Seeking Safety helps people who have experienced trauma and/or substance use disorder gain safe coping skills through a flexible 12-session intervention. The University of California, San Diego Mother Child Adolescent HIV Program and the Multicultural AIDS Coalition implemented Seeking Safety as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. Participants had higher rates of retention in care and viral suppression after 12 months of the intervention.
San Diego, CA
People with HIV are disproportionately impacted by trauma and substance use disorder, which can affect their ability to engage in HIV treatment.1 Seeking Safety, which explores how trauma affects people in the present day instead of delving into past experiences, helps individuals develop safe coping skills and increase their sense of hope. Seeking Safety has been implemented in a broad range of settings and populations, and studies consistently show positive results and high satisfaction with the intervention.2
Safety always remains front-and-center during treatment. Clients are guided to identify what safety means to them, which may include reducing addiction, letting go of dangerous relationships (e.g., a violent partner), and gaining control over unsafe behaviors (e.g., cutting, burning, bingeing).
Integrated treatment means that trauma and addiction are addressed at the same time if both issues are present. Trauma and addiction often reinforce each other; therefore, treating them simultaneously is more helpful than treating them individually.
To inspire hope for the future, Seeking Safety frames each topic as a positive ideal (e.g., compassion, honesty, healing from anger, creating meaning) to counter the loss of ideals in both trauma and substance use.
Seeking Safety topics cover coping skills in four content domains:
- Behavioral: For example, ‘detaching from emotional pain,’ ‘taking good care of yourself.’
- Cognitive: For example, ‘PTSD: Taking back your power,’ ‘recovery thinking.’
- Interpersonal: For example, ‘asking for help,’ ‘honesty.’
- Case Management: For example, ‘introduction to the treatment,’ ‘assessment of needs.’
Staff providing Seeking Safety may have a history of trauma or substance use themselves, or experience emotional reactions to information shared during sessions. Therefore, implementing sites should encourage staff to understand their reactions and provide opportunities for self-care.
Across the two implementation sites, 122 clients participated in this intervention. Participants in Seeking Safety had higher rates of retention in care and viral suppression after 12 months, but findings were not statistically significant.
|Evaluation data||Surveys and medical chart review|
Percentage of clients who:
Percentage of clients who were:
Source: Seeking Safety: E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.
“When it comes to [post-traumatic stress syndrome] and substance use, there are internal conversations clients have with themselves. What Seeking Safety does is bring those internal conversations to the table and help clients understand they are not alone in this journey.”
Obtain materials. To deliver Seeking Safety, sites should obtain Seeking Safety: A Treatment Manual for PTSD and Substance Abuse, available from Guilford Press in paperback and electronic PDF format. The Seeking Safety HIV Guide provides additional guidance on delivering Seeking Safety specifically with people with HIV.
Identify and train staff. Seeking Safety group sessions can be facilitated by health care providers, case managers, or peers. Implementing sites found that staff leading discussion groups should be skilled facilitators with experience managing group dynamics and making referrals to social services, to reduce attendance barriers. Peers can support facilitation. Training to deliver Seeking Safety is highly recommended, but not required. Training opportunities are available through the Seeking Safety website. Other training topics of interest include self-care, strategies for providing trauma-informed and culturally responsive care, and resilience in the workplace. Additional recommended staff include a behavioral health care professional to supervise the facilitators, and program administrators to provide logistical support related to scheduling and obtaining materials needed for group sessions.
Recruit clients. Seeking Safety can benefit anyone who needs stronger coping skills, especially people with trauma or substance use disorder. Providers may use a validated assessment tool, get referrals from clinicians or case managers, or publicize the program via fliers, palm cards or social media to identify potential participants. Providers may also choose to transition an existing support group to the Seeking Safety approach.
Select safe coping skills topics to focus on. Providers can choose up to 25 safe coping skill topics related to behavioral, cognitive, interpersonal, and case management issues. Topics reflect a positive ideal to inspire hope. While the optimal number of topics is at least 12, providers may choose as many or as few as they would like.
Choose delivery format. Seeking Safety is highly flexible. Sessions can be conducted in group or individual format. Groups can be ‘open’ (clients can join at any point) or ‘closed’ (all clients begin and end at the same time). Topics can be provided in any order since each topic is independent of the others. Each topic can be delivered in one or more sessions and sessions can be of any length. To prepare for each session, providers should identify the types of activities that would engage their clients and help explain the content, including videos, handouts, games, role plays, and art.
Adopt a group cycle that works for the setting and clients. The E2i sites delivered Seeking Safety in closed groups in 12-week cycles. Each cycle began with the first four introductory Seeking Safety topics followed by eight topics chosen based on the group’s interests and needs. However, providers can choose to adopt a different approach, conducting sessions individually or allowing clients to join at any point. Sessions typically start with a check-in to gauge how clients are feeling and whether they have applied any good coping skills, engaged in unsafe behavior, or met a predefined commitment (e.g., ask partner not to offer substances) since the last meeting. After discussing an inspirational quote, clients review a handout on the topic chosen for discussion and engage with the topic by discussing how it relates to trauma or addiction, and by role-playing related coping skills. Participants end the session by discussing what they got out of it and suggestions for improvement.
“We have too many stories to share of how this intervention has positively impacted our clients! Because of Seeking Safety, we have been able to reach individuals not previously served by our agency, and we have created active partnerships with other providers in the community.”
Two sites participated in the Seeking Safety E2i initiative. Learn more about their implementations below.
Multicultural AIDS Coalition (Boston, MA)
University of California, San Diego (UCSD) Mother Child Adolescent HIV Program (San Diego, CA)
- Costs incurred by the sites were related to planning and implementation, including recruitment and supervision costs. For more information, see the implementation guide.
- Due to challenges in health care coverage, Seeking Safety typically involves the use of grant funds, such as RWHAP funding for psychosocial support services, and Substance Abuse and Mental Health Services Administration (SAMHSA) funding.
- Providers that implemented Seeking Safety found that the attendance at 12 sessions was not feasible for most clients, and changed their goal to eight sessions; to lower barriers to attendance they held make-up sessions, allowed clients to join other groups, and provided transportation (e.g., bus passes, gas cards, and ride services), childcare, and food. Sessions transitioned relatively easily to virtual platforms during the COVID-19 pandemic.
- To avoid potentially disruptive behavior, providers assessed clients for their readiness to participate in group sessions. A Seeking Safety group agreement also helps clients to better meet expectations for positive group dynamics.
- Session group facilitators spent more time educating clients on the impact of trauma than initially anticipated given that it was a new concept for some.
All Seeking Safety research articles can be found here: https://www.treatment-innovations.org/evid-all-studies-ss.html. Specific articles on use of Seeking Safety with individuals with HIV are below.
Empson S, Cuca YP, Cocohoba J, et al. Seeking Safety group therapy for co-occurring substance use disorder and PTSD among transgender women living with HIV: A pilot study. J Psychoactive Drugs. 2017;49(4):344-351. doi:10.1080/02791072.2017.1320733.
Hien DA, Campbell AN, Killeen T, et al. The impact of trauma-focused group therapy upon HIV sexual risk behaviors in the NIDA Clinical Trials Network "Women and Trauma" multi-site study. AIDS Behav. 2010;14(2):421-430. doi:10.1007/s10461-009-9573-7.