Seeking Safety

1. Introduction

Version followed: adult Seeking Safety as published in Najavits, L. M. (2002), Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Guilford; 25 topics, each with a clinician guide and client handouts; the 2021 Guilford e-book is the same book, and no later edition was found). The session format (check-in, quotation, relating the topic, check-out, with timings), the handouts for Introduction/Case Management, Safety, PTSD: Taking Back Your Power, Grounding and the opening of When Substances Control You, the Safe Coping Sheet, the Commitment handout and the therapist sheets on case management and hard cases come from the developer's own handout PDF (the manual's handouts and therapist sheets, released by Najavits in April 2020 for personal non-commercial use with clients; copy hosted by a Texas A&M University–Corpus Christi training module) and are tagged [source: Najavits handouts]. The manual's chapters (including the Guilford Chapter 1 excerpt), the clinician guides for the other topics and the Life Choices Game rules are not drawn on; content for those stays [synthesis] or [uncertain]. The adolescent version is a separate entry and is not covered here.

Seeking Safety is a present-focused coping-skills therapy for people with trauma and/or substance use problems (including co-occurring PTSD and substance use disorder). It is delivered individually or in groups, by professionals or peers, and alongside other treatment. Its overarching goal is safety: in relationships, thinking, behaviour and emotions. It treats trauma and addiction at the same time when both are present, and it does not ask clients to tell or process trauma memories. Change is understood as replacing unsafe coping (substance use, self-harm, dangerous relationships, dissociation) with safe coping skills learned and rehearsed in session, supported by case management and by restoring the ideals and hope that trauma and addiction erode. [source: CEBC adult profile; Guilford book page; CT DMHAS presentation]

Practical position in trauma care [synthesis]: it sits in the safety and stabilisation phase of phased trauma treatment. It can be the whole intervention, a front-end to later memory-focused work, or a parallel group while a client receives other therapy. The publisher notes it can be combined with the author's past-focused model, Creating Change [source: Guilford book page].

2. Framework

Seeking Safety is not organised into fixed phases. It is a menu of 25 stand-alone topics that can be done in any order and in as many sessions as time allows. [source: CEBC]

The 25 topics, by content area [source: CEBC; Guilford table of contents]

Combination (4): Introduction to Treatment / Case Management; Safety; Life Choices Game (Review); Termination.
Interpersonal (7): Asking for Help; Honesty; Setting Boundaries in Relationships; Healthy Relationships; Community Resources; Healing from Anger; Getting Others to Support Your Recovery.
Behavioural (7): Detaching from Emotional Pain (Grounding); Taking Good Care of Yourself; Red and Green Flags; Commitment; Coping with Triggers; Respecting Your Time; Self-Nurturing.
Cognitive (7): PTSD: Taking Back Your Power; Compassion; When Substances Control You; Recovery Thinking; Integrating the Split Self; Creating Meaning; Discovery.

Manual order (the order the book prints them, usable as a default): Introduction/Case Management, Safety, PTSD: Taking Back Your Power, Grounding, When Substances Control You, Asking for Help, Taking Good Care of Yourself, Compassion, Red and Green Flags, Honesty, Recovery Thinking, Integrating the Split Self, Commitment, Creating Meaning, Community Resources, Setting Boundaries, Discovery, Getting Others to Support Your Recovery, Coping with Triggers, Respecting Your Time, Healthy Relationships, Self-Nurturing, Healing from Anger, Life Choices Game, Termination. [source: Guilford table of contents]

Format and dose [source: CEBC unless noted]

Individual or group; groups of 2 to 50. Open (rolling) enrolment is used in trials: clients can join, miss and rejoin. [source: CEBC; CTN record; ISRCTN protocol]
Session length flexible, from 20 minutes to 2 hours; examples are one hour weekly or 1.5 hours twice weekly. A UK NHS trial uses weekly 60 to 90 minute groups, up to 20 sessions over six months. [source: CEBC; ISRCTN protocol]
Course length flexible: all 25 topics twice weekly takes about three months; 12 topics weekly also about three months. CEBC reports benefit with as few as 6 sessions and some value from 1 to 3 sessions in brief settings such as detox. A large US multisite trial used 12 sessions over 6 weeks. [source: CEBC; CTN record]
Telehealth: an electronic version exists for remote delivery. [source: CEBC]
Between-session work is optional; clients are encouraged to make a "commitment" to one action for their recovery before the next session. [source: CEBC]

Session structure [source: Najavits handouts, session-format sheet; paraphrased]. Every session has the same four parts. (1) Check-in, up to about 5 minutes per client: five brief questions on current feelings, good coping since the last session, any substance use or other unsafe behaviour, whether the commitment was done, and an update on the community resource. (2) Quotation, about 2 minutes: a client reads a quotation aloud, the clinician asks for its main point and links it to the session. (3) Relating the topic to clients' lives, about 30 to 40 minutes, the core of the session: clients look over the handouts briefly (up to about 5 minutes), then the clinician ties the material to clients' current, specific problems; the Safe Coping Sheet is an optional tool here. (4) Check-out, a few minutes: one thing gained from the session plus any problems with it, the new commitment, and which community resource the client will call. An optional brief End-of-Session Questionnaire (simple 0 to 3 ratings plus comments; items not reproduced) can be handed out. The handouts also rank treatment priorities: stop substance use, reduce PTSD symptoms, and increase other safety (e.g. HIV risk, domestic violence, self-harm). In larger groups, shorten check-in turns so the topic keeps its time [synthesis].

