Enhancing Retention through a Condensed

Trauma-Integrated Intervention for Women

with Chemical Dependence
Anna Cash Ghee
Xavier University

Candace S. Johnson and Ann Kathleen Burlew

University of Cincinnati

Lanny C. Bolling
Xavier University
This study examined whether treatment integrated with a condensed
version of Seeking Safety (i.e., six sessions) improved retention compared
to treatment as usual (TAU). The second aim was to investigate whether
the relationship of pretreatment trauma- and depression-related symptoms
to retention was the same for both treatment types. 104 women in
residential treatment for chemical dependence were randomly assigned to
receive either the clinics treatment integrated with condensed Seeking
Safety (SS), or the clinics TAU. Women who received the treatment
integrated with condensed SS had substantially higher rates of retention
within the clinics initial 30-day residential phase of treatment. Further,
retention rates increased when women also had higher levels of
depression at baseline. Treatment retention continues to be an important
issue for women in substance abuse treatment. Utilizing brief traumaintegrated interventions may be an effective and efficient strategy to
improve retention, while providing a gender-relevant treatment for
women.

Women seeking treatment for alcohol and drugs experience distinct

mental health patterns and treatment needs. One such distinction is the
high co-morbidity between psychological disorders and substance abuse
among women who seek treatment for alcohol and drug addiction, which
entails special considerations in treatment programs. In particular, the
prototypical women who enter treatment for chemical dependence share
common histories of traumatic experiences related to adult victimization
from violence and abuse, repeated childhood incest, physical abuse,
and/or sexual abuse (Freeman, Collier, & Parillo, 2002; Newmann &
Sallmann, 2004).
Author info: Correspondence should be sent to: Anna C. Ghee, Dept. of
Psychology, Xavier University, Elet Hall, 201, ML 6511. Cincinnati, OH 45207
Email: ghee@xavier.edu
North American Journal of Psychology, 2009, Vol. 11, No. 1, 157-172.
NAJP

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Compared to their male counterparts, chemically dependent women

have higher incidences of childhood sexual abuse or past rape (Coffey,
Dansky, Falsetti, Saladin, & Brady, 1998; Kang, Deren, & Goldstein,
2002); and some studies have also reported higher prevalence of
posttraumatic stress disorder (PTSD) for women compared to men with
chemical dependence (e.g., Sonne, Back, Zuniga, Randall, & Brady,
2003). Moreover, while co-morbid depression and substance abuse are
common for both genders (Cook, Epperson, & Gariti, 2005; Swendsen &
Merikangas, 2000) among individuals in treatment for chemical
dependence, women more than men may be more prone to preexisting
depression (e.g., Paraherakis, Charney, Palacios-Boix, & Gill, 2000).
Effective treatment for women with co-morbid substance abuse and
mental health disorders must take into account their more complex
clinical profile and gender-specific needs including issues related to child
care, childbirth, child custody, housing, and health (Arfken, Klein, di
Menza, & Schuster, 2001; Gatz, Brounstein, & Taylor, 2005; Najavits,
Weiss & Shaw, 1999).
Treatment retention (i.e., duration in which patients remain in
treatment) is an additional concern for women in treatment (Greenfield,
Brooks, Gordon, Green, & Kropp, 2007). Existing research suggests
intermediate and long-term benefits of retention. Clients who remain in
substance abuse treatment longer are less likely to relapse and more
likely to experience beneficial therapeutic outcomes (Simpson, Joe,
Rowan-Szal, & Greener, 1997; Zhang, Friedmann, & Gerstein, 2003).
Yet, the retention rates for those in substance abuse treatment are
generally low (Dobkin, Civita, Paraherakis, & Gill, 2002), especially
among women with co-occurring substance abuse and psychological
disorders (Amaro, Chernoff, Brown, Arvalo, & Gatz, 2007; Gatz et al.,
2007).
The available evidence suggests that both depression and trauma are
associated with retention. The findings for depression are mixed.
Retention was higher among depressed than non depressed clients for
inpatients with severe alcohol dependence (Martinez-Raga et al., 2002)
and also among cocaine abusers within their initial 60 days of residential
chemical dependence treatment (Levin et al., 2004). However, Levin et
al. reported that after the initial 60 days, retention was lower among the
depressed than non-depressed cocaine abusers. Evidence suggests that
individuals with trauma histories are more prone to prematurely drop out
of treatment (Claus & Kindleberger, 2002; Kang et al., 2002).
The recent shift in womens substance abuse treatment encourages
integrated treatment of coexisting trauma and substance abuse issues
(Huntington, Jahn Moses, & Veysey, 2005; Najavits, 2002). Seeking
Safety (Najavits, 2002) is a manualized, 25-session group intervention

