Seeking Safety: The Benefits of Gender-specific versus Co-Educational Therapy

Transcription

1 Octobr 2014 Rapid Rviw Sking Safty: Th Bnfits of Gndr-spcific vrsus Co-Educational Thrapy Ky Mssags Sking Safty programming is an approach for addrssing co-occurring substanc us disordr and post-traumatic strss disordr. Much of th rsarch on th ffctivnss of Sking Safty has bn carrid out on programming spcific to womn. It is not possibl to dtrmin whthr co-ducational Sking Safty groups ar as ffctiv as programming spcific to womn. Whil thr is growing support in principl for gndr-spcific substanc us tratmnt, mor rsarch on singl-sx and co-ducational Sking Safty groups is rquird to dtrmin th most ffctiv options for womn. Contxt Sking Safty is a thraputic approach for addrssing co-occurring substanc us disordr (SUD) and post-traumatic strss disordr (PTSD) that focuss on stablishing safty for th individual (Najavits, 2002). Sking Safty is a manualizd thrapy, which mans that a manual is followd to nsur that tratmnt follows th sam stps for ach sssion. It combins cognitiv bhavioural thrapy (CBT) and psychodynamic psychothrapy. Sking Safty includs a thrapist guid and patint matrials on 25 topics covring cognitiv, bhavioural and intrprsonal challngs and coping skills for SUD. Th program topics ar indpndnt of ach othr, so sssions can b tailord to focus on th topics that ar idntifid as most prtinnt by th counsllor, th clint or both. Th approach can also b offrd in ithr an individual or group format. Th Issu Thr is growing rsarch on gndr-spcific approachs in substanc us tratmnt and growing vidnc for providing gndr-spcific tratmnt in particular. Rsarchrs hav notd diffring barrirs to accss to tratmnt by gndr; that som gndr-spcific prdictors of outcom xist; and hav calld for study of how participant charactristics and tratmnt approachs can diffrntially affct outcoms by gndr (Cntr for Substanc Abus Tratmnt, 2009; Grnfild t al., 2007; Grlla, 2003). This rviw dtrmins how Sking Safty group tratmnt spcifically for womn for substanc us compars to co-ducational (co-d) Sking Safty group tratmnt for substanc us. 1

2 Approach Rsarchrs conductd a rapid rviw of th litratur on Sking Safty to compar singl sx and co-d tratmnt rsults. Tn databass wr sarchd from 1990 to 2013 using Sking Safty as th subjct sarch trm and a Googl sarch was conductd using th sam trm. (Appndix A provids dtails about sarch stratgy and inclusion critria.) Th databas sarch locatd 56 rfrncs and th Sking Safty wbsit providd 27 additional rfrncs. Of ths studis, 67 did not mt th inclusion critria. Data was xtractd from th rmaining 16 studis for analysis. Findings Fiftn of th 16 studis wr conductd in th Unitd Stats and on study includd participants from both th US and Canada (Najavits t al., 2013) (Appndix B). Narrativ summaris of all studis, including study mthods, variations in how Sking Safty was offrd, study participants and outcoms ar availabl upon rqust. Th following subsctions summariz th outcoms arising from intrvntions that wr offrd to groups of womn only, mn only, and both womn and mn. Outcoms for Womn Twlv studis valuatd Sking Safty thrapy offrd to womn only. Th outcoms masurd in ths studis includd substanc us, drug us, alcohol us, PTSD symptom svrity, trauma rlatd to sxual abus, tratmnt rtntion, tratmnt attndanc, rduction of HIV-rlatd sxual risk, coping, cocain us, dprssiv symptoms, tratmnt allianc, maladaptiv bhaviour and psychopathology. Th populations of womn studid includd incarcratd