Course stages in practice [synthesis built on the topic list]

Start: assessment and Introduction to Treatment / Case Management (orient to the model, identify practical needs, agree on safety goals). Safety is the natural second topic.
Core topics: choose and sequence topics by the client's or group's most pressing unsafe behaviours (e.g. Grounding early for dissociation or flashbacks; When Substances Control You for active use; Red and Green Flags when relapse or crisis risk is high). In open groups, cycle through the topics so newcomers can join anywhere.
Review: Life Choices Game consolidates skills across topics.
End: Termination, with a written plan for continuing safe coping and further care.

Criteria for moving on [synthesis]: move from stabilisation to past-focused trauma work (e.g. Creating Change or a trauma-focused therapy) only when unsafe behaviours are infrequent and managed, substance use is stable, the client can ground themselves from distress reliably, current relationships and housing are reasonably safe, and the client chooses it. Clients who never meet these may still benefit from Seeking Safety alone.

Fidelity and training [source: CEBC; LAC-DMH guidelines]: training is optional for clinical use but required for research. Fidelity tools include a long Seeking Safety Fidelity (adherence) Scale, a brief clinical fidelity form, a Session Format Checklist and a Supervisor Certification Scale. One county system required trainees to score at least 2.0 on each adherence-scale section, held monthly supervision using the model's supervision format, and re-rated staff every six months. Training options include webinars, four training videos (overview, example session, a client's story and grounding, fidelity), phone consultation, and rater, supervisor and conducting certifications.

3. Guiding principles

The five key principles [source: CEBC adult profile]:

Safety as the overarching goal in relationships, thinking, behaviour and emotions. Practical meaning: every session and every topic is linked back to "what will help you be safer this week?"
Integrated treatment of trauma and substance use at the same time when both are present. Practical meaning: do not tell clients to get sober before addressing trauma, or vice versa; link the two in each topic (e.g. how a trigger leads to using).
A focus on ideals to counteract the loss of ideals in trauma and addiction. Practical meaning: use hopeful, value-laden language and the quotation to point to who the client wants to be, not only to symptoms.
Four content areas: cognitive, behavioural, interpersonal and case management. Practical meaning: cover thinking, actions, relationships and practical needs (housing, medical care, legal, benefits) rather than only talk.
Attention to clinician processes: the clinician's emotional responses, self-care and related issues. Practical meaning: monitor your own reactions (frustration, rescuing, harshness, burnout) and take them to supervision.

Further principles visible in the sources:

Present focus; no trauma storytelling. Practical meaning: in groups, members do not share trauma details; they talk about how trauma and substance use affect them now and how to cope [source: CT DMHAS group ground rule; CEBC "present-focused"].
Flexibility. Practical meaning: pick topics relevant to the client or group, in any order, at whatever dose the setting allows [source: CEBC; Guilford].
Accessible to any provider, including peers. Practical meaning: the structure carries the work; licensure is not required, though a licensed clinician must still manage risk in clinical services [source: CEBC; Guilford; risk point is synthesis].
Compatible with other treatment. Practical meaning: run it alongside medication, addiction treatment or individual therapy rather than as a replacement [source: Guilford].
Commitment to action. Practical meaning: end each session with one concrete, achievable step the client chooses [source: CEBC].
Any stage of change and any substance. Practical meaning: do not exclude clients who are ambivalent or still using; work with where they are [source: CT DMHAS implementation].

Client-facing version of the principles [source: Najavits handouts, Introduction topic]: a "Core Concepts of Treatment" handout gives clients about ten short concepts, among them staying safe, respecting yourself, learning to trust, getting help from safe people, using coping rather than substances to escape pain, and persisting (list paraphrased, not reproduced). Practical meaning: refer back to them when a client is stuck or ambivalent [synthesis].

Treatment priorities [source: Najavits handouts]: stopping substance use first, then reducing PTSD symptoms, then increasing other safety (HIV risk, domestic violence, self-harm). Practical meaning: when time is short, work on the most dangerous behaviour first [synthesis].

Additional stance principles [synthesis]: warm and structured at once; praise every instance of safe coping, however small; hold clients accountable for unsafe behaviour without shaming; keep the client's own words central (the topic is applied to their week, not lectured); treat each session as complete in itself so clients who attend once still leave with one skill.

4. Intervention inventory

How to read this section. Part A covers the elements that recur in every session; Part B covers grounding; Part C covers the remaining 24 topics. Part A, Part B and the Introduction, Safety, PTSD, When Substances Control You (opening) and Commitment topics in Part C were checked against the developer's handout PDF and are tagged [source: Najavits handouts]. For the other topics only the name, content area and overall principles were found, so their steps are [synthesis]: built from the topic title, its content area and the model's principles, and not attributed to Najavits. Clinicians who will deliver the model should use the manual's own clinician guide and handouts for each topic (licensed for photocopying by purchasers) [source: Guilford book page]. All example language is illustrative.

Part A. Session elements

A1. Check-in

Purpose: open every session by reviewing safety since the last session, so the topic can be tied to real events and risks are seen early. [source: Najavits handouts, session format]
When: first minutes of every session, individual or group.
Steps [source: Najavits handouts, session format; wording paraphrased]: in a brief turn of up to about 5 minutes, ask each client (1) how they are feeling; (2) what good coping they have done since the last session; (3) whether there has been any substance use or other unsafe behaviour; (4) whether they completed their commitment; (5) for an update on their community-resource contact. Praise specific safe coping, note anything that needs time later (e.g. new risk) rather than processing it during check-in, and keep group turns short and even [synthesis].
Example language (illustrative): "Let's start with check-in. How are you feeling today, what's one safe thing you did this week, any unsafe behaviour we should know about, and how did your commitment go?"
Watch for: check-in turning into a long story or a trauma disclosure. In groups, clients are asked not to describe details of trauma or substance use, to protect other members [source: Najavits handouts, hard-cases sheet]; redirect gently, e.g. "Let's hold that and see how today's topic can help with it" (illustrative). Any disclosure of suicidal intent, overdose or violence needs individual risk assessment that day [synthesis]. Working sign: clients start naming safe coping without prompting [synthesis].

