Safety behaviors

Summary

A person that suffers from an anxiety disorder frequently perform safety behaviors: In an anxiety related situation, he or she does something to relieve the anxiety or to avoid it becoming stronger. Even though safety behaviors may feel like they “work” in difficult situations, they actually maintain the anxiety problem in the long run. Safety behaviors hinder the patient to discover that even without performing them, what he or she fears won’t actually occur. Identifying and helping the patient abstain from safety behaviors is central to successful exposure therapy.

Principles and practice

The understanding of safety behaviors is central when doing CBT, particularly for anxiety disorders. The concept of safety behaviors (or “safety-seeking behaviors”) was developed by Stanley Rachman and further expanded by Paul Salkovskis, David Clark and Adrian Wells in their respective cognitive therapy model for anxiety. In functional analytic terms (see separate article on Functional analysis), it is the equivalent of a negatively reinforced behavior – that is, something the patient does because it has the function of giving relief or avoiding an increase of anxiety. In exposure therapy for OCD, it is simply called a ritual. The main CBT-model for OCD, Exposure and Response Prevention (or Ritual Prevention; see separate article) could in this sense just as well be called “Exposure and prevention of safety behaviors”.

Actually, for all exposure therapy to work, it is precisely very important to help the patient identify and abstain from using safety behaviors during exposure – otherwise the therapy risks to be ineffective. Many, if not all, patients come to therapy saying that they “have already done exposure”, and that “it doesn’t work”. It’s easy to understand what they mean, from their point of view: They have often been in contact with what they fear, maybe hundreds or even thousands of times over the years, but they are still just as afraid. One of the main explanations for this that the patient, every time he or she was in contact with what he or she feared, performed one or several safety behaviors.

Safety behaviors consolidate fear

The patient that suffers from panic attacks and has an agoraphobic fear of taking the bus for example, may always choose the seat closest to the exit, listen to music in her head-phones or try to read in an attempt to distract herself from anxiety. These are all safety behaviors. They usually “work” in the short run, but actually makes the problem worse in the long run: Safety behaviors, just as avoidance, hinders the person to get a new, non-fearful experience of the anxiety-related situation. By doing a safety behavior, the patient acts as if something terrible is about to happen, as if they have to protect themselves from the anxiety rising even more or escalating into something “catastrophic” (like fainting or even dying from strong physical sensations etc). But acting as if something terrible is about to happen actually consolidates and maintains that fear. The goal of all exposure therapy (see specific article) is to expose oneself fully to the feared situation – which means exposing oneself without safety behaviors. Only then will the patient have the transforming experience that the feared catastrophe actually doesn’t happen, even if he or she does nothing to prevent it.

How to assess safety behaviors

But how can the therapist assess if what the patient is doing is a safety behavior or not? Usually, simply by asking: “When you are in that fearful situation (example: the bus), what would happen if you didn’t… (example: put on your head-phones and listen to music)?” If the patient responds that that would be quite difficult and she’s afraid that her anxiety then would become worse and eventually “uncontrollable”, the therapist knows that the music listening functions as a safety behavior. Whereas if the patient answers in a way that shows that the behavior is not functionally related to her anxiety (for example: “I don’t know, nothing would happen I guess, it would just be boring not being able to listen to my favourite artist”), the therapist knows that it doesn’t constitute a safety behavior.

Through these simple questions, the therapist has actually performed a brief functional analysis (see separate article), that is, he or she has found out what is functionally related to the patient’s anxiety and what is not – in other words, the therapist has helped the patient identify one of her safety behaviors.

Inner safety behaviors

A more subtle type of safety behaviors are inner ones; that is, what the patient does in his or her head. An example of this can be the patient suffering from panic disorder that, when the anxiety increases, repeats to himself “My doctor said it’s just anxiety and not a heart attack, my doctor said it’s just anxiety and not a heart attack…!” Even if the statement is true, it doesn’t help – it functions as a safety behavior, that actually maintains the fear. The strongest inner safety behaviors are usually seen in obsessive-compulsive disorder, where they are called mental rituals: common examples of this are for instance to repeatedly going back to a mental image of the door being locked (in checking OCD) or repeating prayers (in religious OCD).

After having explained what a safety behavior is, the patient usually as homework (see separate article) gets the task of trying to identify, and write down, as many safety behaviors as she can, until the next session. This often makes the patient discover a large number of safety behaviors that she wasn’t conscient of before. It can be small, everyday things, like writing a sms to one’s partner to be reassured (which is of course not always a safety behavior, but may be just that on certain occasions, when the patient writes the sms as a way to get reassurance from her partner in some way when she is anxious).

When the patient has identified her safety behaviors, she has taken a very important step to being able to overcome her fears in a CBT – by exposing herself fully, without doing those safety behaviors. Yes, they feel like they work in the short run, but they actually maintain the anxiety in the long run (see separate article on Exposure).