womn, womn in chmical dpndncy tratmnt, incarcratd womn with mntal illnss and womn in th National Institut on Drug Abus (NIDA) Clinical Trials Ntwork Womn and Trauma Multi-Sit Study (Appndix B). Rductions in incrasd tratmnt rtntion wr common outcoms. Th outcom of intrst for this rviw is th ffct on substanc us and was masurd in six studis. Th rsults wr as follows: A significant dcras in alcohol misus: A significant rduction in alcohol us for womn in a Sking Safty group was found, with thos who attndd post-tratmnt twlv-stp programming achiving th gratst rductions ovr tim in alcohol us (Morgan-Lopz, 2013). Substanc us was significantly dcrasd only among thos who rportd havy substanc us at baslin and who had achivd significant PTSD rductions (Hin, 2010c). Som changs in substanc us: A significant dcras in alcohol us was found from baslin to on wk post-tratmnt among tratmnt compltrs, followd by a non-significant incras in alcohol us during follow-up in anothr analysis of th NIDA clinical trials (Hin, 2012). In a study of incarcratd womn, ovr thr-quartrs of womn rportd that Sking Safty was hlpful for addrssing substanc us (Wolff, Fruh, Shi, & Schumann, 2012). No significant changs in substanc us: No significant changs wr found in on of th NIDA Clinical Trials Ntwork studis (Hin, 2009); among womn in a rsidntial chmical dpndnc tratmnt (Gh, Bolling, & Johnson, 2009); and in a study with incarcratd womn (Zlotnick, Johnson, & Najavits, 2009) although thr wr improvmnts ovr tim. 2

3 Outcoms for Mn Th rsarchrs includd studis that addrssd outcoms of gndr-spcific Sking Safty intrvntions for mn to dtrmin if th outcoms shd light on th ffctivnss of gndr-spcific approachs. Two studis wr found that valuatd Sking Safty among mn only and both involvd sampls of vtrans from th US military who had sn activ srvic. Th two studis showd modrat improvmnts in outcoms such as rtntion of tratmnt and rduction in problm gambling, PTSD symptoms, dprssion, and alcohol and marijuana us (Bodn t al., 2012; Norman, Wilkins, Taprt, Lang, & Najavits, 2010). Outcoms for Both Mn and Womn Th two studis that includd both womn and mn dmonstratd improvmnts in som outcoms. Howvr, ths rsults ar inconclusiv sinc on study providd Sking Safty to womn and mn sparatly (Sarcy & Lipps, 2012) and th othr study offrd Sking Safty in an individual format with a vry small sampl siz and no gndr diffrntiation of outcoms (Najavits t al., 2013). Discussion Th availabl litratur dos not offr nough vidnc to dtrmin whthr gndr-spcific or cod Sking Safty programs ar mor ffctiv for womn. Much of th rsarch found on th ffctivnss of Sking Safty has bn carrid out on programming spcifically for womn. Substanc us did not dcras significantly in all of th studis of Sking Safty programming. This lack of a dcras is not surprising as it is commonly rportd by womn with multipl burdns (trauma, mntal illnss and substanc us problms) that thy s substanc us as bnficial in coping with trauma-rlatd symptoms (Bryans t al., 2012; Pool & Parc, 2005). Bcaus of this prcption, changs in substanc us might follow rductions in othr symptoms instad of bing achivd immdiatly or simultanously. Diffring rats of ffctivnss hav bn dmonstratd by tratmnts dsignd for spcific subgroups or that addrss problms mor common to womn with problmatic substanc or dpndncy concrns (Niccols, Dll, & Clark, 2010; Pool & Gravs, 2007). Grnfild and collagus (2008) hav found that singl-gndr group tratmnt might confr addd bnfit ovr co-d group tratmnt for womn