Use Of Safety Behaviors Research Articles

Incorporating the Judicious Use of Safety Behavior Into Exposure-Based Treatments for Anxiety Disorders: A Study of Treatment Acceptability.

This analog study investigated treatment acceptability and preference as a function of safety behavior use (judicious vs. discouraged) and treatment rationale (cognitive vs. extinction). Thirty-two clinically anxious participants and 437 undergraduate students provided ratings of acceptability and adherence, as well as preference ranks for four written vignettes describing a course of cognitive-behavioral therapy (CBT) for fear or anxiety. Treatment descriptions promoting judicious safety behavior use received significantly higher acceptability and adherence ratings compared to those discouraging its use. Descriptions that presented a cognitively based rationale, compared to an extinction-based rationale, were also rated as both significantly more acceptable and easier to adhere to. The highest preference rank was for treatment that included judicious safety behavior use, conveyed via a cognitive rationale. A similar pattern of results was observed in both participant groups. These findings suggest that the judicious incorporation of safety behavior into CBT has the potential to reduce treatment refusal and dropout. Results are discussed in terms of their implications for cognitive-behavioral and exposure-based treatments.

Avoidance of eye gaze by adults who stutter

PurposeAdults who stutter are at significant risk of developing social phobia. Cognitive theorists argue that a critical factor maintaining social anxiety is avoidance of social information. This avoidance may impair access to positive feedback from social encounters that could disconfirm fears and negative beliefs. Adults who stutter are known to engage in avoidance behaviours, and may neglect positive social information. This study investigated the gaze behaviour of adults who stutter whilst giving a speech. Method16 adults who stutter and 16 matched controls delivered a 3-min speech to a television display of a pre-recorded lecture theatre audience. Participants were told the audience was watching them live from another room. Audience members were trained to display positive, negative and neutral expressions. Participant eye movement was recorded with an eye-tracker. ResultsThere was a significant difference between the stuttering and control participants for fixation duration and fixation count towards an audience display. In particular, the stuttering participants, compared to controls, looked for shorter time at positive audience members than at negative and neutral audience members and the background. ConclusionsAdults who stutter may neglect positive social cues within social situations that could serve to disconfirm negative beliefs and fears.Educational objectives: The reader will be able to: (a) describe the nature of anxiety experienced by adults who stutter; (b) identify the most common anxiety condition among adults who stutter; (c) understand how information processing biases and the use of safety behaviours contribute to the maintenance of social anxiety; (d) describe how avoiding social information may contribute to the maintenance of social anxiety in people who stutter; and (e) describe the clinical implications of avoidance of social information in people who stutter.

Using the Subtle Avoidance Frequency Examination in Adolescent Social Anxiety Assessments

Individuals with social anxiety use safety behaviors to directly or indirectly avoid social situations (e.g., remaining quiet in a social setting to avoid saying anything embarrassing). Safety behaviors have been hypothesized to prevent the disconfirmation of feared occurrences while in social situations. Further, research indicates that use of safety behaviors garners negative reactions from others while in social situations, indicating a link between such behaviors and social skills deficits. In light of the focus on addressing social skill deficits in current evidence-based treatments for adolescent social anxiety, we examined whether a measure for assessing safety behaviors in adults [Subtle Avoidance Frequency Examination (SAFE; Cuming et al. in J Anxiety Disord 23(7):879–883 2009)] could be used reliably and validly in adolescent assessments. Participants were 40 adolescents (total sample: age range 14–17 years; 14 boys and 26 girls; M = 15.15 years; SD = 0.97) allocated into age- and gender-matched groups in terms of whether they were (n = 20) or were not (n = 20) clinic referred for a social anxiety assessment. Results demonstrate that the SAFE (a) has adequate internal consistency; (b) relates positively and uniquely to a widely used measure of adolescent social anxiety, when considering measures of other distinct psychopathology domains; and (c) differentiates clinic referred from community control adolescents. These findings indicate that the SAFE can be reliably and validly administered in adolescent social anxiety assessments and thus have implications for improvements in treatment monitoring and the study of mechanisms of change for adolescent social anxiety treatments.