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ENHANCING TREATMENT 159

grounded in cognitive behavioral therapy that was developed by Najavits

to integrate trauma-specific treatment with substance abuse treatment.
Recent research has demonstrated that chemically dependent women
participating in SS along with their substance abuse treatment have better
retention rates than those participating in only standard substance abuse
treatment (Gatz et al., 2007).
Despite the promise of Seeking Safety (SS), several issues remain
unaddressed. First, Najavits argues that the SS intervention is effective
even if as few as six sessions are included in the intervention. The basis
for this claim appears to be a finding that positive outcomes were evident
even among those who attended as few as six of the standard 25 sessions.
However, to our knowledge, no study has systematically examined the
efficacy of a condensed (six session), version of Seeking Safety (SS) that
is integrated into standard treatment. A condensed version of SS may
prove to be a cost-effective strategy for trauma-integrated treatment.
Thus, the effectiveness of a shorter intervention is an important question,
given that it is well established that several barriers (e.g., family,
employment, financial) prevent most women from entering and staying
in long-term treatment programs (e.g., Kelly, Blacksin, & Mason, 2001;
Knight, Logan, & Simpson, 2001). Our previous research has already
demonstrated the efficacy of a condensed version for reducing trauma
symptoms (Ghee, Bolling, & Johnson, in press). However, two additional
gaps remain in our understanding of the efficacy of the condensed
version. First, it is not yet clear whether participation in the condensed
treatment improves retention in the overall substance abuse program.
One aim of this study is to evaluate the effectiveness of chemical
dependence treatment integrated with condensed SS on retention.
A second issue not fully explored in the literature is the relationship
of individual characteristics and intervention type to retention. Amaro et
al. (2007) found that mental health problems, trauma symptoms, and
severe alcohol or drug problems were all associated with lower retention
rates. However, since the type of intervention was not included in their
analyses, it is unclear whether the relationship between each of these
characteristics to retention was the same for those who received the
Seeking Safety (SS) enhanced intervention as those who received
treatment as usual (TAU). Gatz et al. (2007) added intervention type as a
variable in their examination of the relationship of individual
characteristics to retention. However, their focus appeared to be solely on
trauma symptoms at baseline and not other psychological symptoms,
such as depression which may affect womens retention in particular.
Therefore, the second aim of this research is to examine whether the
relationships of baseline trauma-related symptoms and depression-related
symptoms to retention are the same for the groups of chemically

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dependent women who received treatment integrated with condensed SS

