Book Review
Psychotherapy 
Seeking Safety: A Treatment Manual for Posttraumatic Stress Disorder and Substance Abuse. Lisa M Najavits. New York: The Guilford Press; 2002. 401 p. US$35.00.
Reviewer
rating*: Fair to Good
Review by: George A Fraser, MD
Ottawa, Ontario
Because the dual diagnosis of posttraumatic stress disorder (PTSD) and substance abuse is rather common (according to this book the figures are 12% to 34% for women and 30% to 59% for men), I was pleased to discover a book that focuses on this specific area. The author notes, “most clinical programs treat PTSD and substance abuse, but rarely both. The majority of patients with PTSD and substance abuse do not receive PTSD-focused treatment.” The inspiration for the book is apparent from the observation, “Treatments that are effective for PTSD or substance abuse separately may not be advisable when the two disorders occur together.”
This book is essentially a workbook for both therapist and the patient, or client, who suffers this combination of disorders. The program that is presented is the result of extensive research trials with clinical groups, involving patients at McLean Hospital (Belmont, Massachusetts), as well as collaboration with many of the author’s colleagues. Much work appears to have gone into developing the therapy program that this book offers. The therapy focuses on cognitive, behavioural, and interpersonal domains. The title of the book derives from the philosophy of the treatment: “when a person has both active substance abuse and PTSD, the most urgent need is to establish safety.” The book challenges the old belief that these conditions should be treated sequentially (that is, treat the substance abuse first, then the PTSD or vice versa). Instead, an integrated model is recommended as the treatment of choice (which most centres do not perform yet).
The workbook focuses on 25 therapy topics that can be used on either an individual or group basis. Each topic, essentially a chapter in length, can be conducted as a therapy session. The topics include detaching from emotional pain (grounding), when substances control you, coping with triggers, and healing from anger. The therapist can choose the most suitable order to introduce these topics. Each topic has suggestions for the therapist for that particular session, as well as handout pages to photocopy and to present to the patient, or client, (that is, safe coping skills and ideas for commitment, in which old ineffective solutions are written and then compared with new ways that the therapy session hopefully produced).
I am impressed with the work and thought that has gone into this pu blication. It is a fairly comprehensive work on how to manage the dual disorders of PTSD and substance abuse. Early in the book, the author points out that this program can be carried out in conjunction with psychopharmacology, but the reader who looks for ideas in this latter area will not discover a discussion of medications. I’m unsure, however, whether all therapists would be enthusiastic about this book. Some experienced therapists may view many of the ideas as old maxims, merely presented in a new way. Many may feel uncomfortable with the recommended format of having patients, or clients, fill in forms and commitments (homework). Others may object to perhaps too much of a cookbook approach, being essentially told what should be discussed at each session. Yet for others, this format may be the ideal guide to a more organized and comprehensive therapy. I did give a few dual diagnosis patients the assignments and literature and asked for their replies. The answers varied from “this is great stuff” to “I found this too elementary and insulting to my intelligence.”
Likewise, therapists will have diverse opinions about this book. I suspect that those who deal with group and community-based programs will find the book helpful. However, it may not be the same for psychotherapists who are experienced in individual therapy. Being in this latter group, I suspect that the book will not significantly impact my practice. Even so, at the same time, I see much that is positive, and for some therapists, this will be a very valuable contribution. Perhaps, someone involved in such groups should also be invited to review this book. In my rating, I use “fair” for experienced one-on-one therapists and “good” for those involved in group therapies, especially if they are relatively new in the field of PTSD—a field that is gaining much more recognition and understanding.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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