Identifying Specific Interpretations and Use of Safety Behaviours in People with Distressing Visual Hallucinations: An Exploratory Study

Visual hallucinations (VH) are a common experience and can be distressing and disabling, particularly for people suffering from psychotic illness. However, not everyone with visual hallucinations reports the experience to be distressing. Models of VH propose that appraisals of VH as a threat to wellbeing and the use of safety seeking behaviours help maintain the distress. This study investigated whether people with distressing VH report threat appraisals and use safety behaviours. The study utilized a single group descriptive design, in which 15 participants with psychosis and VH were asked questions in order to assess the content, distress, appraisals, and behaviours associated with visual hallucinations. People who found visual hallucinations distressing (n = 13) held negative appraisals about those hallucinations and specifically saw them as a threat to their physical or psychological wellbeing. They also engaged in safety seeking behaviours that were logically related to the appraisal and served to maintain the distress. People with distressing VH regard them as a threat to their wellbeing and use safety seeking behaviours as a result of this perceived threat. These key processes are potential targets for treatments that will alleviate the distress associated with VH.

The effects of safety behaviors on health anxiety: An experimental investigation

The present study examined the extent to which safety behaviors exacerbate symptoms of hypochondriasis (severe health anxiety). Participants were randomized into a safety behavior ( n = 30) or control condition ( n = 30). After a baseline period, participants in the safety behavior condition spent one week actively engaging in a clinically representative array of health-related safety behaviors on a daily basis, followed by a second week-long baseline period. Participants in the control condition monitored their normal use of safety behaviors. Compared to control participants, those in the safety behavior condition reported significantly greater increases in health anxiety, hypochondriacal beliefs, contamination fear, and avoidant responses to health-related behavioral tasks after the safety behavior manipulation. In contrast, general anxiety symptoms did not significantly differ between the two groups as a function of the manipulation. Mediational analyses were consistent with the hypothesis that changes in the frequency of health-related thoughts mediated the effects of the experimental manipulation on health anxiety. These findings suggest that safety behaviors are associated with increases in health anxiety, perhaps by fostering catastrophic thoughts about health. The implications of these findings for the conceptualization of hypochondriasis as an anxiety disorder are discussed.

Differential effects of safety behaviour subtypes in social anxiety disorder

Clinical observations indicate that individuals with Social Anxiety Disorder (SAD) use a variety of safety behaviours; however, virtually no research has examined the functional effect of different safety-seeking strategies. Accordingly, we conducted two studies to address this issue. Study 1 measured global patterns of safety behaviour use in a large analogue sample. Factor analysis revealed two primary safety behaviour categories, avoidance and impression management. Study 2 assessed situational use of safety behaviours during a controlled social interaction in a clinical sample of 93 patients with Generalised SAD. Factor analysis again revealed support for avoidance and impression-management subtypes. Notably, the two types of safety behaviours were associated with different social outcomes. Avoidance safety behaviours were associated with higher state anxiety during the interaction and negative reactions from participants’ interaction partners. Impression-management strategies appeared to impede corrections in negative predictions about subsequent interactions. These findings suggest that it may be beneficial to consider the unique effects of different safety-seeking strategies when assessing and treating SAD.

Rethinking Safety Behaviors in Insomnia: Examining the Perceived Utility of Sleep-Related Safety Behaviors

Harvey's cognitive model of insomnia (2002a) proposes that sleep-related safety behaviors play a central role in the maintenance of insomnia because such maladaptive coping strategies are thought to reinforce threat-based appraisals of the likelihood and consequences of poor sleep. Research to date has assessed the frequency of safety behavior use in those with insomnia only; however, in addition to the frequency of occurrence, the function of safety behaviors (i.e., a belief that they will prevent a feared outcome from occurring), may be an important consideration. The purpose of this study was to examine sleep-related safety behaviors based on an expanded theoretical understanding of such behaviors across psychological disorders; that is, by examining both their frequency and perceived utility. Undergraduate students ( N = 376) completed an online survey about their sleep, mood, and use of sleep-related safety behaviors. Insomnia severity was associated with a greater perceived need to use safety behaviors (i.e., utility) but not with frequency of safety behavior use. Higher perceived utility of safety behaviors was also associated with unhelpful beliefs about sleep, fear and avoidance of fatigue, and both general and sleep-specific helplessness. These results suggest that these behaviors and the associated underlying maladaptive beliefs may be important targets in cognitive behavioral therapy for insomnia. The current study extends the existing literature and refines the concept of safety behaviors in insomnia to include both the function and frequency of these behaviors.

Does the judicious use of safety behaviors improve the efficacy and acceptability of exposure therapy for claustrophic fear?

Does the judicious use of safety behaviors improve the efficacy and acceptability of exposure therapy for claustrophic fear?