versus treatment as usual.
Method
Participants
This study was conducted with 104 women who were undergoing
substance abuse treatment at a community residential facility. In order to
meet the facilitys admission criteria, these clients did not have severe
medical conditions or active psychosis. However, the majority of
admitted clients typically have histories of generational substance abuse,
untreated histories of violence, physical and sexual abuse, and/or other
mental health needs (Director, D. S. Hollis, personal communication,
December 9, 2003). In the current study, trauma histories were not taken
and PTSD was not formally diagnosed. However, as listed in Table 1, the
baseline PTSD mean for the current sample was above the clinical cutoff
score of 28 as reported by Coffey et al. (1998). In addition, the baseline
BDI II mean score corresponds to the cutoff score of 17, suggesting
significant depressive symptoms for chemically dependent patients as
reported by Ruben et al. (2007).
The participants self-reported ethnic identities were 50.5%
Caucasian/White, 47.4% African American, 1% bi-racial, and 1% Native
American. The mean age of participants was 34.7, ranging from 21-60
years old, and their mean number of children was 2.5. More than half
(56.2%) had either graduated high school or earned a GED.
Measures
Trauma-related symptoms were assessed using two measures, the
Modified PTSD Symptom Scale-Self Report (MPSS-SR, Falsetti,
Resnick, Resick, & Kilpatrick, 1993; Foa, Riggs, Dancu, & Rothbaum,
1993) and the Trauma Symptom Checklist-40 (TSC-40, Briere, 1996;
Briere & Runtz, 1989). The MPSS-SR assesses the intensity and severity
of symptoms associated with Posttraumatic Stress Disorder (PTSD). This
17-item measure has been used as a screening tool within substance
abusing populations to increase the diagnosis and subsequent treatment
of PTSD (Coffey et al., 1998; Falsetti et al., 1993). Good overall internal
consistency (alpha = .97) has been demonstrated (Coffey et al., 1998)
and its items correspond to the DSM-IV symptom criteria for PTSD. In
the current study, the coefficient alpha for the full scale MPSS-SR was
.97, (n = 87).
The TSC-40 assesses the presence of symptoms associated with past
childhood or adult traumatic experiences. The TSC-40 consists of 40
items that are rated according to frequency of occurrence over the prior
two months, using a 4-point scale ranging from 0 to 3. Studies using the
TSC-40 indicate that it is a relatively reliable measure with alpha values

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ENHANCING TREATMENT 161

averaging between .89 and .91; and it has predictive validity with a wide
range of traumatic experiences, including sexual and emotional abuse
(Binder, McNeil & Goldstone, 1994; Dutton, 1995; Dutton & Painter,
1993). While the TSC-40 is not a measure of PTSD in particular, it was
included in this study because it can be used to measure clusters of
symptoms associated with PTSD, as this measure consists of six
subscales (Anxiety, Depression, Dissociation, Sexual Abuse Trauma
Index, Sexual Problems, and Sleep Disturbance). In the current study, the
coefficient alpha for the full scale TSC-40 was .93, (n = 94).
Depressive symptoms were measured in the current study with the
Beck Depression Inventory II (BDI-II, Beck, Steer & Brown, 1996) and
the TSC-40 Depression subscale. The BDI-II is a widely used 21-item
screen for symptoms of depression that have occurred over the past two
weeks. The BDI-II uses a four-point scale ranging from 0 to 3. Good
reliability (alpha = .92) has been demonstrated for the BDI-II (Beck, et
al., 1996). In the current study, the coefficient alpha for the BDI was .88,
(n = 99). The TSC-40 Depression subscale assesses depressive symptoms
associated with past trauma. It consists of nine items, and has reasonable
reliability, alpha = .70 (Elliot & Briere, 1992).
Treatment retention was operationalized as either staying in
treatment or prematurely leaving treatment. Staying in treatment was
considered affirmative if a participants name appeared on the treatment
roster or the residential enrollment log on the date that their posttreatment measures were due to be administered. At this point in time, a
participant would have undergone approximately 30 days of residential
treatment, which is the typical duration of Phase I standard treatment
(i.e., psychoeducation, therapy, relapse prevention, case management) at
the facility. Those who leave treatment before the completion of Phase I
treatment are considered to have prematurely terminated and have missed
the Phase I evaluation which determines their next level of their
treatment. There are a few methods in which residential clients may
prematurely leave treatment. Most commonly they fail to return after
either weekend passes, or medical or social services appointments.
However, residential clients may elect to depart against medical advice,
as the building is unlocked during daytime treatment hours.
Design and Procedure
The sample of participants was obtained from adult women in their
first week of initial residential treatment (Phase I) in a publicly-funded
residential treatment center. The women were invited to an information
meeting that explained the study, and were provided an opportunity to
sign a consent form indicating whether they would participate in the
study. The overwhelming majority agreed to participate. The most

