Attendance and Substance Use Outcomes for the Seeking Safety Program: Sometimes Less Is More

Epidemiological and clinical studies have established that the majority of women in substance abuse treatment have been exposed to interpersonal trauma in their lifetimes (Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Lincoln, Liebschutz, Chernoff, Nguyen, & Amaro, 2006; Mills, Lynskey, Teesson, Ross, & Dark, 2005) and commonly meet diagnosis for co-occurring post-traumatic stress disorder (Brady, 2001; Najavits, Weiss, & Shaw, 1997). As the extent of such comorbidity and its implications for treatment have come to light, a number of manualized cognitive behavior therapy approaches have been developed to address the complex needs of this population with the aim of improving treatment outcomes. Empirical support for these cognitive behavioral approaches, such as the Seeking Safety program (Najavits, Weiss, Shaw, & Muenz, 1998) and substance dependence posttraumatic stress disorder (PTSD) therapy (Triffleman, 2000), has been promising overall. However, the lack of well-controlled and sufficiently powered trials combined with small effect sizes among trials that were controlled (e.g., Hien, Cohen, Miele, Litt, & Capstick, 2004) have resulted in limited evidence that trauma treatments can significantly impact substance use outcomes. To date, no single treatment study has shown a magnitude of symptom improvement such that it could be recommended among guidelines for best clinical practices among women with co-occurring PTSD and addiction. As we have detailed elsewhere (Hien, Cohen, & Campbell, 2009), applying conventional statistical methodologies for randomized controlled trials using an intent-to-treat approach can be problematic when examining the efficacy of treatments for co-occurring disorders because of a number of assumptions typically made in group therapy treatment trials for substance abuse (Feaster, Newman, & Rice, 2003). These assumptions and the ways that they fail to fit the comorbid PTSD/SUD population are examined and include (a) homogeneity of patient population and treatment response, (b) a dose–response relationship between treatment attendance and outcome, and (c) similarity between patient attendance in groups.