with substanc abus and high psychiatric symptom svrity. Spcializd tratmnt for womn has also bn found to promot continuing car (Claus t al., 2007). In a 2011 study womn participating in gndr-spcific tratmnt rportd significantly lss substanc us and criminal activity following tratmnt than thos participating in th mixd-gndr tratmnt (Prndrgast, Mssina, Hall, & Warda, 2011). Conclusion Whil th Sking Safty approach offrd to womn alon shows som promis in rducing alcohol us, thr is insufficint rsarch to dtrmin whthr offring Sking Safty to womn alon is mor or lss ffctiv than offring it to womn and mn togthr. 3

4 Acknowldgmnts This rviw was conductd by Ros Schmidt, Natali Hmsing, Lorrain Gravs and Nancy Pool of th British Columbia Cntr of Excllnc for Womn s Halth. Rsourcs Dll, C., & Pool, N. (2009). Applying a sx/gndr/divrsity-basd analysis within th national framwork for action to rduc th harms associatd with alcohol and othr drugs and substancs in Canada. Ottawa: Canadian Cntr on Substanc Abus. Canadian Cntr on Substanc Abus. (2010) Bringing gndr and divrsity analysis to our work: A chcklist. Ottawa: Author. Clow, B., Pdrson, A., Haworth-Brockman, M., & Brnir, J. (2009). Rising to th Challng: Sx and gndr-basd analysis for halth policy, planning and rsarch in Canada. Halifax: Atlantic Cntr of Excllnc for Womn s Halth. Rfrncs Bodn, M. T., Kimrling, R., Jacobs-Lntz, J., Bowman, D., Wavr, C., Carny, D., Walsr, R., & Trafton, J. A. (2012). Sking Safty tratmnt for mal vtrans with a substanc us disordr and post-traumatic strss disordr symptomatology. Addiction, 107(3), CanFASD. (2012). Supporting prgnant and parnting womn who us substancs: What communitis ar doing to hlp Ottawa: Author. Rtrivd from Cntr for Substanc Abus Tratmnt. (2009). Substanc abus tratmnt: Addrssing th spcific nds of womn. Rockvill, MD: Substanc Abus and Mntal Halth Srvics Administration. Claus, R. E., Orwin, R. G., Kissin, W., Krupski, A., Campbll, K., & Stark, K. (2007). Dos gndr-spcific substanc abus tratmnt for womn promot continuity of car? Journal of Substanc Abus Tratmnt, 32(1), Gh, A. C., Bolling, L. C., & Johnson, C. S. (2009). Th fficacy of a condnsd Sking Safty intrvntion for womn in rsidntial chmical dpndnc tratmnt at 30 days posttratmnt. Journal of Child Sxual Abus, 18(5), Gh, A. C., Johnson, C. S., Burlw, A. K., & Bolling, L. C. (2009). Enhancing rtntion through a condnsd trauma-intgratd intrvntion for womn with chmical dpndnc. North Amrican Journal of Psychology, 11(1), Grnfild, S. F., Brooks, A. J., Gordon, S. M., Grn, C. A., Kropp, F., McHugh, R. K., Mil, G. M. (2007). Substanc abus tratmnt ntry, rtntion, and outcom in womn: A rviw of th litratur. Drug and Alcohol Dpndnc, 86(1), Grnfild, S. F., Pottr, J. S., Lincoln, M. F., Popuch, R. E., Kupr, L., & Gallop, R. J. (2008). High psychiatric symptom svrity is a modrator of substanc abus tratmnt outcoms among womn in singl vs. mixd gndr group tratmnt. Amrican Journal of Drug and Alcohol Abus, 34(5), Grlla, C. E. (2003). Effcts of gndr and diagnosis on addiction history, tratmnt utilization, and psychosocial functioning among a dually-diagnosd sampl in drug tratmnt. Journal of Psychoactiv Drugs, 35(Suppl 1), Hin, D. A., Campbll, A. N., Killn, T., Hu, M.-C., Hansn, C., Jiang, H., Nuns, E. V. (2010). Th impact of traumafocusd group thrapy upon HIV sxual risk bhaviors in th NIDA Clinical Trials Ntwork Womn and Trauma multisit study. AIDS and Bhavior, 14(2), Hin, D. A., Campbll, A. N., Ruglass, L. M., Hu, M. C., & Killn, T. (2010). Th rol of alcohol misus in PTSD outcoms for womn in community tratmnt: a scondary analysis of NIDA's Womn and Trauma Study. Drug and Alcohol Dpndnc, 111(1 2),