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common reason for refusing to participate was that the women expected
to leave treatment before they would have an opportunity to complete the
program. The consenting women completed the baseline administration
of the set of study measures, demographic information, and a phone
contact list to be used for the follow-up administrations. The forms from
consenting women were counted, and half were drawn to participate in
the intervention group (treatment integrated with condensed Seeking
Safety) and half to participate in the treatment as usual (TAU) group.
When the number of consenting forms was an odd number, then the extra
count went to the intervention group. There were 104 women who
consented, 52 assigned to both conditions. One of the women who
initially consented later indicated that she no longer wanted to be part of
the study. Her baseline data were removed from the study, leaving 51
women in the intervention group and 52 women in the TAU group.
TAU consisted of the facilitys required Phase I programming
(psychoeducation, group and individual therapy, relapse prevention, case
management), residential unit meetings, and elective or recommended
programming (e.g., anger management, family and parenting support,
physical health activities, crafts, guest lectures on health, education, and
recovery issues). Women in TAU did not receive any of the Seeking
Safety (SS) intervention. Women assigned to the treatment integrated
with condensed SS received the programming and services provided in
TAU when not attending the six 90-minute SS group sessions. These
sessions were offered twice a week at the facility. Six topics were
covered over the course of the SS sessions, including: (1) Introduction to
Safety, (2) PTSD: Taking Back Your Power, (3) Detaching from
Emotional Pain (Grounding), (4) Setting Boundaries in Relationships, (5)
Asking for Help, and (6) Commitment. These topics were selected after
consulting with the developer (Najavits), members of the research team,
and the staff psychologists at the substance treatment facility.
The Primary Investigator (ACG) recruited and trained advanced
graduate students to collect the baseline and follow up data. The Primary
Investigator (PI) attended Seeking Safety (SS) training, then recruited and
trained a separate team of advanced graduate students and a postdoctoral
fellow to conduct the six SS sessions. The postdoctoral fellow had prior
training and experience conducting SS, and one of the graduate students
had attended a SS workshop. To ensure treatment fidelity, the SS team
was recruited according to the skills (e.g., compassion) suggested by
Najavits (2006), and the team conducting the SS sessions met weekly
with the PI for supervision and SS training.
The topics were presented in a continuous, six-session schedule that
was repeated until the study was completed. In general, the women
completed the six SS sessions within 3-4 weeks, considering that some

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sessions had to be made up due to conflicting appointments (e.g. court

appearances, medical appointments). At this point in time, a participant
would have undergone approximately 30 days of residential treatment,
thus, the post-treatment administration of the studys measures were
scheduled for both treatment groups.
RESULTS
Preliminary Analyses
All analyses were conducted using SPSS 15.0 software. Preliminary
analyses revealed that no transformations were required because the
skewness and kurtosis coefficients for the TSC-40, MPSS-SR, and the
BDI-II were within the acceptable ranges described by Tabachnik and
Fidell (1996).
The typical woman in the sample was currently not married (87.8%)
with a household income below poverty level (i.e., 59.8% reported less
than $500 per month, and 25.3% reported less than $1000 per month).
Over one half (53.9%) of the women did not graduate from high school.
TABLE 1 Baseline Means, Standard Deviations, and Significance Tests
of Trauma and Depression Scores for Women Assigned to
Condensed SS and TAU

MPSS-SR
TSC-40
TSC-40Dep
BDI-II

Overall
M (SD)
n

C-SS
M (SD)
n

TAU
M (SD)
n

T (p)

48.1
(31.0)
47.8
(22.9)
12.3
(5.8)
17.2
(10.2)

46.9
(29.7)
47.7
(21.4)
11.9
(5.4)
16.7
(9.5)

49.4
(30.9)
47.9
(24.5)
12.7
(6.2)
17.7
(10.9)

0.38
(.71)
0.07
(.95)
0.76
(.45)
0.53
(.60)

87
101
99
101

43
51
49
51

44
50
50
50

Note. C-SS=Condensed Seeking Safety; TSC-40-Dep=TSC-40 Depression

Baseline Psychological Symptoms

Table 1 provides the means and standard deviations on the TSC-40,
MPSS-SR, BDI-II, and the TSC-40 Depression subscale, overall and by
intervention type. The overall means for the current sample on the
baseline trauma measures were (M = 47.8, SD = 22.9) on the TSC-40 and
(M = 48.1, SD = 31.0) on the MPSS-SR. The overall means for the
baseline depression measures were (M = 12.3, SD = 5.8) on the TSC-40
Depression subscale and (M = 17.2, SD = 10.2) on the BDI. As indicated
in Table 1, there was no significant difference between the group of

