Washington State Institute for Public Policy
Seeking Safety
Substance Use Disorders: Treatment for Adults
Benefit-cost estimates updated May 2017.  Literature review updated May 2014.
Seeking Safety is a manualized, standalone therapy designed to treat comorbid trauma/PTSD and substance use disorders. Seeking Safety covers 25 topics over two to three months. In the included studies, each topic is independent of the others, and allows for flexible use (mixed settings, fewer topics, etc.). The five main principles of Seeking Safety are (1) safety in relationships, thinking, behavior, and emotions; (2) treating trauma/PTSD and substance abuse at the same time; (3) a focus on ideals; (4) four content areas: cognitive, behavioral, interpersonal, and case management; and (5) attention to clinician processes (e.g. clinician self-care).
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $5,367 Benefits minus costs $16,409
Participants $9,332 Benefit to cost ratio $42.40
Others $1,642 Chance the program will produce
Indirect $464 benefits greater than the costs 88 %
Total benefits $16,805
Net program cost ($396)
Benefits minus cost $16,409
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $0 $0 $0 $0 $0
Labor market earnings associated with alcohol abuse or dependence ($27) ($60) $0 ($1) ($88)
Health care associated with alcohol abuse or dependence ($2) $0 ($2) ($1) ($6)
Property loss associated with alcohol abuse or dependence $0 $0 $0 $0 $0
Labor market earnings associated with PTSD $4,069 $8,960 $0 $0 $13,029
Health care associated with PTSD $1,328 $432 $1,644 $664 $4,068
Adjustment for deadweight cost of program $0 $0 $0 ($198) ($198)
Totals $5,367 $9,332 $1,642 $464 $16,805
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $526 2013 Present value of net program costs (in 2016 dollars) ($396)
Comparison costs $141 2013 Cost range (+ or -) 10 %
In the included studies, Seeking Safety was administered over a two- to three-month period. The per-participant cost of treatment is the weighted average estimate of the individual or group therapy sessions provided in the studies included in the analysis. We calculated this average estimate using Washington's Medicaid hourly reimbursement rate for outpatient individual and group therapy multiplied by the weighted average of the total hours of these therapies across the studies (averaging 24 total hours). Comparison group costs are computed in a similar manner based on treatment received in the studies (no treatment or standard group treatment).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Alcohol use disorder 2 72 0.009 0.175 41 0.000 0.187 44 0.009 0.957
Illicit drug use disorder 5 346 -0.058 0.093 41 0.000 0.187 44 -0.058 0.535
Post-traumatic stress 6 409 -0.211 0.102 41 -0.211 0.102 42 -0.211 0.039
Psychiatric symptoms^ 2 84 0.057 0.305 41 0.000 0.000 42 0.057 0.852
Citations Used in the Meta-Analysis

Boden, M.T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., Walser, R., ... Trafton, J.A. (2012). Seeking Safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction, 107(3), 578-586.

Desai, R.A., Harpaz-Rotem, I., Najavits, L.M., & Rosenheck, R.A. (2008). Impact of the Seeking Safety Program on Clinical Outcomes Among Homeless Female Veterans With Psychiatric Disorders. Psychiatric Services, 59(9), 996-1003.

Hien, D.A., Cohen, L.R., Miele, G.M., Litt, L.C., Capstick, C. 2004. Promising treatments for women with comorbid PTSD and substance use disorders. American Journal of Psychiatry, 161(8), 1426-1432.

Hien, D.A., Wells, E.A., Jiang, H., Suarez-Morales, L., Campbell, A.N., Cohen, L.R., Miele, G.M., ... Nunes, E.V. (2009). Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. Journal of Consulting and Clinical Psychology, 77(4), 607-619.

Lynch, S., Heath, N., Mathews, K., & Cepeda, G. (2012). Seeking Safety: An Intervention for Trauma-Exposed Incarcerated Women?. Journal of Trauma & Dissociation, 13(1), 88-101.

Zlotnick, C., Johnson, J., & Najavits, L.M. (2009). Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD. Behavior Therapy, 40(4), 325-336.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov