Book Reviews

Seeking Safety is a treatment manual for patients who have been dually diagnosed with post-traumatic stress disorder (PTSD) and substance abuse. Lisa Najavits emphasizes the importance, in treating patients who suffer from both of these disorders, of treating both disorders at the same time. She points out that the different treatment programs for PTSD do not take into consideration that if substance abuse exists, as it often does with PTSD patients, it tends to worsen when you try to treat the PTSD. In the same way treatment programs for substance abuse tend to neglect the fact that the symptoms of PTSD often worsen when a person stops abusing alcohol or drugs. This might be a problem in the USA, but in Sweden psychiatric care rarely works in the way that when you seek help, you are diagnosed with either PTSD or substance abuse and referred to evidence-based treatment programs for your disorder. Apart from this, Najavitas presents many wise and helpful ideas about how to treat the two problems in parallel and observe how they go together functionally. Najavitas’ descriptions of her patients remind me of patients who would probably be given a borderline diagnosis in Swedish psychiatry. She states, however, that only 29 % of the patients in the studies are diagnosed with borderline personality disorder. The treatment is short, about 3 months duration, and the goal is to get these dually diagnosed patients to live less unsafe and destructive lives and then go on and use other community-based services for fuller healing. The manual is educational, with a lot of information and instruction on how substance abuse works and how PTSD affects people. It teaches patients to handle the symptoms of PTSD in a safe way and how to stop using substances, cope with cravings and other substance abuse related problems. Several of the topics covered in Seeking Safety are the same as those brought up in DBT (Dialectical Behavior Therapy) skills training. For example “grounding” is much the same as “mindfulness”, how to have good and safe relationships, problem-solving, how to stop selfinvalidation, etc. The main focus of the treatment is safe behaviour (not safety behaviours) and the person’s responsibility for planning his or her own safety. It does not include exposure-treatment of trauma, it stresses how to live with and handle the symptoms of PTSD in a safe way, sometimes with the goal of continuing to an exposure-treatment later on. The manual brings together parts of several other treatments, in a way that seems appealing and adequate for this group of patients. It is clinically tested, but not in a controlled study. There are some concepts that I, as a behaviour therapist, would have preferred to describe and label in a different way (for example transference and counter-transference). It is good, however, that the manual takes into consideration the fact that support, both from the organization and from colleagues, is very important when working with difficult patients with a potential for violence towards themselves or others. Since I have worked a great deal with DBT, which in several ways is similar to Seeking Safety, I miss the thorough base of learning-theory and thorough work with ensuring real behaviour change, generalization to everyday life and methodology to bring it about. As with many other manual-based treatments Seeking Safety sometimes gives the impression that knowledge is enough to make people change. In reality it is much more difficult than this. However, for a group of dually diagnosed patients who do not have the severe emotion dysregulation problem of borderline patients, Seeking Safety can surely work to stabilize their lives and enable them to go forward in a less destructive way and perhaps benefit from other treatments if needed. As with other interactive material this manual has to be translated into the patient’s language to be used in the way it is meant. This will probably impede its more extensive use in non-English speaking countries, but Seeking Safety is still valuable reading for anybody who has contact with this group of patients. Parts of the program can surely be picked out and used successfully. For example, the way in which the program looks at these coexisting problems, and above all its focus on safe behaviour as a priority. It is a relief to have a treatment that is systematic and tested for a group of patients for whom you might think a DBT program would be suitable, but for whom the difficulty of finding such a program and the time aspects and extent of DBT makes it a less attractive option.