Safety Behavior and PTSD Treatment Outcome: A Call to Arms for Investigators

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By: Hannah C. Levy, MA
HannahLevyProlonged exposure (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD; for a review, see Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010), which involves gradual and systematic exposure to feared trauma-related situations and memories. PE is rooted in emotional processing theory (Foa & Kozak, 1986), which proposes that full activation of the “fear structure” is critical to the success of exposure. In other words, individuals undergoing exposure therapy must become sufficiently anxious during the process in order to disconfirm their fears and ultimately achieve successful treatment outcomes. As such, any efforts to reduce anxiety during exposure, such as employing safety behaviors, are likely to undermine the efficacy of the intervention. Safety behaviors are anxiety-control strategies that are used in feared situations to reduce distress and/or prevent feared outcomes (Salkovskis, 1991). Indeed, the most recent edition of the PE treatment manual states, “…it is helpful to look closely at what the client is actually doing during the in vivo exposure exercises…look for subtle avoidance and ‘safety behaviors’…these behaviors interfere with fear reduction by maintaining the client’s perception that she was not harmed only because of the protective measures she took” (Foa, Hembree, & Rothbaum, 2007, p. 114). Until recently, there was little reason to question the notion that safety behaviors interfere with the efficacy of PE. However, emerging literature suggests the use of safety behavior in exposure is not so black and white: in fact, some authors have reported more favorable exposure outcomes, in terms of fear reduction and approach behavior, when safety behaviors were used as compared to when they were withheld (e.g., Milosevic & Radomsky, 2008). In this article, I review the current literature on the effects of safety behavior in exposure therapy, considers the applicability of these findings to individuals with PTSD, and then issues a “call to arms” for investigators to expand the extant literature into PTSD.

Contrary to emotional processing theory (Foa & Kozak, 1986) and cognitive-behavioral theory more generally (Salkovskis, 1991; Salkovskis, Clark, & Gelder, 1996), empirical research on the effects of safety behavior on treatment outcome in exposure therapy has yielded mixed findings. Several studies have demonstrated that safety behavior undermines the efficacy of exposure therapy for a range of anxiety disorders, including social anxiety disorder (McManus, Sacadura, & Clark, 2008), specific phobia (Sloan & Telch, 2002), and panic disorder with agoraphobia (Salkovskis, Clark, Hackman, Wells, & Gelder, 1999). These studies have shown that participants using safety behavior during exposure had poorer treatment outcomes than those who refrained. By contrast, numerous other studies have failed to find differences in treatment outcome as a function of safety behavior use for many anxiety problems, including specific phobia (Milosevic & Radomsky, 2008) and contamination fear (Rachman, Shafran, Radomsky, & Zysk, 2011). These mixed findings have led to calls for a “reconceptualization” of safety behavior as not necessarily detrimental to exposure therapy, and potentially beneficial in some cases (Rachman, Radomsky, & Shafran, 2008). These authors propose that the careful and strategic use of safety behavior in exposure therapy may provide an increased sense of confidence and control, which may in turn facilitate approach behavior and the disconfirmation of feared outcomes. The authors further theorize that using safety behavior in the early stages of treatment may reduce refusal and dropout rates, as clients/patients may feel less apprehensive about engaging in exposure exercises if they are permitted to use safety behavior.

To this author’s knowledge, no prior studies have examined whether safety behavior decreases the likelihood of refusal and/or dropout in exposure-based treatments. However, recent research has demonstrated other potentially beneficial effects of safety behavior in exposure therapy, including increased approach behavior towards feared stimuli (Milosevic & Radomsky, 2008), greater change in maladaptive beliefs about feared stimuli (Milosevic & Radomsky, 2013), greater perceived control over distressing emotions when in the presence of feared stimuli (van den Hout, Engelhard, Toffolo, & van Uijen, 2011), and greater treatment acceptability (Levy & Radomsky, 2014; Levy, Senn, & Radomsky, 2014). On the other hand, it is important to note the limitations of these studies. For example, all of the studies were intended as preliminary investigations, and as such employed single-session designs with no long-term follow-up period. Therefore, the long-term effects of using safety behavior in exposure therapy are unknown and must be evaluated in future studies.

There are other important limitations of the extant literature on safety behavior. For instance, there appear to be no prior studies that have examined the effect of safety behavior on exposure outcome among individuals with PTSD. Some research has examined the bivariate association between safety behavior use and PTSD symptom severity (e.g., Dunmore, Clark, & Ehlers, 2001), but no studies have compared treatment outcome as a function of safety behavior use in this population. This represents a significant limitation of the existing literature, as it cannot be assumed that the findings from prior studies necessarily generalize to PTSD. The lack of prior research in this area may come as a surprise to some readers, as current PE guidelines strongly discourage the use of safety behavior during exposure in order to achieve successful outcomes. Indeed, the PE treatment manual (Foa et al., 2007) teaches therapists to discourage clients/patients from using safety behavior during exposure exercises. Therapists are also taught to explicitly instruct clients/patients not to use relaxation training, an anxiety-reduction strategy that is introduced in the first session of PE, during exposure exercises. Interestingly, in a review paper on the efficacy of PE, McLean and Foa (2011) acknowledge the lack of research on safety behavior in PTSD, and recommend that future studies address this gap in the literature.

Given the limitations of prior research in this area, this author encourages investigators to conduct research on safety behavior in PTSD. As described previously, there are theoretical (Foa & Kozak, 1986) and empirical (Dunmore et al., 2001) reasons to believe that safety behavior may undermine the efficacy of PE for PTSD, but no formal studies to support this claim. First, it will be essential to establish a valid and reliable measurement tool for safety behaviors in PTSD. Dunmore and colleagues (1999, 2001) developed the Behaviour After Assault Scale, which contains some items designed to assess safety behavior use, but the psychometric properties of this self-report measure have not been formally assessed. Second, using validated measures, it will be important to examine the impact of safety behavior on the efficacy of PE by comparing outcomes and retention rates among individuals who do and do not employ safety behaviors during exposure exercises. This research may provide the necessary empirical support for current PE treatment guidelines discouraging safety behavior (Foa et al., 2007), or it may demonstrate the benign or potentially facilitative effects of safety behavior that have been shown in prior studies (e.g., Milosevic & Radomsky, 2008, 2013). Third, more research on safety behavior may clarify mixed and inconclusive findings on the effects of safety behavior on exposure therapy outcomes, which will have implications for assessment and treatment of anxiety problems. It is my hope that this “call to arms” will inspire research in this area, with the ultimate goal of improving current treatments for individuals with PTSD and other anxiety-related disorders.


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Hannah C. Levy, MA is a psychology resident at the University of Mississippi Medical Center/G. V. (Sonny) Montgomery VA Medical Center Consortium in Jackson, MS. She received her B.A. in psychology from Boston University in 2008, and her M.A. in clinical psychology from Concordia University in 2012. Hannah will receive her Ph.D. in clinical psychology from Concordia University in November, 2016 after completion of her residency. Her research interests include cognitive-behavioral therapy for anxiety and related disorders, mechanisms of change in cognitive-behavioral therapy, and the development of novel treatment approaches for anxiety and related problems.