Letter

Seeking Safety ( 1 ) is a manualized treatment protocol designed to simultaneously treat substance use disorders and posttraumatic stress disorder (PTSD). This innovative approach was originally created for and has been empirically validated with female trauma survivors ( 2, 3, 4 ).

In designing and proposing the first randomized controlled treatment trial of Seeking Safety with men with substance use disorders and PTSD, we consistently heard concerns about the application of this "female-oriented" approach to men. There were concerns about an excessive focus on sexual trauma, presumably uncommon in men; lack of focus on combat trauma; and general gender bias in the wording—for instance, examples of physical abuse are from the perspective of the victim rather than the perpetrator. Only after assurances that we would first pilot-test the program with a group of men and would make necessary changes to the manual were our protocols approved. It should be noted that because we were motivated by the prospect of writing a new version of—or supplement to—the manual, any bias on our part was in favor of revising the program.

In 2006 we conducted a 12-week pilot test of Seeking Safety with male veterans in methadone maintenance treatment at a Department of Veterans Affairs (VA) mental health clinic before the initiation of a five-year randomized controlled trial. We then conducted a semiformal focus group of volunteer participants to ask about general concerns, such as what we could improve, and specific concerns, such as whether the examples of sexual trauma were a problem. We also asked a male researcher and a male veteran who was also a counselor to review the protocol for gender-biased language. In addition, we consulted extensively with the therapist who ran the pilot therapy sessions and the therapist's clinical supervisor, the latter of whom has extensive experience training and supervising clinicians to conduct Seeking Safety.

Without exception, the consensus was that the protocol did not need substantive gender-related changes to work well with our population of male patients with substance use disorders and PTSD. For instance, despite specific concerns, sexual trauma examples helped our participants who had a relevant history discuss this more "taboo" form of trauma, perhaps for the first time. In contrast, those with primarily combat trauma very readily brought the general concepts to bear on their experience. In our view, this phenomenon actually increased the need for sexual trauma examples, while decreasing the need for additional explicit combat examples. No protocol modification could have kept combat trauma from being a prominent focus in our groups. Modifying the focus away from sexual trauma could actually have exacerbated inequality in our group and reinforced avoidance of sexual trauma issues.

Careful wording in the Seeking Safety protocol also appears to avoid appreciable gender bias. For instance, the manual discusses domestic violence in terms of "violent" or "unsafe" relationships. Rather than reading a victim bias into this, even men who were perpetrators agreed that their relationships were "violent" or "unsafe." Similar examples exist throughout the manual.

Although initial concerns that Seeking Safety would need significant adaptation for use with men made excellent clinical sense, the consensus of our experts and consumers indicates that this does not appear to be the case. The careful construction of the manual appears to allow for adaptation as a natural part of the group process. Although these observations are preliminary, they challenge the notion that Seeking Safety as currently written is inappropriate for use with male veterans.

This research was supported by grant IIR-04-175-3 from VA Health Service Research and Development.

The authors report no competing interests.

Dr. Weaver and Dr. Trafton are affiliated with the Center for Health Care Evaluation, VA Palo Alto Health Care System, and with Stanford University School of Medicine. Dr. Weaver, Dr. Walser, and Dr. Kimerling are with the National Center for Posttraumatic Stress Disorder, VA Palo Alto Health Care System.