5 Hin, D. A., Jiang, H., Campbll, A. N., Hu, M.-C., Mil, G. M., Cohn, L. R., Nuns, E. V. (2010). Do tratmnt improvmnts in PTSD svrity affct substanc us outcoms? A scondary analysis from a randomizd clinical trial in NIDA's Clinical Trials Ntwork. Amrican Journal of Psychiatry, 167(1), Hin, D. A., Morgan-Lopz, A. A., Campbll, A. N. C., Saavdra, L. M., Wu, E., Cohn, L., Nuns, E. V. (2012). Attndanc and substanc us outcoms for th Sking Safty program: Somtims lss is mor. Journal of Consulting and Clinical Psychology, 80(1), Hin, D. A., Wlls, E. A., Jiang, H., Suarz-Morals, L., Campbll, A. N. C., Cohn, L. R., Nuns, E. V. (2009). Multisit randomizd trial of bhavioral intrvntions for womn with co-occurring substanc us disordrs. Journal of Consulting and Clinical Psychology, 77(4), Lynch, S. M., Hath, N. M., Mathws, K. C., & Cpda, G. J. (2012). Sking Safty: An intrvntion for trauma-xposd incarcratd womn? Journal of Trauma and Dissociation, 13(1), Morgan-Lopz, A. A., Saavdra, L. M., Hin, D. A., Campbll, A. N., Wu, E., & Ruglass, L. (2013). Synrgy btwn Sking Safty and twlv-stp affiliation on substanc us outcoms for womn. Journal of Substanc Abus Tratmnt, 45(2), Najavits, L. M. (2002). Sking Safty: A tratmnt manual for PSTD and substanc abus. Nw York, NY: Guilford Prss. Najavits, L. M., Smyli, D., Johnson, K., Lung, J., Gallop, R. J., & Classn, C. C. (2013). Sking Safty thrapy for pathological gambling and PTSD: A pilot outcom study. Journal of Psychoactiv Drugs, 45(1), Niccols, A., Dll, C. A., & Clark, S. (2010). Tratmnt issus for aboriginal mothrs with substanc us problms and thir childrn. Intrnational Journal of Mntal Halth and Addiction, 8(2), Norman, S. B., Wilkins, K. C., Taprt, S. F., Lang, A. J., & Najavits, L. M. (2010). A pilot study of sking safty thrapy with OEF/OIF vtrans. Journal of Psychoactiv Drugs, 42(1), Pool, N., & Gravs, L. (Eds.). (2007). Highs & lows: Canadian prspctivs on womn and substanc us. Toronto, ON: Cntr for Addiction and Mntal Halth. Pool, N., & Parc, D. (2005). Sking Safty: An intgratd modl for womn xprincing post-traumatic strss disordr and substanc abus A pilot projct of th Victoria womn's sxual assault cntr, valuation rport. Victoria, BC: Victoria Womn's Sxual Assault Cntr. Prndrgast, M. L., Mssina, N. P., Hall, E. A., & Warda, U. S. (2011). Th rlativ ffctivnss of womn-only and mixdgndr tratmnt for substanc-abusing womn. Journal of Substanc Abus Tratmnt, 40(4), Ruglass, L. M., Mil, G. M., Hin, D. A., Campbll, A. N., Hu, M. C., Caldira, N. Nuns, E. V. (2012). Hlping allianc, rtntion, and tratmnt outcoms: A scondary analysis from th NIDA Clinical Trials Ntwork Womn and Trauma Study. Substanc Us & Misus, 47(6), Sarcy, V., & Lipps, A. (2012). Th ffctivnss of Sking Safty on rducing PTSD symptoms in clints rciving substanc dpndnc tratmnt. Alcoholism Tratmnt Quartrly, 30(2), Wolff, N., Fruh, B. C., Shi, J., & Schumann, B. E. (2012). Effctivnss of cognitiv-bhavioral trauma tratmnt for incarcratd womn with mntal illnsss and substanc abus disordrs. Journal of Anxity Disordrs, 26(7), Zlotnick, C., Johnson, J., & Najavits, L. M. (2009). Randomizd controlld pilot study of cognitiv-bhavioral thrapy in a sampl of incarcratd womn with substanc us disordr and PTSD. Bhavior Thrapy, 40(4), Disclaimr: Rapid rviws ar producd using acclratd and stramlind