Effects of safety behaviors on fear reduction during exposure

The use of safety behaviors has been considered one of the primary maintaining mechanisms of anxiety disorders; however, evidence suggests that they are not always detrimental to treatment success ( Milosevic & Radomsky, 2008). This study examined the effects of safety behaviors on behavioral, cognitive, and subjective indicators of fear during exposure for fear of spiders. A two-stage design was used to examine fear reduction and approach distance during an in vivo exposure task for participants ( N = 43) assigned to either a safety behavior use (SBU) or no safety behavior use (NSB) condition. Overall, both groups reported significant and comparable reductions in self-reported anxiety and negative beliefs about spiders at posttest and 1-week follow-up. Participants in the SBU group approached the spider more quickly than did participants in the NSB condition; however, participants in the SBU condition showed a small but significant decrease in approach distance at follow-up. These results call for a reconceptualization of the impact of safety behaviors on in vivo exposure.

Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders.

[Clin Psychol Sci Prac 17: 218–233, 2010] Cognitive-behavioral models emphasize maintaining effects of safety behavior in anxiety disorders. Experimental evidence for deleterious effects of those behaviors is less consistent, leading to a controversy about their therapeutic use. The systematic integration of findings is hampered by the variety of concepts used to describe safety behavior, and methodological differences in empirical studies. This article provides a definition and classification of safety behavior in contrast to adaptive coping strategies. Existing evidence regarding contributions of safety behavior to onset and maintenance of anxiety disorders as well as effects of safety behavior on therapeutic outcome is reviewed. In contrast to previous justifications of safety behavior use, a rigorous procedure of identifying safety behavior and abandoning it throughout therapy is suggested.

A Randomized Controlled Trial of a Brief Emergency Department Intimate Partner Violence Screening Intervention

We evaluate the efficacy of emergency department (ED) brief intimate partner violence screening intervention in reducing short-term revictimization. A randomized controlled trial with blinded 3-month follow-up was conducted in an urban New Zealand ED. Participants included 399 nonacute, English-speaking women aged 16 years and older, 199 randomly assigned to the treatment group and 200 to the control group. Participants in both groups received usual emergency health care. Women assigned to the treatment group received a standardized 3-item intimate partner violence screen, statements about the unacceptability of violence, risk assessment, and referral by a health professional research assistant. The main outcome measure was self-reported intimate partner violence exposure. Secondary outcomes included self-care strategies (use of safety behaviors and community resources). Forty-four of 344 (12.8%) women reported intimate partner violence during the 3-month follow-up period: 24 of 177 (13.6.%) among women in the usual care group and 20 of 167 (12.0%) among women in the treatment group. The adjusted odds ratio, controlling for design effects and covariates, was 0.86 (95% confidence interval 0.39 to 1.92). This brief intimate partner violence screening intervention did not significantly reduce short-term violence exposure. Continuing work is needed to maximize intervention effectiveness and monitor medium- and long-term outcomes.

Negative intrusive memories in depression: The role of maladaptive appraisals and safety behaviours

Background Evidence from non-clinical studies suggests that both negative appraisals of intrusive memories and the use of safety behaviours to manage these memories play a role in depression. This study extended this research by exploring its generalisability to a clinically depressed sample. Methods 85 participants (25 depressed, 30 recovered depressed, 30 never-depressed) were administered the SCID-I/NP (First et al., 1996), mood measures, and self-report questionnaires that indexed intrusive memory frequency and avoidance, appraisals and strategies used to manage the memories. Results Depressed participants endorsed higher ratings of negative appraisals of intrusive memories than the never-depressed group, with the recovered group reporting intermediate ratings across most appraisal themes. Depressed individuals reported more safety behaviours and passive strategies in response to their memories than the other two groups. Limitations The cross-sectional design of this study prevents conclusions regarding the causal role of both appraisals and safety behaviours. Conclusions These results highlight the importance of negative appraisals, safety behaviours and passive strategies that are used to manage intrusive memories in depression, and provide further support for the proposal that psychological interventions for depression could usefully incorporate components that aim to reduce intrusions and associated maintaining variables.

Does the judicious use of safety behaviors improve the efficacy and acceptability of exposure therapy for claustrophobic fear?