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women assigned to the treatment integrated with condensed SS and the

treatment as usual (TAU) group on any of these measures at baseline.
Treatment Type and Treatment Retention
The overall retention rate of the current sample was 53.8%. The
average number of condensed SS sessions completed by the women in
the treatment integrated intervention group was 4.7 sessions. We
investigated whether the proportion of women staying in treatment would
be higher for those who received the treatment integrated with condensed
SS (n = 51), compared to the TAU group (n = 52). The Chi-Square Test
of Independence was significant, (X 2 = 10.71, p = .001), indicating that
the groups differed significantly in treatment retention. The proportion of
women in the treatment integrated with condensed SS who stayed in
treatment during the initial 30 days (70.6%, n = 36) was higher than the
proportion in treatment as usual (38.5%, n = 20).
TABLE 2 Means, Standard Deviations, and Significance Tests of
Baseline Trauma and Depression Scores, by Retention Status
Variable
TSC-40
MPSS-SR
TSC-40Depression
BDI-II

Stayed in Treatment
M (SD), n
51.33 (21.85),
n = 54
53.04 (29.66),
n = 46
13.46 (5.54),
n = 52
19.46 (9.88),
n = 54

Left Treatment
M (SD), n
43.74 (23.55),
n = 47
42.61 (31.87),
n = 41
11.02 (5.87),
n = 47
14.60 (9.97),
n = 47

Baseline Symptoms and Treatment Retention Comparing Treatment

Type
Table 2 provides the means and standard deviations for the
psychological variables (TSC-40, MPSS-SR, BDI-II, and the TSC-40
Depression subscale) grouped by retention status (i.e., staying in
treatment and prematurely terminating). Additional analyses were
conducted to determine the psychological predictors of retention and
whether these predictors varied across treatment groups. The
psychological variables were tested as predictors of retention in separate
logistic regression analyses. Treatment type was added as a variable in
each regression analysis to control for the effects of treatment
assignment. In addition, to determine if the relationship of the predictor
to retention varied for the treatment integrated with condensed SS and the
treatment as usual groups, we added a product term to each analysis. The

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ENHANCING TREATMENT 165

product terms (i.e., the product of treatment type and the predictor
variable) were computed based on strategies outlined by Baron and
Kenny (1986).
TABLE 3 Logistic Regression Models of Treatment Retention

SE

Walds

Odds
Ratio

2.61

.95

7.51

.01

13.64

.09

.03

7.15

.01

1.09

-.06

.05

1.43

.23

.95

Group

3.46

1.16

8.92

.00

31.87

TSC-40-Depression

.17

.06

7.97

.01

1.18

Group x TSC-40-Depress.

-.15

.08

3.38

.07

.86

2.70
.03
-.03

1.07
.01
.02

6.34
4.31
1.56

.01
.02
.10

12.53
1.03
.98

2.53
.03

.93
.01

7.42
5.18

.01
.04

14.87
1.03

-.03

.02

2.67

.21

.98

Predictor
Model One
Group
BDI-II
Group x BDI-II
Model Two

Model Three
Group
TSC-40-Total
Group x TSC-40
Model Four
Group
MPSS-SR-Total
Group x MPSS-SR-Total
Note. Df=1

As listed in Table 3, the logistic regression results indicated that each

model significantly predicted treatment retention. The non-significant
Hosmer-Lemeshow (H-L) chi-square values, the Cox and Snell R square,
and Nagelkerke R square statistics provide additional support for the
utility of the models tested. (see Table 4). Bonferroni correction was
applied to reduce experimentwise error, which reduced our alpha level to
.0125. The odds of retention increased with higher scores on the two
depression variables (BDI-II, p =.007; TSC-40 Depression subscale, p
=.005). Further, the nonsignificant findings on the product terms indicate
that these relationships were evident for both the treatment integrated

