Abstract

“Objective: Seeking Safety is a manualized cognitive-behavioral therapy intervention that is designed to treat clients with comorbid substance abuse and trauma histories. This study examined its effectiveness when used with homeless women veterans with psychiatric or substance abuse problems at 11 Department of Veterans Affairs medical centers that had Homeless Women Veterans Programs.

Methods: The intervention consists of 25 sessions that cover topics to help build safety in clients’ lives and is present-focused, offering psycho-education and coping skills. A cohort of homeless women veterans (N=359) was recruited before Seeking Safety was implemented (phase I). After clinicians were trained and certified in Seeking Safety, a post-implementation cohort was recruited and offered Seeking Safety treatment (phase II, N=91). Phase I lasted from January 2000 to June 2003. Phase II lasted from June 2003 to December 2005. The intervention lasted for six months. All participants were interviewed every three months for one year and received intensive case management and other services during the study. Mixed models were used to compare one-year clinical outcomes across phases.

Results: There were few differences across groups at baseline. All women entering the Homeless Women Veterans Programs showed significant improvement on most clinical outcome measures over one year. The Seeking Safety cohort reported significantly better outcomes over one year in employment, social support, general symptoms of psychiatric distress, and symptoms of posttraumatic stress disorder, particularly in the avoidance and arousal clusters. However, the Seeking Safety cohort was significantly more likely to have used drugs in the past 30 days.

Conclusions: Seeking Safety appears to have had a moderately beneficial impact on several clinical outcomes. Although the nonequivalent comparison groups and low follow-up rates limit the internal validity of these results, availability of Seeking Safety may be of benefit for homeless female veterans. It is noteworthy that it could be delivered and implemented by case managers with little or no prior counseling experience.”

Implications

For Practice

The Seeking Safety program examined in this study was shown to be a beneficial program for homeless women veterans by improving PTSD symptoms, psychiatric symptoms and social support in this population. Although this program was originally developed to address the needs of individuals with comorbidities including PTSD and substance abuse, this model resulted in improvements for homeless women veterans who reported high levels of traumatic events and varying forms of substance abuse. As the Seeking Safety program was fairly simple to implement, clinicians in community-based clinics and those serving homeless women should be offered training on using this tool with the appropriate populations. The topics included in the Seeking Safety program are applicable beyond PTSD and substance abuse, and do not need to be covered in a certain order, giving clinicians and therapists the flexibility necessary to successfully tailor the intervention to individual women. Although the women in this study increased their social support and their PTSD and psychiatric symptoms decreased as a result of the Seeking Safety program specifically, perhaps cognitive-behavioral interventions in general would be beneficial to homeless veteran women, as they experience a variety of unsafe situations and can draw direct benefits from developing tailored skills. Unfortunately, the Seeking Safety program was not associated with a significant decrease in substance abuse, possibly because of initial substance use misrepresentation.

For Policy

Although few of the clinical staff included in this study had been trained extensively in using the Seeking Safety program, there were significant positive differences in social support and reduction in psychiatric symptoms for the homeless women veteran participants. This information, coupled with the fact that supervision during phase II included development of clinical skills in therapeutic sessions, indicates that the skill with which the therapy was delivered could be directly related to the social and psychiatric outcomes. As this general trend applies to the administration of cognitive-behavioral therapies, policy makers may need to focus on policies insuring that clinicians, especially those working with homeless veteran populations, continuously engage in trainings and professional development of their clinical and therapeutic skills. As programs for homeless veterans typically focus more on housing and mental health concerns, this may indicate another area for policy-related improvements. Policies supporting funding and infrastructure for homelessness programs could add a therapeutic provision, or link with nearby clinicians for therapy referrals, that would be extremely beneficial to homeless veteran women.

For Future Research

Future researchers may need to focus on the ways in which care is provided to homeless veteran women in health systems outside of the VA network. In this study, the participants were connected to care through the VA, which has similar rules and procedures throughout all of its facilities. The VA system is so well integrated that the results are only generalizable throughout the VA and not necessarily applicable to other healthcare systems. Future studies can also assess substance use through both self-reporting and more objective measures to verify self-reported data, such as biochemical testing. In addition, it is vital that both the clinicians performing biochemical tests and the research interviewers be uninvolved with the participants outside of the study so as not to bias results. In this study, participants may have wanted to create a good impression; they were also likely to face negative consequences, such as eviction from their current housing, upon reporting substance use. These circumstances likely resulted in the underreporting of substance use overall, as well as a reduction in the researchers’ ability to detect any effects of the Seeking Safety program on substance use. Finally, researchers should further study the long-term effects of this program, as there was a large attrition rate during this study. Researchers should seek out ways to improve and maintain contact with participants to observe the effectiveness of the Seeking Safety program beyond the six-month treatment period.