A2. Quotation

Purpose: a short quotation links the session to ideals and hope, consistent with the "focus on ideals" principle. [source: Najavits handouts, session format; CEBC principle]
Steps [source: Najavits handouts, session format, for steps 1, 2 and 4; step 3 is synthesis]: (1) A client reads the quotation aloud. (2) Ask what its main point is. (3) Invite a brief link to the client's own recovery. (4) Connect it to today's topic. About 2 minutes in all.
Example language (illustrative): "What does this quote say to you? How might it apply to your week?"
Watch for: clients finding it trite; invite them to bring their own quotations or sayings [synthesis].

A3. Relating the topic to the client's life

Purpose: the core of the session (about 30 to 40 minutes): teach the topic and apply it to clients' current, specific problems. [source: Najavits handouts, session format]
Steps: (1) Clients look through the topic handouts briefly, up to about 5 minutes [source: Najavits handouts]. (2) Relate the material to each client's current, specific problems rather than discussing it in the abstract [source: Najavits handouts]. (3) Optionally work one real situation on the Safe Coping Sheet (A5) [source: Najavits handouts]. (4) Rehearse the skill on that situation: role-play, rewrite the thought, or plan the action [synthesis]. (5) Summarise the one or two points most useful to this client [synthesis].
Example language (illustrative): "Rather than going through every line, which part of this fits something that happened to you this week?"
Watch for: lecturing; abstract discussion; group members giving advice to each other instead of practising. Working sign: the client can say how they would use the skill in a named upcoming situation.

A4. Check-out and commitment

Purpose: consolidate learning and secure one concrete step before the next session. [source: Najavits handouts, session format and Commitment handout; CEBC]
Steps [source: Najavits handouts; paraphrased]: (1) Ask the client to name one thing they got from today's session, and any problems with it. (2) Agree on a new commitment. (3) Ask which community resource they will call. (4) Record the commitment on the Commitment handout (action, deadline, resource), with a copy for the clinician (see C12). (5) Optionally hand out the brief End-of-Session Questionnaire. Keeping commitments small, specific and within the client's control is [synthesis].
Example language (illustrative): "What's one thing you'll do before we meet again that would move your recovery forward? Make it something you can definitely do."
Watch for: vague or over-ambitious commitments; repeated non-completion (see section 5). Working sign: commitments get done and grow in scope.

A5. Safe Coping Sheet / commitment sheet

Purpose: an optional worksheet for working through one real situation by comparing the client's old way of coping with a new, safe way [source: Najavits handouts, Safe Coping Sheet and its worked example]. One implementing service reports clients using it to get through suicidal feelings [source: CT DMHAS presentation].
Steps [source: Najavits handouts; paraphrased]: (1) Pick a recent or expected difficult situation (the manual's worked example is a flashback). (2) In one column write the old way of coping (in the example, heavy drinking to numb feelings) and what it led to. (3) In the other write a new, safe way (in the example, several grounding methods) and what it led to. (4) Rate how safe each way is on 0 to 10; the new way should bring the intensity of feelings down. (5) Review the sheet at the next check-in [synthesis].
Watch for: sheet becoming paperwork; keep it to one situation.

A6. Case management and community resources

Purpose: case management is one of the four content areas; clients with trauma and addiction often have unmet needs (housing, medical care, legal, benefits, childcare, addiction or psychiatric care) that undermine safety. The manual asks the clinician to act as the client's primary case manager even when other treaters are involved. [source: Najavits handouts, case-management therapist sheet; CEBC; CT DMHAS]
Steps [source: Najavits handouts, case-management therapist sheets; paraphrased]: (1) Review areas of need in the first session (Introduction/Case Management). (2) Deal with life-endangering needs first. (3) Break complex goals into small steps with a deadline, ideally by the next session. (4) Give two specific referrals per goal, with name and phone number, never vague advice. (5) Do not send the client into a system you do not understand yourself: make the call together in session, or find the answer before next time. (6) If a goal is missed: role-play the call, set an immediate deadline, find practical obstacles (transport, phone, childcare, fear of an abusive partner), consider small rewards, involve supportive family with consent, and seek supervision. (7) Do not push a client to stay in a treatment they find unhelpful. (8) Keep a tabbed Resource Book of local services by need (e.g. housing, job training, domestic violence, therapists). Follow up at each check-in.
Example language (illustrative): "Of everything on this list, what would make the biggest difference to your safety if it got sorted out?"
Watch for: referral without follow-through; vet resources for quality and safety before recommending (see Community Resources topic).

Part B. Detaching from Emotional Pain: Grounding

Source note: the procedure below is now checked against the manual's own Grounding therapist sheet and client handout in the developer's handout PDF [source: Najavits handouts], which agree with the unattributed grounding handout used in the first pass [source: grounding handout, psychdb]. Content paraphrased; the manual's scripted demonstration is not reproduced.

