. No,
I arn rwt strryid,, and I did, rct enjog it. It sinkøns m,e when I tlrínk about ít. I couldlít go for
heþ becmse tlwn mg sísters uould. haoe been furt. I was heþless. He was my føtlwr a
oery powedul frgurt in my lì,fr. I rnay rwt haoe gotten hølp th,en, but l'm gettångfuþ mw,
It's rwtser too løte to askfor lwlp. I wiII gøt rn7 W in orilpr and stand, tn rn7 own two feet.
If I talked then, bad, thíngs watld haoe høppened. WeIl, rc more, I u)¡ll not be hurt any
more ín mg ffi."
Quotation
'And the trouble is,
¡f you don't risk anything,
you risk even more."
-Erica Jong
(20th-century American writer)
From Seekr'ing Safety by Lisa M. Najavirs (2002).
170
HANDOUT
1
Asking for Help
Asking for nelp
MAIN POINTS
*
tt is very common to have difficulty askíng for help if you have
*
You must get help from others to recover. No one can do it alone.
PTSD and substance abuse,
rt ln 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 tlme-before, during,
or after a hard time.
*
Prepare how you'll handle
*
ln asking for help, you don't have to "spill" everything.
*
Asking for help makes you stronger and more independent in the rong run.
*
Learning to ask for help may feel very awkward at first.
*
lf 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 âre accurate: compare your prediction
*
Carry in your wallet a list
it if the person refuses your request for
of phone numbers you can
171
to
reality.
call.
Safefy by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission
llol
oook feetlne
tor personal use only (see copyright page
for details).
herp.
to photocopy this lorm
is
granted to purchasers of this
Asking for Help
Ideas for a Commitment
Commit to one action that will move your life forward!
can be anything you feel will help yo.r, or you can try one of the ideas below.
Keeping your commitment is a way of respecting, honoring, and caring for yourself.
It
f
Option 1:Write a list of people you can call when you are having problems (e.9., wanting to talk, feeling
afraid, drug cravings, needing a ride, etc.). lnclude friends, family members, self-help sponsors, treaters, hotlines, dropin centers, and anyone else you can think of (see example below).
List
of
people
to
call for help
1. My friend Martha: 46æ215 or 252-7655
*
2,
My therapist (Dr. Klein): 855-1111 or can page at 855-1000
3.
My AA sponsor (Barbara): 731-1502
Option 2: Go for
it!
Fill out the Approach Sheet.
APPROACH SHEET-EXATqPLE
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 ElizabeEh.
(2) What will you say?
"Please help me noL drink at the party t.onight-you can help
by not offering me any alcohoJ" and checking in with me
at times during the party to see íf I,m okay.,,
(3) What do you predict will happen?
She
won't want to help me. She'll think I'm paÈhetic.
(a) What did happen in reality?
T called Elizabeth She was very willing to watch out for me
at the party, and also gave me the phone number for a good eA group
in to!ìrn. She dÍdn't convey any judgrment or negative views of me.
From Seekrng Safetyby Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form
book for personal use only (see copyright page for details).
173
is granted
to purchasers of this
Asldng for Help
HANDOUT 2
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 prejiç! will happen?
(a) What did happen in reality?
*
You may want to ask yourse/f;
o
What did you learn from trying this?
Did you get what you wanted, or at least part of what you wanted?
ls there anything you might do differently next time?
o How do you feel about your experience?
o How difficult was iti
r
t
From Seekrng Sa/ety by Lisa M. Najavis (2002). Copyright by The Guílford
book for personal use only (see copyright page for details).
Press. PermÍssion
't72
to photocopy this lorm
is
granted to purchasers of this
rUU07
Seekins Safetv
Scale-Brief Version
Part l: Interventions
For each of these questions, please rate your feelings of how well Seekins Safety was facilitated using the
following scale:
-Not Done
l-DoneaLittle
2-DoneaLot
3 - Done Thoroughly
0
The facilitator(s):
l.
2.
3.
4.
5.
6.
7.
8.
9.
did a check-in at the start of the session and worked to keep it brief (up to 5 minutes per person).
had a client read the quote; and asked "What is the main point of the quote?".
gave handouts and made use of them during the session.
did a check-out at the end of the session and worked to keep this brief (up to 2 minutes per person).
focused on how the topic related to trauma/PTSD.
focused on how the topic related to substance use.
focused the discussion on safe coping skills.
kept discussions focused on the session topic and practicing or rehearsing skills.
tried to keep everyone safe by making sure that no graphic details of substance use or trauma were
discussed.
Part2:. Processes
Please rate how helpful the session was, using the following scale:
0
* Harmful
I - Ineffective (Not too helpful)
2
3
The
1.
2.
3.
4.
5.
6.
7.