systmatic rviw mthods, usually in rspons to a qustion or topic idntifid by th fild. Th information in this rapid rviw is a summary of availabl vidnc basd on a limitd litratur sarch. CCSA dos not warrant th currncy, accuracy or compltnss of this rapid rviw and dnis any rprsntation, implid or xprssd, concrning th fficacy, appropriatnss or suitability of any intrvntion or tratmnt discussd in it. ISBN Canadian Cntr on Substanc Abus 2014 Th Canadian Cntr on Substanc Abus changs livs by bringing popl and knowldg togthr to rduc th harm of alcohol and othr drugs on socity. W partnr with public, privat and non-govrnmntal organizations to improv th halth and safty of Canadians. CCSA activitis and products ar mad possibl through a financial contribution from Halth Canada. Th viws of CCSA do not ncssarily rprsnt th viws of th Govrnmnt of Canada. 5

6 Appndix A: Mthods Rsarch Qustion In adults with substanc us problms, how dos Sking Safty group tratmnt spcifically for womn only compar to co-ducational Sking Safty group tratmnt in trms of ffct on substanc us? Databas Sarching Th following databass wr sarchd with Ebsco Host from 1990 to Dcmbr 5, 2013, using Sking Safty as a subjct trm: 1. Acadmic Sarch Complt 2. Bibliography of Nativ North Amricans 3. CINAHL with Full Txt 4. ERIC 5. Family & Socity Studis Worldwid 6. LGBT Lif with Full Txt 7. MEDLINE with Full Txt 8. PsycINFO 9. Social Work Abstracts 10. Womn's Studis Intrnational Additional Sourcs Additionally, a Googl sarch was prformd using th ky words Sking Safty and Evidnc. Th scond hit was for a pag on th wbsit of Lisa M. Najavits, crator of Sking Safty. Th pag is calld Outcoms Sking Safty and it contains a summary and brif dscription of ach compltd study of Sking Safty. Th first fiv pags of Googl rsults rturnd no additional ffctivnss studis of Sking Safty. Inclusion Critria Th following inclusion critria wr applid whn rtriving articls from th databass: 1. Dos th study valuat th intrvntion Sking Safty; 2. Was th study publishd in 1990 or latr; 3. Was th study publishd in English; 4. Was th articl publicly availabl or abl to b purchasd and dlivrd within on wk of th initial rqust? Studis that did not valuat th ffctivnss of Sking Safty wr not includd in th rviw. Howvr, som of ths studis provid contxtual matrial for th rviws and ar covrd in th background sction. Systmatic rviws wr xcludd, but individual studis covrd by ths rviws wr scrnd for inclusion in this rviw. Aftr consultation with partnrs, th inclusion critria wr rvisd and rapplid to th rfrncs in th EndNot databas. Th rvisd inclusion critrion was: 2. Was th study publishd in th last fiv yars (i.., btwn 2008 and 2013)? 6

7 Appndix B: Includd Studis Study 1 Aim Mthod Population Outcoms Bodn, t al. (2012) To dtrmin whthr substituting Sking Safty for part of tratmnt-as-usual (TAU) improvs substanc us outcoms. Random izd controlld trial () Mal vtrans with SUD and PTSD, who participatd in Opration Enduring Frdom / Opration Iraqi Frdom (OEF/OIF) and wr out-patints of Vtrans Administration (VA) Halth Car Systm SUD clinic. Sking Safty compard to TAU was associatd with bttr drug us outcoms, but alcohol us and PTSD svrity dcrasd qually undr both tratmnts. Sking Safty vrsus TAU was associatd with incrasd tratmnt attndanc, clint satisfaction and activ coping. Nithr ths factors nor dcrass in PTSD svrity mdiatd th ffct of tratmnt on drug us. n=177 (Sking Safty=59, TAU=58) Gh, Bolling, and Johnson (2009) To xamin th fficacy of a condnsd vrsion of