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Program Profile: "Seeking Safety" for Incarcerated Women

Evidence Rating: Promising - One study Promising - One study

Date: This profile was posted on September 08, 2015

Program Summary

A manualized cognitive–behavioral intervention for incarcerated women with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders. The program is rated Promising. Evaluation results suggest that the program significantly reduced PTSD and depression scores in program participants.

Program Description

Program Goals
Seeking Safety is a manualized cognitive–behavioral intervention for individuals with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders. Seeking Safety has been used for a number of different populations, including incarcerated women. The intervention targets many of the unique needs of incarcerated women with PTSD and substance use disorders, which could interfere with their recovery and thus place them at risk for reoffending. The overall goal of Seeking Safety is to improve PTSD, depression, interpersonal skills, and coping strategies of incarcerated women.

Program Components/Target Population
Seeking Safety (SS) is a 12-week intervention, during which groups meet twice a week for 2 hours each time. As part of the treatment, SS provides psychoeducation, which seeks to educate participants about the consequences of trauma and the links between trauma and substance use. SS also integrates cognitive, behavioral, and interpersonal topics, and teaches specific coping skills. The treatment consists of 25 topics (such as asking for help and coping with triggers), which address the cognitive, behavioral, interpersonal, and case management needs of persons with both substance use disorders and PTSD. The intervention emphasizes the importance of stabilization, coping skills, and the reduction of self-destructive behavior (Zlotnick et al. 2003).

Program Theory
Seeking Safety therapy draws upon cognitive–behavioral therapy, and therefore the cognitive model. The cognitive model holds that individuals’ perceptions and thoughts about a situation will influence their emotional and behavioral reactions. Further, the cognitive model argues that individuals’ perceptions and thoughts are often distorted when they are distressed. It is through cognitive therapy that individuals can learn to correct this negative thinking; identify and modify distorted beliefs about themselves, the world, and others; and learn to accept their difficulties (Beck Institute for Cognitive Behavior Therapy 2015).

In addition to the cognitive model, Seeking Safety also draws upon psychoeducation, which includes an array of approaches such as ecological systems theory and group practice models. Ecological systems theory focuses on helping people understand their illness or experience in relation to others (i.e., partners or family). In line with this approach is group practice, which sets the stage for individual interaction, social learning, expansion of support, and the potential for group reinforcement of a positive change in behaviors (Lukens and McFarlane 2004). Using the cognitive model along with psychoeducation, Seeking Safety aims to address PTSD and substance use disorders in a population that needs an integrated treatment approach for these co-occurring disorders. 

Evaluation Outcomes

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Study 1
Posttraumatic Stress Disorder (PTSD) Scores
Lynch and colleagues (2012) found that at the 12-week follow up interview, women in the Seeking Safety treatment condition showed significantly greater decreases in their PTSD scores compared with women in the wait-list control condition.

Depression Scores
At the 12-week follow up interview, women in the Seeking Safety treatment condition showed significantly greater decreases in their depression scores than women in the wait-list control condition. 
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Evaluation Methodology

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Study 1
To evaluate the impact of Seeking Safety for incarcerated women, Lynch and colleagues (2012) used a quasi-experimental design comparing Seeking Safety treatment provided to a group in a correctional facility (treatment condition) to a wait-list control group (comparison condition). Program participants were recruited over a 3-year period. The women lived in a state prison that housed both minimum- and medium-security inmates. To be eligible for inclusion, women had to have a history of trauma, a history of substance use disorder, and moderate to severe posttraumatic stress disorder (PTSD) symptoms (defined by a source of 30 or greater on the PTSD Checklist). Women also had to be proficient in English, at least 18 years old, and eligible for release within 3 years. The final sample included 114 participants: 59 participants in the treatment condition and 55 women in the wait-list control condition. The overall sample included the following racial /ethnic groups: white, Native American, Hispanic, African American, and Asian American/Pacific Islander. Regarding offense type, the majority of the sample had been incarcerated for nonviolent crimes, such as property damage, burglary or forgery, or drug-related crimes. Further, the majority of the sample had been incarcerated before their current incarceration. Preliminary analyses were conducted to detect significant associations between demographic characteristics and outcome variables. These analyses revealed significant associations between frequency of lifetime intimate partner violence and initial levels of PTSD and depression symptoms, negative associations between education levels and initial depression symptoms, and that women of color had higher initial levels of coping skills than white women. As a result, these variables were included as covariates in the relevant repeated measures of analyses of covariance (ANCOVAs). 

A total of eight groups of Seeking Safety were offered, with group sizes of between 8 and 15 members. After being cleared for participation by prison staff, participants were screened in a brief interview for history of family trauma, substance use, and PTSD symptoms. After the initial interview, eligible participants were assigned to either the treatment or comparison condition. Assignment to either condition was dependent on the inmates’ anticipated release or transfer. 

The following measures were analyzed to determine the impact of the Seeking Safety intervention: a trauma history questionnaire, which assessed exposure to various types of trauma; the PTSD Checklist-Civilian Version, which assessed symptoms of PTSD during the past 30 days; the Alcohol and Drug Use History Questionnaire, which assessed the presence/absence of Diagnostic and Statistical Manual of Mental Disorders criteria for substance dependence prior to incarceration; the Center for Epidemiological Studies–Depression Scale, which measured the frequency of participants’ depression symptoms during the past week; Brief COPE, which measured the frequency of participants’ use of coping skills; and the Inventory of Interpersonal Problems, which measured how often participants had experienced various interpersonal difficulties. These measures were given to all participants at the initial interview, and again at the end of the 12-week follow-up interview (i.e., following treatment for the treatment condition, and following wait-list control for the comparison condition). Five repeated measures of ANCOVAs were used to test for differences in PTSD and depression. However, it is important to note that this review only focused on the outcomes of PTSD and depression. 
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There is no cost information available for this program.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Lynch, Shannon M., Nicole M. Heath, Kathleen C. Matthews, and Galatia J. Cepeda. 2012. “Seeking Safety: An Intervention for Trauma-Exposed Incarcerated Women?” Journal of Trauma & Dissociation 13: 88­–101.

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Additional References

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These sources were used in the development of the program profile:

Beck Institute for Cognitive Behavior Therapy. 2015. Cognitive Model. Bala Cynwyd, Pa.: Beck Institute for Cognitive Behavior Therapy.

Lukens, Ellen P., and William R. McFarlane. 2004. “Psychoeducation as Evidence-Based Practice: Considerations for Practice, Research, and Policy.” Brief Treatment and Crisis Intervention 4(3):205–25.

Zlotnick, Caron, Lisa M. Najavits, Damaris J. Rohsenow, and Dawn M. Johnson. 2003. “A Cognitive-Behavioral Treatment for Incarcerated Women with Substance Abuse Disorder and Posttraumatic Stress Disorder: Findings from a Pilot Study.” Journal of Substance Abuse Treatment 25: 99–105. 
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Program Snapshot

Age: 18+

Gender: Female

Race/Ethnicity: Black, American Indians/Alaska Native, Asian/Pacific Islander, Hispanic, White

Setting (Delivery): Correctional

Program Type: Alcohol and Drug Therapy/Treatment, Cognitive Behavioral Treatment, Gender-Specific Programming, Group Therapy, Victim Programs

Targeted Population: Victims of Crime, Prisoners

Current Program Status: Active