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with condensed SS and the treatment as usual groups. However, based

on the adjusted alpha, the trauma variables were non-significant
predictors (MPSS-SR, p = .023; TSC-40, p =.038).
TABLE 4 Treatment Retention Models-Goodness of Fit Statistics
2
df
Model One
Hosmer & Lemeshow
5.06
8
Cox and Snell
.19
--Nagelkerke
.26
--Model Two
Hosmer & Lemeshow
5.55
8
Cox and Snell
.19
--Nagelkerke
.26
--Model Three
Hosmer & Lemeshow
4.96
8
Cox and Snell
.14
--Nagelkerke
.19
--Model Four
Hosmer & Lemeshow
3.41
8
Cox and Snell
.16
--Nagelkerke
.21
---

p
.75
----.70
----.76
----.91
-----

DISCUSSION
Premature termination is considered a problem of paramount
importance in substance abuse treatment (Ball, Carroll, Canning-Ball, &
Rounsaville, 2006; Greenfield et al., 2007). Further, the literature reveals
that standard approaches that separately treat either substance abuse or
mental health are ineffective for patients with co-occurring mental health
concerns and substance abuse disorders (Buckley, 2007). Consistent with
previous research findings that support substance abuse treatment models
which address the unique concerns for women (e.g., Najavits, Weiss, &
Shaw, 1999), the current study involves a women-only treatment setting.
The first aim of this study was to determine if the treatment integrated
with condensed SS improved retention, compared to treatment as usual.
The second aim was to identify the predictors of retention and to
determine if these predictors varied for the two treatment groups.
Perhaps the most important finding of this study is the association
between participation in treatment integrated with condensed SS and
treatment retention during the initial 30-day residential phase of
treatment. A notably higher percentage of women who were randomly
assigned to the treatment integrated with condensed SS remained in
treatment throughout the initial phase compared to women in treatment
as usual (TAU). This finding lends support to evidence by Najavits and

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ENHANCING TREATMENT 167

colleagues (2002) that women participating in the treatment integrated

with condensed SS are more likely to remain in treatment. Importantly,
this study extends those findings with its investigation of treatment
integrated with condensed SS (six sessions over a 3-week duration). In
the recent co-morbidity literature, there is an increased focus on
investigations of specific intervention strategies that can be added to
existing treatment programs (Minkoff, 2007). Further, these findings are
important in that they fit well with the time-limited nature of short-term
or brief treatment programs, highlighting the feasibility of providing an
intervention that addresses several aspects of the multifaceted needs of
women seeking treatment. While previous research (Ghee, Bolling, &
Johnson, in press) has demonstrated trauma symptom reduction
associated with treatment integrated with condensed SS in comparison to
TAU, the current studys findings demonstrate additional efficacy, i.e.,
improvement in treatment retention so women may receive services to
concurrently address comorbid substance abuse and trauma-related
symptoms.
Existing literature remains mixed and inconsistent in regards to
pretreatment clinical characteristics that predict treatment retention
among substance abusers. Consistent with some, but not all previous
findings, we found that higher levels of baseline depression-related
symptoms increased the probability of retention. Interestingly, traumarelated symptoms were not related to retention. Our findings pertaining
to the relation of depressive symptoms and retention are consistent with
previous findings reported for inpatients with severe alcohol dependence
(Martinez-Raga et al., 2002) and for cocaine abusers during their initial
60 days of treatment in a therapeutic community (Levin et al., 2004). In
both studies, those experiencing more depressive symptoms were more
likely to remain in initial treatment.
However, our findings that trauma-related symptoms were not
associated with retention are inconsistent with previous literature in
which lower trauma levels predicted retention (Amaro et al., 2007; Gatz
et al., 2007). Considering the few studies investigating the relationship of
trauma symptoms and retention among women in chemical dependence,
the mixed findings in the literature suggest that additional research is
encouraged. An important finding in our study was that the impact of
baseline depression on treatment retention was the same for women who
received treatment integrated with condensed SS and those who received
treatment as usual. Our findings suggest that treatment retention rates
increased when women had higher levels of depression, suggesting that
such women were more likely to accept that treatment was indicated
regardless of treatment type. Our findings extend the understanding that