Purpose: a set of simple strategies for detaching from emotional pain (cravings, self-harm urges, rage, sadness, flashbacks, dissociation) by focusing outward on the external world and anchoring in the present; it helps balance feeling too much (overwhelm, flashbacks) against feeling too little (numbing, dissociation). The handout presents it as more active than relaxation training and believed to work better for PTSD [source: Najavits handouts]. Other names clients may prefer: centring, distraction, looking outward, healthy detachment [source: grounding handout, psychdb].
When to use: during triggers, anger, dissociation, cravings, or when distress is roughly above 6 on a 0 to 10 scale; anywhere, without others noticing.
Guidelines given to clients: keep eyes open and scan the room; rate distress before and after; do not talk or write about the painful feelings during grounding (the aim is to detach); stay neutral, describing rather than judging; focus on the present.
Three types:
- Mental: describe surroundings in detail using all the senses; category games (name cities, TV programmes); age progression (if feeling younger, count up in years to the current age); describe an everyday task in detail; imagery; a safety statement (own name, where you are, today's date, that you are safe now); read words or letters backwards; humour; count or say the alphabet slowly. [source: Najavits handouts; psychdb handout]
- Physical: run water over the hands; grip the chair; touch and compare objects; dig heels into the floor; carry a grounding object; jump or stretch; clench and release fists; walk slowly noticing each step; eat slowly describing the flavours; breathe slowly repeating a calming word. [source: Najavits handouts; psychdb handout]
- Soothing: kind self-talk; think of favourites (colour, animal, song); picture or look at people you care about; recall an inspiring quotation, poem or prayer; imagine a safe place; a coping statement; plan a safe treat; think of things you are looking forward to. [source: Najavits handouts; psychdb handout]
In-session teaching steps [source: Najavits handouts, Grounding therapist sheet, which builds in a guided demonstration of about 10 minutes; psychdb handout]:
1. Introduce the exercise as brief and structured so it does not catch clients off guard; tell them they stay in control and can stop.
2. Ask for a 0 to 10 rating of negative feeling (a number, not a story) and note it.
3. Explain the goal of moving attention outward, like changing a channel; eyes open.
4. Lead mental, then physical, then soothing grounding, about a minute or more each. Individually, the client answers aloud; in a group, members answer silently.
5. Re-rate 0 to 10 and compare.
6. Discuss what helped and what did not; praise effort; accept negative reactions; plan specific real situations to use it (cravings, anger, self-harm urges).
7. Commitment options for this topic: practise grounding for 10 minutes or more with before-and-after ratings, reread the handout and mark preferred methods, carry a meaningful grounding object, or complete a Safe Coping Sheet [source: Najavits handouts]. Optional: record the exercise for home practice and share it with a trusted person [source: Najavits handouts (recorded message); psychdb handout].
Example language (illustrative): "Keep your eyes open and look around. Tell me five things you can see, and describe them as if to someone who's never been here... Now press your feet into the floor and notice how solid it is... What number would you give your distress now?"
Watch for: anxiety showing as joking or mocking (explore individually; in groups set a gentle limit and offer the option to step out) [source: psychdb handout]; closing eyes or a pure breath focus, which can increase dissociation in some people with PTSD (the manual keeps eyes open) [source: Najavits handouts; psychdb handout]; objections such as "it only works when you lead it", "I should face my feelings", "it's like dissociating", "I forget", "it feels silly": address each directly (e.g. grounding is chosen and reversible, unlike dissociation [synthesis]). Praise early successes and accept and discuss negative reactions [source: Najavits handouts]. If the rating does not fall, ask what would make it work better and review the handout; client-level fixes in the manual include practising often even when not in crisis, going faster, trying longer runs of 20 to 30 minutes, choosing and inventing preferred methods, starting early as a mood rises, keeping an index card of best methods, involving supportive others, preparing materials in advance and using a recorded grounding message [source: Najavits handouts]. Working sign: lower post-rating and the client reports using it outside session.
Safety note [synthesis]: if a client dissociates in session, switch to physical and mental grounding in a firm, calm voice, use their name, orient to time and place, and do not end the session until they are oriented and have a plan for getting home safely.

Part C. The other 24 topics

Topic names and content areas: [source: CEBC; Guilford table of contents]. For Introduction/Case Management, Safety, PTSD: Taking Back Your Power, When Substances Control You (opening only) and Commitment, handout content was checked [source: Najavits handouts] and is tagged inline. For the other topics the manual's clinician guide is not drawn on: everything under them is [synthesis] built from the title, content area and principles, and not attributed to Najavits [uncertain]. Each topic fills the "relating the topic" slot (A3) of a session framed by check-in, quotation and check-out.

C1. Introduction to Treatment / Case Management (combination)

Purpose: orient the client to Seeking Safety and start case management; usually the first session.
Steps: (1) Explain the model briefly: present-focused, safety first, both trauma and substance use, no need to tell the trauma story [model features: CEBC; wording synthesis]. (2) Explain its cognitive-behavioural structure, the session format and commitments [source: Najavits handouts, Introduction]. (3) Go through the practical-information handout, including emergency procedures and contacts, which client and clinician sign [source: Najavits handouts]; if the service uses urine testing, explain it (the handout covers it; follow local policy) [source: Najavits handouts]. (4) Make clear that clients are not discharged for using; discharge is reserved for serious danger to others, such as assault or selling drugs [source: Najavits handouts]. (5) In a group, agree rules, including no details of trauma or substance use [source: Najavits handouts], plus confidentiality and respect [synthesis]. (6) Start case management: review needs and pick one to act on (A6) [source: Najavits handouts, case-management sheets].
Example language (illustrative): "Here we work on staying safe now. You won't be asked to go into what happened to you; we focus on coping with how it affects you today."
Watch for: clients who expect to process trauma and feel let down (explain stabilisation first and when trauma work can follow); unmet basic needs that will derail attendance.

