Exposure therapy is a highly effective treatment for anxiety disorders. This approach calls for individuals to remain in anxiety-provoking situations long enough to acquire threat-disconfirming information about the situation and build new safety associations. A commonly debated aspect of exposure delivery is the inclusion/exclusion of safety behaviors. Safety behaviors are actions taken by anxious individuals to prevent or minimize feared outcomes and associated distress (e.g., using hand sanitizer to touch a “contaminated” item). Exposure protocols have traditionally called for safety behaviors to be rapidly eliminated at the outset of treatment, as they have the potential to undermine the quality and durability of safety learning. However, a competing view suggests that the “judicious use” of safety behaviors (i.e., the introduction of safety behaviors in the earlier and/or more challenging stages of treatment) does not necessarily interfere with the process of exposure therapy and may in fact facilitate treatment engagement. Clinical trials testing the relative effectiveness of exposure with and without safety behaviors have yielded inconclusive findings and the clinical utility of including safety behaviors in the delivery of exposure remains unclear. The goal of our recent study was to move beyond the current inclusion/exclusion debate to look at whether the manner in which safety behaviors were incorporated into exposure tasks (i.e., made available “just in case” versus actually utilized) influences specific aspects of learning.
Safety behaviors are often present during exposure therapy for a variety of reasons, including client reluctance to fade the behaviors or therapist reservations about a client’s ability to handle an exposure task without access to safety behaviors. Unfortunately, little research has investigated whether exposure outcomes are differentially affected by safety behavior availability (SBA) as compared to safety behavior utilization (SBU) during treatment. Although merely making safety aids available “just in case” might appear relatively innocuous, this practice may paradoxically increase the perception of danger during exposure tasks; that is, the availability of safety aids implies the presence of aid-related threat via the reasoning process “if a safety aid is made available, there must be danger.” To illustrate, imagine going for a swim and seeing that the pool is surrounded by 20 lifeguards. Rather than make you feel safe, you are likely to start scanning for threats that would warrant the need for extra lifeguards. Making safety behaviors available during exposure is thought to trigger the same process of inferring danger from the presence of safety cues. Conversely, SBU may not trigger the same processes of inferring danger and scanning for threat, as the use of the safety behavior (e.g., applying hand sanitizer) would be expected to neutralize any associated threat (e.g., contamination) during the exposure.
To test this concept we re-analyzed data from a study by Sy and colleagues (2011) using a multilevel modeling approach that captured changes in cognitive processes (i.e., inferences of danger and hypervigilance toward threat) and learning variables (i.e., danger expectancy and self-efficacy) across trials in a brief exposure intervention for individuals with claustrophobia concerns.
Undergraduates with claustrophobia concerns were randomly assigned to an SBA or SBU condition and completed a series of six exposures in a claustrophobia chamber; each trial lasted five minutes. Those in the SBU condition were offered three coping aids to assist them during their exposures: (a) opening a small door on the side of the chamber to let in air blowing from a fan, (b) having the chamber door unlocked, and (c) communicating with the experimenter via a two-way radio. SBU participants were instructed to utilize these safety behaviors during the exposure trials and all of them did so. Participants in the SBA condition were provided access to the same three safety aids, but discouraged from using them. The experimenter told participants, “In order to assist you in coping with your fear while in the chamber, three coping aids will be available to you. However, please only use these aids if you feel you must.”
Before and after each trial, participants filled out the two cognitive process measures (i.e., inference of danger from the presence of safety aids and hypervigilance toward threat) and measures of threat expectancy and self-efficacy in the exposure task. Changes in these measures were assessed across the six exposure trials. Consistent with our hypotheses, participants’ inferences of danger from the presence of safety cues and expectations for threat during exposure tasks were slower to reduce across trials in the SBA condition. This pattern of group differences did not apply, however, to our measure of hypervigilance toward threat or perceptions of self-efficacy, as both groups demonstrated similar rates of reduction in these domains over the course of treatment.
Our findings suggest the manner in which safety behaviors are incorporated into the delivery of exposure therapy can influence individuals’ inferences of danger expectations for threat. It is important to emphasize that these findings are relevant to instances when safety is introduced by someone other than the client during exposure delivery. The process of inferring danger from the presence of safety aids applies when someone else (e.g., therapist) introduces a safety aid, and the client is left wondering why the availability of a safety aid might be necessary. Therefore, we would not expect these findings to have the same relevance for safety behaviors that are already part of the client’s repertoire for dealing with anxiety-provoking situations. Our findings are most applicable to instances when therapists have reservations about their client’s ability to tolerate an exposure task and elect to make safety aids available “just in case” to mitigate any potential negative outcomes. In such cases, making safety aids available during exposure may ironically preserve the client’s perceptions of threat across exposure trials. If safety aids are to be introduced during exposure, as advocated in the “judicious use” literature, they should be utilized rather than simply made available to prevent interference with safety learning during treatment.
Read the full paper: Kemp, J. J., Blakey, S.M., Wolitzky-Taylor, K. B., Sy, J. T. & Deacon, B. J. (in press). The effects of safety behavior availability versus utilization on inhibitory learning during exposure. Cognitive Behaviour Therapy. doi.org/10.1080/16506073.2019.1574312
Photo by: Sari Montag
Pictured: Joshua Kemp