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psychological symptoms may serve as motivation to remain in treatment,

particularly for chemically dependent women.
Integration of a condensed version of the SS intervention during the
initial phase of chemical dependence treatment appears feasible and
promising for improving treatment retention among women in treatment.
A strength of our study is that it utilized random assignment into either
the treatment integrated with condensed SS or treatment as usual group.
An additional strength is that it investigated a specific population of
chemically dependent women in a publicly-funded residential treatment
program. Our sample provided a good representative of such publicly
funded facilities (e.g., participants were economically and educationally
disadvantaged, more likely to be unmarried with children, and more
likely to have trauma histories). Another strength is how the specific
themes for the SS condensed intervention were selected, i.e., after
consulting both SS experts and authorities who were knowledgeable of
the sample. According to the developer of the SS model, effectiveness is
not contingent upon the specific topics that are selected (Najavits,
personal communication, September 9, 2005). Nonetheless, future
studies might compare the effectiveness of other SS topics to the six
topics used in this study.
Certain limitations of the present study should be considered when
interpreting these results. First, the relatively small sample size may limit
how well these findings generalize to women in other residential
treatment settings. Second, the women in the present study were not
specifically assessed for posttraumatic stress disorder (PTSD) or other
psychological disorders based on the DSM-IV criteria, except for
substance-use disorders. Including a comprehensive and standardized
diagnostic instrument (e.g., Hien, Cohen, Miele, Litt, & Capstick, 2004;
Zlotnick, Najavits, Rohsenow, & Johnson, 2003) would have expanded
our understanding of the relationship of specific co-morbid psychological
disorders and the treatment integrated with condensed SS on retention.
Finally, our objective for this study was to conduct an initial study on the
efficacy of this condensed SS intervention. Since the findings are
promising, future research is recommended to better evaluate whether the
condensed version is effective for women who are members of different
ethnic groups. Similarly, other background factors may be investigated
(e.g., familial factors, treatment history, involvement in the criminal
justice system) in regard to the role of psychological symptoms and the
effectiveness of enhancing chemical dependence treatment with a
condensed trauma-integrated intervention like Seeking Safety toward
improving treatment retention.
The present study demonstrated that the integration of a condensed
version of SS into the initial phase of treatment can be effective for

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treatment retention, thus allowing chemically dependent women to

remain in treatment in order to progress toward their treatment goals.
Including trauma-integrated interventions, especially abbreviated,
condensed versions early in treatment has promise to be more beneficial
for this population, allowing them to address trauma-related risk factors
for relapse in a timely manner. Our finding that including a condensed
(six-session) SS intervention can effectively improve retention has
important implications pertaining to the practicality and costeffectiveness of this strategy. In our sample, 70% of the women who
received the treatment integrated with condensed SS remained in
treatment, compared to less than 40% of the TAU group. It is quite
feasible for existing treatment programs to incorporate such a model that
requires minimal changes and time demands on their standard treatment
schedules, but has a large impact on retention. While these findings are
promising, the scarcity of existing literature implicates the need for
further research that investigates the effectiveness of brief integrated
treatment for chemical dependence and trauma-related symptoms.
Further, our findings showed that women with higher levels of
preexisting depressive symptoms remained in treatment longer,
regardless of treatment type. While the literature remains mixed in
regards to the association between psychological symptoms, trauma, and
retention, it will be important to discern whether additional factors such
as prolonged existence of psychological symptoms have an impact on
retention. Moreover, it will be important to determine whether specific
aspects of depression, trauma symptoms, and trauma histories might be
better treated by brief concurrent trauma-addictions interventions, as
compared to intermediate and long-term treatment. Studies similar to
Kopta, Howard, Lowry & Beutlers (1994) investigation of outpatient
mental health clients which determined that the improvement schedules
depended on whether the symptoms were acute or chronic, can be
targeted for chemically dependent women enrolled in integrated models
of treatment. We recommend that researchers pay greater attention to
how pretreatment clinical characteristics, concurrent treatment for
chemical dependence and psychological symptoms, and retention are
related.
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