C2. Safety (combination)

Purpose: define safety and its place in recovery, identify current unsafe behaviours, and build a repertoire of safe coping. [source: Najavits handouts, Safety topic; CEBC]
Steps: (1) Discuss what safety means across relationships, thinking, behaviour and emotions [source: CEBC; Najavits handouts]. (2) Present the handout's three stages of healing from trauma (safety, then mourning, then reconnection), with safety as the current stage, and its signs of recovery [source: Najavits handouts]. (3) List the client's current unsafe behaviours and choose the highest-risk one [synthesis]. (4) Go through the manual's long list of Safe Coping Skills (about 100 short coping actions, such as asking for help, leaving a bad scene, setting a boundary, noticing the choice point) and have the client mark the ones to try [source: Najavits handouts; list not reproduced]. (5) Make a related commitment [source: Najavits handouts].
Example language (illustrative): "If you were completely safe a year from now, what would be different in your relationships, your thinking, what you do, and how you handle feelings?"
Watch for: minimising; disclosure of current violence or suicidal risk (assess and safety-plan immediately).

C3. PTSD: Taking Back Your Power (cognitive)

Purpose: psychoeducation on trauma and PTSD and its link to substance use, so symptoms make sense and feel less shameful.
Steps: (1) Explain PTSD in plain language, including the difference between simple and complex PTSD [source: Najavits handouts, PTSD topic]. (2) Ask which reactions the client recognises, without trauma detail [synthesis]. (3) Explain the links between PTSD and substance use (e.g. using to numb or to sleep) [source: Najavits handouts]. (4) Use the handout's exercise contrasting a harsh view with a compassionate view of oneself, and help the client rewrite one harsh judgement [source: Najavits handouts; steps paraphrased]. (5) Identify one symptom they want more control over and one safe coping step [synthesis]. Use a recognised PTSD screen if the service uses one, without reproducing items [synthesis].
Example language (illustrative): "Many people use substances to turn the volume down on these symptoms. It makes sense, and it also keeps the symptoms going. Which of these do you notice most?"
Watch for: rising distress during psychoeducation; ground and slow down. Clients without PTSD: frame as trauma effects generally.

C4. When Substances Control You (cognitive)

Purpose: psychoeducation on substance use and how it interacts with trauma; set a goal about use. The handout describes substance abuse as the substance controlling one's life, frames it as a medical illness rather than a character flaw with biological and/or life-experience causes, and gives a self-check separating abuse from dependence (not reproduced) [source: Najavits handouts, opening of handout only; the rest uncertain]. Clients are accepted at any stage of change [source: CT DMHAS].
Steps: (1) Review the client's pattern of use and its consequences, using the handout's self-check [source: Najavits handouts]. (2) Explore how trauma symptoms drive use and how use worsens trauma symptoms [synthesis]. (3) Weigh the pros and cons of change [synthesis]. (4) Agree on a goal: the manual's first priority is stopping substance use [source: Najavits handouts]; with a client not yet ready, agree the safest step they will commit to while keeping abstinence as the aim [synthesis]. (5) Link to addiction care; refer for detox where there is severe danger or a need for medically supervised withdrawal, while for clients not in acute danger outpatient supports are often preferable [source: Najavits handouts, hard-cases sheet].
Example language (illustrative): "What does using do for you, and what does it cost you? What would you want to try this week?"
Watch for: unsafe unsupervised withdrawal from alcohol or sedatives (refer for medical assessment); moralising.

C5. Asking for Help (interpersonal)

Purpose: build the ability to ask for help, often eroded by trauma and addiction.
Steps: (1) Explore beliefs blocking help-seeking ("I'll be let down", "it's weak"). (2) Identify safe people and services. (3) Script a specific request. (4) Role-play it. (5) Commit to one request.
Example language (illustrative): "Let's practise exactly what you'd say. I'll be the person; go ahead."
Watch for: asking unsafe people; help-rejecting patterns.

C6. Taking Good Care of Yourself (behavioural)

Purpose: improve basic self-care (health care, sleep, food, hygiene, finances, leisure) that trauma and addiction undermine.
Steps: (1) Review self-care areas and rate each. (2) Pick one neglected area. (3) Plan a specific step (e.g. book a medical or dental appointment). (4) Commit.
Example language (illustrative): "Which part of looking after yourself has slipped the most? What's one small step on it?"
Watch for: overwhelm from a long list; keep to one item. Eating or weight issues: focus on regular care, no targets.

C7. Compassion (cognitive)

Purpose: replace harsh self-talk with compassion as a basis for change.
Steps: (1) Notice the client's self-criticism in check-in material. (2) Ask how they would speak to a friend in their situation. (3) Rewrite one self-statement compassionately. (4) Practise saying it.
Example language (illustrative): "If someone you cared about had been through what you have and slipped this week, what would you tell them?"
Watch for: belief that self-compassion means letting oneself off the hook; frame it as what makes change possible.