Sking Safty in th rduction of traumarlatd symptoms and improvd drug abstinnc rats among womn in rsidntial chmical dpndnc tratmnt. Womn with traumarlatd symptoms undrgoing substanc abus tratmnt at a community rsidntial facility. n=104 Sking Safty participants rportd lowr sxual-abus-rlatd trauma symptoms at 30 days post-tratmnt compard to participants who rcivd only standard tratmnt. Howvr, Sking Safty was not mor advantagous in rducing ovrall trauma symptoms, nor mor advantagous in rducing rlaps 30 days aftr tratmnt ndd. Gh, Johnson, Burlw, and Bolling (2009) To xamin whthr tratmnt intgratd with a condnsd vrsion of Sking Safty (i.., six sssions) improvd rtntion compard to TAU, and to invstigat whthr th rlationship of pr-tratmnt traumaand dprssion-rlatd symptoms to rtntion was th sam for both tratmnt typs. Womn undrgoing tratmnt for SUD at a community rsidntial facility. n=104 Th ovrall rtntion rat of th sampl was 53.8%. Th avrag numbr of condnsd Sking Safty sssions compltd by th womn in th tratmnt intgratd intrvntion group was 4.7 sssions. Womn who rcivd intgratd Sking Safty had substantially highr rats of rtntion within th initial 30-day rsidntial phas of tratmnt. *Hin, Campbll, Killn, t al. (2010) To xamin th impact of two group thrapy intrvntions on rduction of unprotctd sxual occasions (USO) among womn with SUD and PTSD. Womn with cooccurring SUD attnding on of svn communitybasd substanc us tratmnt programs offring intnsiv outpatint tratmnt. Sking Safty was significantly mor ffctiv in rducing HIV sxual risk for womn with highr lvls of unprotctd sx whn compard with a Womn s Halth Education (WHE) curriculum. Th ffct of tratmnt on USO was statistically diffrnt among individuals with highr baslin lvls of USO. n=346 *Hin, Campbll, Ruglass, t al. (2010) To xplor ffctivnss of two intrvntions for womn with comorbid SUD. To Womn with cooccurring SUD attnding on of svn community- Among womn with alcohol misus, PTSD scors wr significantly lowr in Sking Safty during tratmnt and follow-up. Alcohol misusrs in Sking 1 Svn of th includd studis usd data from th sam sampl of participants. Ths paprs ar markd with an astrisk (*) and all rportd on data collctd as part of th NIDA Clinical Trials Ntwork Womn and Trauma Multi-Sit Study. 7

8 Study 1 Aim Mthod Population Outcoms xamin whthr individuals with alcohol misus in th Womn and Trauma Study had diffrntial tratmnt rsponss to Sking Safty vs. WHE groups on PTSD symptoms in comparison to thos with no misus. basd substanc us tratmnt programs offring intnsiv outpatint tratmnt. n=353 Safty who had highr baslin hyprarousal svrity improvd mor quickly than thos with lowr baslin hyprarousal svrity during tratmnt. *Hin, Jiang, t al. (2010) To xamin th tmporal cours of improvmnt in symptoms of SUD among womn in outpatint substanc abus tratmnt. Womn with cooccurring SUD attnding on of svn communitybasd substanc us tratmnt programs offring intnsiv outpatint tratmnt. n=353 Subjcts xhibiting nonrspons, SU rspons or global rspons (rduction in both SU and PTSD) tndd to maintain original classification; subjcts xhibiting PTSD rspons wr significantly mor likly to transition to global rspons ovr tim, indicating maintaind PTSD improvmnt was associatd with subsqunt substanc us improvmnt. Sking Safty was significantly mor ffctiv than WHE in rducing SU, but only among havy substanc usrs at baslin who also achivd significant PTSD rductions. *Hin, t al. (2012) To assss if thr ar diffrnt tratmnt attndanc pattrns in th Womn