The Unintended Risk of Playing It Safe

Recent research examines whether safety behaviors do more harm than good.

Posted Mar 20, 2019

Roman Bilik/Unsplash
Source: Roman Bilik/Unsplash

Safety behaviors. They sound like a good thing, right? After all, most of us have probably heard or uttered the words, “safety first!” at some point in our lives. And when feeling anxious, safety behaviors, defined as actions taken with the intent of preventing, escaping from, or reducing the severity of a feared outcome, may lessen the anxiety that we feel in the moment. However, recent research suggests that safety behaviors may not be as helpful as they sound. 

The Problem with Safety Behaviors

Ironically, safety behaviors can actually be quite detrimental as they often play a critical role in the emergence and maintenance of clinical levels of anxiety. This is because when we rely on crutches to get us through feared but low-risk situations, we are likely to believe that the only reason we survived these encounters is because of our use of safety behaviors. As a result, we never get to learn what would happen if we did not use these behaviors, and instead, strengthen our fearful assumptions.

To give an example, let’s say that Mia is afraid that others might reject her if they see that she has sweaty armpits. As a way of reducing the likelihood of this happening, Mia might choose to wear blazers on top of her shirts when attending social gatherings, even in warm weather. Though this might ensure that no one notices that her armpits are sweaty, Mia’s decision to hide her armpits when around others prevents her from realizing that she would be able to tolerate social get-togethers even if she were to ditch her blazer and wear a shirt with visible sweat marks on it. Instead, she likely leaves social encounters thinking that the only reason that she did not get laughed at is because of the fact that her armpits were concealed.

Exposure Therapy Allows for the Corrective Learning that Safety Behaviors Prevent

Given that reliance on avoidance and safety behaviors maintains anxiety, the gold standard treatment for anxiety disorders involves intentionally approaching feared situations without safety behaviors. Though initially distressing, individuals learn a number of important lessons when these “exposures” are conducted intentionally, repeatedly, and for a prolonged period of time (e.g., 30-60 minutes) within the context of exposure therapy.

First, exposure teaches us that anxiety does not last indefinitely or get worse and worse, but eventually either decreases or plateaus. Second, our urges to avoid or perform safety behaviors also decrease with repeated exposure practice. Third, exposure helps us see that our feared outcomes are unlikely to happen and that even if they do occur, we can tolerate this. Alternatively, in cases where it is impossible to know whether our feared outcomes occurred (e.g., others might privately judge Mia but refrain from expressing this judgment), we learn that we can tolerate this uncertainty. Indeed, exposure therapy works in large part because it helps us build muscles for better tolerating both distress and uncertainty.

Do Safety Behaviors Need to be Eliminated All at Once?

Exposure therapy is highly effective in treating anxiety disorders and in helping patients regain control of their lives, rather than letting their anxiety control them. However, while most exposure therapists agree that eliminating safety behaviors is crucial in order for treatment to be successful, some argue that gradually fading safety behaviors over time, rather than removing them all at once, could help make exposure therapy more palatable. After all, the idea of intentionally seeking out the thing that you fear most can be hard to swallow, even for the bravest among us. Yet, it remains unclear whether the benefits of allowing patients to utilize safety behaviors early on in treatment with the goal of eventually fading them outweigh the cons of doing so.  

Examining the Effects of Safety Behaviors on Treatment Outcomes

In a recent attempt to answer this question, Blakey and colleagues (2019) examined treatment outcomes among 60 adults with a spider phobia who engaged in exposure therapy with or without safety behaviors on board. Treatment consisted of four hour-long sessions, three of which involved 30-minute exposures to a live tarantula.

Before doing any exposures, half of the participants were informed that they would not be allowed to perform any safety behaviors during the exposures while the remaining participants were told that the number of safety behaviors permitted would decrease from two to none over the course of treatment. Progress was evaluated immediately after treatment and one month later by assessing, among other things, participants’ self-reported spider phobia symptoms, their willingness to approach a second tarantula, and their distress while doing so.

Study Results and Take-Home Messages

Contrary to the investigators’ hypothesis that safety behaviors would decrease the efficacy of exposure therapy, the two groups did not differ significantly with regard to treatment outcomes. Notably, however, participants in the group that was allowed to use safety behaviors reported believing that their feared outcomes did not occur, at least in part, due to their use of these behaviors.

Thus, although this study suggests that people may still benefit from exposure therapy even if they do not eliminate all safety behaviors at once, continued use of unnecessary aids may prevent individuals from learning that their safety does not hinge on their use of safety behaviors. Accordingly, in an ideal world, Mia would stop using all safety behaviors and learn that she can tolerate high levels of anxiety and distress in social settings and that she does not need to change her behavior at all in response to this discomfort.

Go for It!

Though further research is needed in order to better understand the effects of continued safety behavior use on exposure therapy outcomes, the findings from the study discussed here further my resolve to help patients give up their own unique safety behaviors as early in treatment as possible. And hopefully, this post will encourage you to be courageous enough to experiment with dropping your safety behaviors, perhaps with the help of a therapist. While I cannot guarantee that doing so will work for you, I can say with confidence that anxiety is more likely to stick around or strike back if you continue to use these behaviors.

References

Blakey, S.M., Abramowitz, J.S., Buchholz, J.L., Jessup, S.C., Jacoby, R.J., Reuman, L., & Pentel, K.Z. (2019). A randomized controlled trial of the judicious use of safety behaviors during exposure therapy. Behavior Research and Therapy, 112, 28-35.