C8. Red and Green Flags (behavioural)

Purpose: recognise warning signs of danger (relapse, self-harm, crisis) and plan responses at each level of risk. The manual places its Safety Plan in this topic [source: Najavits handouts, therapist-sheet cross-reference]; the plan's content is not drawn on, so the steps below are [synthesis].
Steps: (1) List the client's early, mid and late warning signs. (2) List signs of stability and safe progress. (3) Write a plan for each level: coping steps, people to call, services and emergency numbers. (4) Include lethal-means counselling where there is suicide risk (safe storage or removal of means with a supporter, no method detail). (5) Give the client a copy.
Example language (illustrative): "What's the first sign that things are starting to slide for you? What would you do at that point, before it gets worse?"
Watch for: plans that rely on willpower alone; plans without phone numbers. Review after every crisis.

C9. Honesty (interpersonal)

Purpose: practise honesty with self and others as part of recovery, while judging when and with whom disclosure is safe.
Steps: (1) Explore how secrecy has been part of trauma and use. (2) Discuss the costs and benefits of honesty in a chosen situation. (3) Role-play an honest statement. (4) Include honesty in check-in about use.
Example language (illustrative): "In here, telling us you used is a success, not a failure; it's how we can help."
Watch for: clients pressured to disclose trauma or use to unsafe people; respect safety in disclosure decisions.

C10. Recovery Thinking (cognitive)

Purpose: identify thoughts that drive unsafe behaviour and replace them with thoughts that support recovery.
Steps: (1) Pick a recent unsafe episode. (2) Identify the thought just before it (e.g. "one won't matter", "I deserve to hurt"). (3) Examine it: effects, evidence, what a recovery-minded person would say. (4) Write a replacement thought. (5) Rehearse it for the next trigger.
Example language (illustrative): "What went through your mind right before you picked up? What would the part of you that wants recovery say back?"
Watch for: clients who cannot find a thought; start with the feeling or situation.

C11. Integrating the Split Self (cognitive)

Purpose: help clients notice and integrate conflicting sides of themselves (e.g. the side that wants to use and the side that wants recovery; all-or-nothing swings) rather than acting from one extreme.
Steps: (1) Name the opposing sides in the client's language. (2) Explore what each wants and fears. (3) Find a stance that holds both, aligned with safety. (4) Practise recognising the switch in the moment.
Example language (illustrative): "It sounds like part of you wants to stop and part of you doesn't. Both are real. What does each one need?"
Watch for: clients with dissociative identity features; keep to present-day coping and grounding, and refer for specialist assessment rather than exploring parts in depth [synthesis].

C12. Commitment (behavioural)

Purpose: strengthen keeping promises to oneself and others. The manual describes a commitment as a promise to oneself, one's recovery and one's therapist; the Commitment handout records the action, a deadline and a community resource to call, with a tear-off copy for the clinician, and each topic offers commitment ideas (e.g. a journal of successes, an inspiration box, trying one new safe coping skill, a Safe Coping Sheet) [source: Najavits handouts; CEBC]. The topic-specific steps below are [synthesis].
Steps: (1) Review the client's record with commitments without blame. (2) Explore what helps and what blocks follow-through. (3) Teach making commitments specific, small, scheduled and supported. (4) Make one with these features.
Example language (illustrative): "When you did keep a commitment, what made the difference?"
Watch for: shame about past failures; see section 5 on non-adherence.

C13. Creating Meaning (cognitive)

Purpose: examine the meanings and beliefs clients have drawn from trauma and addiction (e.g. "I'm damaged", "I can't trust anyone") and build meanings that support recovery; links to the ideals principle [source for principle: CEBC].
Steps: (1) Identify one belief that shapes current unsafe behaviour. (2) Explore where it came from and what it costs now. (3) Develop an alternative meaning that is believable to the client. (4) Plan one action consistent with it.
Example language (illustrative): "What has all this taught you about yourself that you'd like to unlearn?"
Watch for: drift into trauma narrative; keep to present beliefs and effects.

C14. Community Resources (interpersonal)

Purpose: connect clients to helpful services and supports and teach them to judge those services. The manual's topic includes national and toll-free help numbers, and the clinician keeps a Resource Book of local services (A6) [source: Najavits handouts, cross-references]. Steps below are [synthesis].
Steps: (1) Identify needed resources (self-help groups, addiction services, trauma services, legal, housing, medical, crisis lines). (2) Discuss how to judge whether a service is safe and helpful. (3) Plan and rehearse the first contact. (4) Follow up at check-in.
Example language (illustrative): "What would you want to know before trusting a new service? Let's make a list of questions to ask them."
Watch for: past bad experiences with services; prepare for barriers rather than dismissing them.

C15. Setting Boundaries in Relationships (interpersonal)

Purpose: set boundaries that protect safety, both saying no to harm and allowing appropriate closeness.
Steps: (1) Identify a relationship where boundaries are too loose (exploitation, pressure to use) or too rigid (isolation). (2) Define the boundary wanted. (3) Script and role-play it. (4) Plan for the other person's reaction and for safety. (5) Commit.
Example language (illustrative): "What exactly do you want to say to him? Let's try it a few ways and see which feels safe and clear."
Watch for: domestic violence; never encourage confrontation that increases danger; do safety planning and refer to specialist services.

C16. Discovery (cognitive)

Purpose: replace fixed assumptions with curiosity, testing beliefs by gathering information and trying things out.
Steps: (1) Identify a belief that keeps the client stuck ("nobody in that group will like me"). (2) Ask how they could find out whether it is true. (3) Design a small, safe experiment. (4) Review the result at next check-in.
Example language (illustrative): "How could you test that out this week in a way that's safe?"
Watch for: experiments that carry real risk; keep them low-stakes.

C17. Getting Others to Support Your Recovery (interpersonal)

Purpose: help clients enlist family, friends or partners in supporting recovery and identify who undermines it.
Steps: (1) Map supportive, neutral and unsupportive people. (2) Decide what to ask of supportive people. (3) Plan how to explain needs (optionally bring a supporter to a session if the service allows). (4) Plan distance from those who undermine recovery.
Example language (illustrative): "Who in your life would want to help if they knew how? What would you ask them to do?"
Watch for: supporters who use with the client or are abusive.

C18. Coping with Triggers (behavioural)

Purpose: identify triggers for trauma symptoms and substance use and plan coping.
Steps: (1) List the client's triggers (people, places, times, feelings, sensations, anniversaries). (2) For each high-priority trigger choose a strategy: avoid where possible and sensible, change the situation, or cope through it with grounding and safe coping. (3) Rehearse the plan for the next likely trigger.
Example language (illustrative): "When's the next time you expect to run into this? What will you do in the first minute?"
Watch for: plans based only on avoidance that shrink the client's life; this is coping, not exposure therapy, so do not set up deliberate exposure within Seeking Safety [synthesis].

C19. Respecting Your Time (behavioural)

Purpose: use time in a way that supports recovery; unstructured time and chaotic schedules are common risks.
Steps: (1) Review a typical week, especially high-risk times. (2) Plan structure for those times (activities, contacts, meetings). (3) Balance obligations with rest and enjoyment. (4) Schedule one change.
Example language (illustrative): "Which hours of the week are the riskiest for you? What could fill them?"
Watch for: over-scheduling; perfectionism.

C20. Healthy Relationships (interpersonal)

Purpose: recognise features of healthy and unhealthy relationships and choose safer ones.
Steps: (1) Discuss what makes a relationship safe or harmful. (2) Apply this to one current relationship. (3) Identify a step toward a healthier pattern. (4) Plan support.
Example language (illustrative): "How do you feel about yourself after time with this person? What does that tell you?"
Watch for: current abuse (safety planning, specialist referral, safeguarding duties where children are involved).

C21. Self-Nurturing (behavioural)

Purpose: build safe pleasure and comfort to replace substances and other unsafe soothing.
Steps: (1) Distinguish safe nurturing from unsafe soothing. (2) Brainstorm safe, accessible, low-cost options. (3) Schedule one daily. (4) Review effects at check-in.
Example language (illustrative): "What used to give you a bit of pleasure that didn't cost you anything later?"
Watch for: anhedonia or guilt about pleasure; start very small.

C22. Healing from Anger (interpersonal)

Purpose: understand anger as a common trauma response and express it safely, neither exploding nor turning it inward (self-harm, using).
Steps: (1) Identify the client's anger cues. (2) Distinguish safe expression from harmful acting out. (3) Practise grounding and time-out at early cues. (4) Plan an assertive response for a typical situation.
Example language (illustrative): "Your anger makes sense given what you've been through. The question is how to use it so it doesn't cost you."
Watch for: violence risk to others (assess and act on duty-to-warn or safeguarding rules); anger in group (clear limits).

C23. Life Choices Game (Review) (combination)

Purpose: review and consolidate skills across topics. The manual presents this as a game; its rules and materials are not drawn on, so the game format is [uncertain] and the review approach below is [synthesis], not the manual's game.
Steps (review approach, [synthesis]): (1) Present realistic everyday dilemmas (e.g. an old using friend calls; a trigger at work). (2) Ask the client or group what safe coping they would use. (3) Link answers to topics covered. (4) Identify skills still weak and plan practice.
Example language (illustrative): "Here's a situation. What would you do, and which of the skills we've covered would help?"
Watch for: competitiveness or shame in groups; keep it light.

C24. Termination (combination)

Purpose: end treatment well, review progress and plan continued safety and care.
Steps: (1) Review gains in each safety domain. (2) Name the most useful skills. (3) Update the Red and Green Flags plan. (4) Arrange next care (continued group, individual therapy, addiction services, past-focused trauma work if ready). (5) Allow feelings about ending, which may echo losses.
Example language (illustrative): "What are you proudest of from our work, and what will you keep doing?"
Watch for: relapse or crisis near the end; dropping out to avoid goodbye. In open groups, mark individual endings even if the group continues.

5. Handling problems

The developer's consultation curriculum for one large county system names the problem areas clinicians most need help with: engaging resistant clients, working with unsafe behaviour, focusing on trauma, focusing on addiction, adapting the model, and tough cases [source: LAC-DMH guidelines, theme list only; content not drawn on]. The manual's own guidance on hard cases, from its therapist sheets, is summarised just below. Except where tagged, the responses after it are [synthesis].

The manual's hard-case guidance [source: Najavits handouts, hard-cases and case-management therapist sheets; paraphrased]

Substance use during treatment: clients are not discharged for using; discharge is reserved for serious danger to staff or other clients (e.g. assault, selling drugs).
Suicide or homicide risk: where risk is serious (a plan, intent, and the client cannot agree to stay safe), inpatient care is typically recommended; involuntary admission calls for supervision and legal advice. Current practice prefers a collaborative written safety plan to a "no-harm contract" [synthesis].
Threat to a third party: follow your jurisdiction's duty-to-warn standard, which usually means promptly warning the intended victim; get supervision and legal advice, ideally in advance.
Child or elder abuse: report to protective services as the law requires.
Domestic violence: recognise that leaving may be very hard for the client; consult a supervisor and a domestic-violence hotline.
Detox: refer when there is severe danger or medically supervised withdrawal is needed; for clients not in acute danger, outpatient supports are often preferable.
Groups: members do not discuss details of trauma or substance use, to protect other members.
Missed case-management goals: role-play the call, set an immediate deadline, identify practical obstacles (transport, phone, childcare, fear of an abusive partner), consider rewards, involve supportive family with consent, and take it to supervision.
Do not keep pushing a client to stay in a treatment they find unhelpful.