- Somewhat helpful
- Extremely helpful
facilitator(s):
was supportive and gave positive feedback while also helping clients take responsibility for their
recovery.
was genuinely warm, caring, and compassionate.
was helpful in managing crisis and strong emotions in a professional and kind way.
really listened to what clients had to say and were involved and interested in the discussions.
worked to create a bond between the group members (if group modality).
engaged clients in the work (rather than facilitator talking too much, lecturing, or over-controlling)
overall, did a good job helping clients work on safe recovery from trauma and/or substance use.
How group members interacted with each other (d group modølity):
1.
2.
3.
The group members were genuinely warm, caring, and compassionate with each other.
The group members really listened to what each other had to say and were involved and interested in
the discussions.
The group members worked to create a bond among each other.
Najavits, L.M., Liese, 8.S., and Heath, N. (2007). Adapted version of the Seeking Safety Adherence Scale, based on the original
version: Najavits, L.M, & Liese, B.S. (1996). Seeking Safety Adherence Scale. Unpublished scale. Mclean Hospital / Harvard
Medical School. For permission to adapt or distribute, please contact L. Najavits at [email protected] or 617 -731-1501 .
@
Seekinq Safetv Session Format Worksheet
As you listen, please check off whether the clinician did the following, which serves as a quick checklist
key
format elements of a Seeking Safety session. For a group session, check as complete only if done
of the
for each client. Use left margin to keep track of each client This worksheet is not meant to be overly detailed.
Rather, it reinforces the key parts of the session that help to build a sense of safety and consistency. The
format mirrors the process of recovery from trauma and substance abuse: balanced and safe, good use of
time, clear boundaries, and attention to each client's current issues.
I ) Check-ln. Note: the clinician does not ask each of these questions. lnstead, s/he can guide the client to
look at pg. 55 from manual (posted on the wall or in hand). Soon clients go through the questions on their own
readily. Throughout, the clinician just redirects if needed and asks any missed questions.
D "How are you feeling?"
a "What good coping have you done?" [does not have to relate to prior question]
Did the clinician guide clients to use the Safe Coping List if they can't name anything?
tr "Any substance use or other unsafe behavior?"
lf yes, did the clinician ask about amount and type? (e.9., number of drinks)
"Did you complete your commitment?"
Did the clinician remember what the client's commitment was?
Did the clinician express concern if the client forgot the commitment, and discuss how the client
can keep track of the commitment?
tr "Community resource update"
Did the clinician remember what the client's community resource was?
Also, did the clinician:
Contain the check-in to no more than five minutes per client? (e.9., redirecting in kind way)
Mostly listen to client, and speak little (e.9., short statements of concern or praise; no major
interventions, no problem-solving)?
For group:have each client answer all five questions before going on to the next client?
For group: preserve each client's check-in "space" and prevent others from talking during it?
For group:ask for a volunteer to start the check-in?
1l Quotation. Did the clinician:
Ask the client to read the quote? (if group, ask for a volunteer)
u Ask "What is the main point of the quote?"
o Limit discussion of the quote to no more than about 2 minutes?
u Tell clients what the quote means, if they don't understand
n Avoid making the quote into a school-like exercise (e.9., "Let's break down each part...")
l) Hand-Outs. Did the clinician:
Er Give clients the handouts?
tr Give clients a few minutes to look over the handouts?
o Ask "What strikes you?" or "Anything you'd like to start in on?" [i.e., start with clients' reactions]
tr Periodically connect the discussion to the handouts?
4) Check-out. Did the clinician:
tr Guide clients to look at the ldeas for a Commitment at the end of the handouts?
o Ask "Name one thing you got out of today's session?"
Allow client to name anything (does not have to relate to the topic covered)
Support, but do not judge/correct client (e.9., "l think you got something else out of it")
"Any
problems with the session?"
u Ask
r
o
o
o
o
o
tr
o
tr
n
tr
r
o
o
o
n
n
Ask "What is your new commitment?"
Suggest ideas if they can't think of commitment
Encourage client to choose any helpful commitment (does not have to be from manual)
Make sure each commitment is concrete enough to actually do it
Make sure client is writing it down/clinician is writing it down
Contain check-in to no more than about 2-3 minutes per client?
Avoid bringing up new interventions during check-out?
o
o
o
o
Special circumstances? Note below any compelling reasons why the clinician may not have followed the
format. For example, if a group has 15 people, the check-in may be limited to just a few people answering
each question, with different people on each question.
General notes. Note below any general notes you would like to discuss with the clinician. This may include,
for example, themes or areas of growth across the clinician's work, and ideas for additional reading or further
training.
Treatment lnnovations, 2003 / updated 2015. Seeking Safety session format worksheet.
Unpublished measure. Newton Centre, MA
@ Lisa Najavits /
Downloaded from www.treatment-innovations.org, section Training / Materials.