and Trauma Study, and, if so, dos on of th pattrns involv a titration of tratmnt frquntly obsrvd among individuals with SUD? Ar thr diffrntial substanc us outcoms by tratmnt typ associatd with ths attndanc pattrns? Womn with cooccurring SUD attnding on of svn communitybasd substanc us tratmnt programs offring intnsiv outpatint tratmnt. n=353 Tratmnt attndanc pattrns mrgd: compltrs nvr dcrasd blow an 80% probability of attndanc, dropprs nvr xcdd a 41% probability of attndanc, and titrators dmonstratd a 50% to 80% probability of attndanc. Among compltrs, thr wr significant dcrass in alcohol us from baslin to on-wk posttratmnt, followd by non-significant incrass in alcohol during follow-up. Diffrncs btwn tratmnt conditions wr dtctd. Titrators in Sking Safty had lowr rats of alcohol us from on-wk through 12- month follow-ups, compard with control participants. Dropprs had nonsignificant incrass in alcohol during both study phass. Cocain us findings wr similar, but did not rach significanc lvls. *Hin, t al. (2009) To compar th ffctivnss of Sking Safty for SUD and PTSD to an activ comparison halth ducation group. Womn with cooccurring SUD attnding on of svn communitybasd substanc us tratmnt programs offring intnsiv outpatint tratmnt. Thr wr larg, clinically significant rductions in PTSD symptoms, but thy did not diffr significantly btwn conditions. Substanc us outcoms wr not significantly diffrnt ovr tim btwn th two tratmnts and at follow-up showd no significant chang from baslin. n=353 (Sking Safty=176, WHE=177) 8

9 Study 1 Aim Mthod Population Outcoms Lynch, Hath, Mathws, and Cpda (2012) To xamin th ffctivnss of Sking Safty with incarcratd womn. Nonrandomizd controlld trail (N-) Womn with trauma historis incarcratd at a northwstrn womn s minimum and mdium scurity stat prison. n=114 (Sking Safty=59, Waitlist=55) Both tratmnt and wait-listd participants showd significant dcrass in PTSD symptoms. Howvr, womn in th tratmnt condition showd mor significant dcrass in PTSD at th follow-up than did th wait-listd womn. A gratr numbr of tratmnt participants indicatd rliabl improvmnt in symptoms of dprssion, intrprsonal difficultis, and maladaptiv coping as compard to th wait-listd group. *Morgan- Lopz, t al. (2013) To xamin th intractiv ffcts of a tratmnt for comorbid substanc us, Sking Safty and posttratmnt Twlv-Stp Affiliation (TSA) on alcohol and cocain us. Womn with cooccurring SUD attnding on of svn communitybasd substanc us tratmnt programs offring intnsiv outpatint tratmnt. n=353 Thr wr significant rductions in alcohol us among womn in Sking Safty, and womn in Sking Safty who followd up with TSA had th gratst rductions ovr tim in alcohol us. Rductions in cocain us ovr tim wr also obsrvd, but did not diffr btwn tratmnt conditions nor wr thr intractions with post-tratmnt TSA. (Sking Safty=176, WHE=177) Najavits, t al. (2013) To pilot valuat individual Sking Safty thrapy for svn outpatints with currnt comorbid pathological gambling and PTSD. Ongroup prtst post-tst (Pilot) Mn and womn with co-occurring problm gambling. womn n=4 mn n=3 Significant improvmnts wr found in trauma symptoms, problm gambling, functioning, psychopathology, slf-compassion and hlping allianc. Norman, Wilkins, Taprt, Lang, and Najavits (2010) This rport offrs an xampl of implmntation of a Sking Safty group with OEF/OIF vtrans at a VA including prliminary data on nin OEF/OIF vtrans who compltd Sking Safty. Ongroup prtst post-tst (Pilot) Mal vtrans with SUD and PTSD, who