Stuck clients (attend but nothing changes)

Shrink the commitment until it is certain to succeed, then build up.
Switch content area: a client stuck in cognitive topics may move with a behavioural one (Grounding, Respecting Your Time) or a case-management win (housing, benefits).
Return to the client's own definition of safety (Safety topic) and ask which domain they want to work on.
Check for untreated drivers: medication review, withdrawal, untreated depression, ongoing abuse at home.

Resistance and low engagement

Accept any stage of change and any substance [source: CT DMHAS]; do not require abstinence to attend unless the setting demands it.
Let clients choose topics; the model allows any order [source: CEBC].
Ask what they want from the session at check-in and connect the topic to it.
Normalise ambivalence (Integrating the Split Self); avoid argument.
Prepare clients before the first group and reduce access barriers (transport, timing, gender-specific groups) [source: CT DMHAS implementation topics and adaptations].

Overwhelm, flashbacks and dissociation in session

Stop topic work and ground immediately: eyes open, physical then mental grounding, re-rate distress 0 to 10 [source for grounding method: grounding handout; attribution uncertain].
Do not ask for trauma detail; redirect to present coping. In groups, protect other members from trauma detail by redirecting gently but firmly [source for no-trauma-detail rule: CT DMHAS].
Before the client leaves: oriented to time and place, distress back to a manageable level, plan for the next few hours, someone to contact.
If overwhelm recurs, prioritise Grounding, Coping with Triggers and Red and Green Flags, and slow the pace.

Unsafe behaviour and crisis (substance use, self-harm, suicidality, violence)

Treat check-in disclosures of unsafe behaviour as information to work with, praise honesty, and link the episode to a skill.
Suicide or self-harm risk: follow your service's standard risk assessment (current ideation, intent, plan, access to means, protective factors), update the Red and Green Flags crisis plan, use lethal-means counselling (safe storage or removal with a supporter), and increase contact or refer to crisis services as needed. In a group, assess individually after or outside the group, not in front of members.
Intoxication at a session: assess safety (medical risk, getting home), keep contact brief and supportive, and plan to discuss when sober.
Current domestic violence or child safeguarding concerns: safety planning and statutory reporting duties apply as in any therapy.

Non-adherence (commitments not done, missed sessions)

Explore without blame what got in the way; problem-solve the barrier.
Make the next commitment smaller, scheduled and supported; write it down (Safe Coping Sheet).
Because topics stand alone, a client who misses sessions can rejoin at any point; open groups allow re-entry [source: ISRCTN protocol; CTN record (open enrolment)].
Outreach after missed sessions (call or text) is a reasonable service practice.

Ruptures

Name the rupture early and invite the client's view; acknowledge your part.
Watch your own reactions, which the model explicitly flags as a clinical process to attend to (frustration with relapse, urge to rescue, harshness) [source: CEBC principle "attention to clinician processes"]; take them to supervision.
Collect check-out feedback each session to catch problems before they become ruptures.

Modality-specific difficulties

Client wants to tell the trauma story: validate the wish; explain that this phase builds safety first; offer referral to past-focused work later (e.g. Creating Change, which the publisher describes as combinable with Seeking Safety) [source: Guilford].
Group members trigger each other: set and enforce the no-trauma-detail rule and respectful-language rules; separate gender groups can help [source: CT DMHAS].
Mixed groups with very different substances or trauma types: keep focus on shared coping skills rather than specific events.
Peer-delivered or non-specialist groups: ensure a licensed clinician is available for risk assessment and supervision [synthesis; CEBC notes peer delivery is used].
Fidelity drift (sessions become unstructured talk or lectures): use the Session Format Checklist or brief fidelity form, record sessions with consent for supervision [source: CEBC; LAC-DMH].
Very brief settings (detox, inpatient): even 1 to 3 sessions can help; prioritise Safety, Grounding and Red and Green Flags [source: CEBC for dose; topic choice is synthesis].
Telehealth: use the electronic materials [source: CEBC]; agree in advance a crisis plan, the client's location and a contact person, and check privacy at each session [synthesis].

Sources

Sources:

Books and papers cited as further reading (not drawn on) [uncertain where relied on]:

Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. Guilford Press. (Session format, therapist sheets and handouts for the first topics from the developer's handout PDF; chapters, including the Chapter 1 excerpt, not drawn on.)
Najavits, L. M. (2009). Seeking Safety: An implementation guide. In A. Rubin and D. W. Springer (Eds.), The Clinician's Guide to Evidence-Based Practice. Wiley.
Najavits, L. M. (2004). Implementation article, Alcoholism Treatment Quarterly, 22(1), cited by CEBC.
Hien, D. A., et al. (2009). Fidelity scale psychometrics, Journal of Consulting and Clinical Psychology (doi 10.1037/a0016227), cited by CEBC.
Morgan-Lopez, A. A., et al. (2014). Indirect effects of 12-session Seeking Safety on substance use outcomes. American Journal on Addictions, 23(3), 218-225.

Further reading (not drawn on): treatment-innovations.org and seekingsafety.org (developer sites), the Guilford Chapter 1 excerpt and reproducible-forms page, and PubMed Central. Not covered here: the Life Choices Game rules, the Red and Green Flags Safety Plan content, and the clinician guides for the topics whose handouts were not in the PDF.

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