participatd in OEF/OIF in th San Digo VA. n=14 Attndanc avragd 7.64 sssions. Eight of th nin vtrans (89%) dcrasd in PTSD scors (six dcrass wr statistically significant) and on worsnd. *Ruglass, t al. (2012) To xamin th impact of th thraputic allianc on tratmnt rtntion and outcoms among this sampl of womn with comorbid SUD. Womn with cooccurring SUD attnding on of svn communitybasd substanc us tratmnt programs offring intnsiv outpatint tratmnt. Both groups of participants rportd high lvls of allianc, with avrag scors btwn 5.15 and 5.33 (out of 6). Thr was a significant diffrnc btwn tratmnt conditions in allianc ratings at Wk 2, with Sking Safty participants rporting significantly highr allianc than WHE participants. Allianc was rlatd to significant dcrass in PTSD symptoms and highr attndanc in both intrvntions. Allianc was not rlatd to substanc us outcoms. 9

10 Study 1 Aim Mthod Population Outcoms Sarcy, and Lipps, (2012) To valuat th ffctivnss of th Sking Safty program in rducing PTSD symptoms in clints in tratmnt for substanc dpndnc. Ongroup prtst post-tst (Pilot) Mn and womn attnding a co-d 28- day intnsivrsidntial substanc abus tratmnt. womn n=28 mn n=12 Ovrall, thr wr statistically significant pr-tst to post-tst dcrass on th total scal and on all six subscals of th Trauma-Symptom Chcklist. Dcrass in mal symptoms on th Anxity, Sxual Abus Trauma Indx and Sxual Problms subscals of th Trauma-Symptom Chcklist-40 wr not statistically significant. For womn, howvr, th total scal and all six subscals showd statistically significant post-tratmnt dcrass. Womn s prtst to post-tst scors also changd mor than th mn s. Among womn, th subscal with th gratst dcras in symptoms was Dprssion followd by Dissociation. For mn, Slp Disturbanc scors dcrasd th most, followd by Dprssion. Wolff, Fruh, Shi, and Schumann (2012) To provid implmntation and ffctivnss data on a group thrapy modality of Sking Safty providd to incarcratd womn with mntal illnsss in addition to SUD housd in gnral (non-thraputic) population. Ongroup pr-tstpost-tst Incarcratd womn with mntal illnss and substanc us disordrs. n=111 Implmntation fasibility was dmonstratd by th ability to rcruit, scrn, assign and rtain participation. Effctivnss was supportd by changs pr post intrvntion of PTSD symptoms. At last thr-quartrs of participants rportd Sking Safty was hlpful in ach of th following aras: ovrall, for traumatic strss symptoms, for substanc us, to focus on safty and to larn saf coping skills. Zlotnick, Johnson, and Najavits (2009) To valuat outcoms of Sking Safty plus TAU to TAU-alon in an incarcratd sampl of womn on ky variabls: PTSD diagnosis, substanc us, prison rcidivism, lgal problms and psychopathology. Incarcratd womn with substanc us disordr and PTSD n=49 Intrvntion n=27 Control n=22 Thr wr no significant diffrncs btwn conditions on PTSD, SUD, psychopathology or lgal problms. Howvr, both conditions showd significant improvmnts on all of ths outcoms across tim. At follow-up, Sking Safty participants showd improvmnts on clinician ratd PTSD symptoms and TAU participants worsnd on slf-rportd PTSD symptoms. Sking Safty dmonstratd continud improvmnt on psychopathology at 3 and 6 months, whras TAU did not. Howvr, alcohol us improvd mor for TAU during follow-up. Satisfaction with Sking Safty was high and a gratr numbr of Sking Safty sssions was associatd with gratr improvmnt on drug us. Six months aftr rlas from prison, 53% of womn in both conditions rportd a rmission in PTSD