Exposure therapy is traditionally conducted with an emphasis on the elimination of safety behaviors. However, theorists have recently suggested that the judicious use of safety behaviors may improve the tolerability of this treatment without reducing its efficacy. The present study tested this notion by randomly assigning participants with high claustrophobic fear to receive a single-session intervention with or without access to safety aids during early exposure trials. Improvement was generally equivalent between the treatment conditions, and no reliable benefits or drawbacks were associated with the judicious use of safety behaviors. The theoretical and clinical implications of these findings are discussed.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well‐being of women who experience intimate partner abuse

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well‐being of women who experience intimate partner abuse

PROTOCOL: Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well‐being of women who experience intimate partner abuse

The World Health Organisation estimates that between 10% and 50% of women worldwide report having been assaulted physically or sexually by an intimate partner at some time in their lives, and when threats, financial and emotional abuse are included the prevalence rates are even higher. Abused women can suffer injury and long‐lasting physical and emotional health problems. One form of interventionto assist these women is advocacy. Advocacy interventions aim to help abused women directly by providing them with information and support to facilitate access to community resources. However, before recommending them to health policy makers we need to know whether they improve the health and well‐being of abused women. In other words, are advocacy interventions effective?After searching the world literature for randomised controlled trials evaluating advocacy programmes for abused women, we found ten trials, involving 1,527 women. The studies comparing advocacy with “usual care” were conducted in a variety of settings both within and outside of healthcare. Participants were recruited from diverse ethnic populations and across a wide age range (15‐61 years), but manyhad a relatively deprived socioeconomic status. Most were experiencing current, often severe, abuse. All of the interventions sought to empower the women by helping them to achieve their goals. They differed in: duration (from 30 minutes to 80 hours), the outcomes reported, and the length of time the women were followed up.The evidence is consistent with intensive advocacy decreasing physical abuse more than one to two years after the intervention for women already in refuges, but there is inconsistent evidence for a positive impact on emotional abuse. Similarly, there is equivocal evidence for the positive effects of intensive advocacy on depression, quality of life and psychological distress. There is evidence that brief advocacy increases the use of safety behaviours by abused women.Taken as a whole, we conclude that at present there is equivocal evidence to determine whether intensive advocacy for women recruited in domestic violence shelters or refuges has a beneficial effect on their physical and psychosocial well‐being. Further, we do not know if less intensive interventions in healthcare settings are effective for women who still live with abusive partners. Too few studies evaluated interventions of comparable intensity and duration, measured the same outcomes, or had comparable follow‐up periods.

Evidence-based treatment and therapist drift

Cognitive-behavioural therapy (CBT) has a wide-ranging empirical base, supporting its place as the evidence-based treatment of choice for the majority of psychological disorders. However, many clinicians feel that it is not appropriate for their patients, and that it is not effective in real life-settings (despite evidence to the contrary). This paper addresses the contribution that we as clinicians make to CBT going wrong. It considers the evidence that we are poor at implementing the full range of tasks that are necessary for CBT to be effective – particularly behavioural change. Therapist drift is a common phenomenon, and usually involves a shift from ‘doing therapies’ to ‘talking therapies’. It is argued that the reason for this drift away from key tasks centres on our cognitive distortions, emotional reactions, and use of safety behaviours. A series of cases is outlined in order to identify common errors in clinical practice that impede CBT (and that can make the patient worse, rather than better). The principles behind each case are considered, along with potential solutions that can get us re-focused on the key tasks of CBT.

Acting on voices: Omnipotence, sources of threat, and safety‐seeking behaviours

Previous research indicates that beliefs about voice power and omnipotence are associated with distress, depression, and compliance. The present study investigates whether acting on voices to mitigate perceived threat, in a broader sense than compliance, is driven by delusional beliefs, as the Chadwick, Birchwood, and Trower cognitive-behavioural model of voices would suggest. The role of safety behaviours in maintaining beliefs about voice omnipotence and distress is also examined. A cross-sectional investigation of 30 individuals with current experience of auditory verbal hallucinations was conducted. Participants were assessed on self-report measures of voice topography, voice-related threat and distress, safety behaviour use, beliefs about voices, and depression and anxiety. Three sources of threat were identified: physical harm, shame, and loss of control. Twenty-six individuals had recently used safety behaviours, believing them to be effective in threat reduction. The degree of safety behaviour use and voice-related distress were associated with voice omnipotence beliefs; mood or voice characteristics did not account for this relationship. The association of safety behaviours with increased distress was mediated by beliefs about voice omnipotence. Acting on voices can be conceptualized as a form of safety seeking, associated with maintaining beliefs about voice omnipotence and distress.

The use of safety behaviours to manage intrusive memories in depression

Cognitive models of clinical disorders conceptualise cognitive and behavioural safety-seeking behaviours as central to symptom persistence because they prevent disconfirmation of key maintaining beliefs. Despite growing evidence of the role of negative beliefs about intrusive memories in depression, it remains unclear why such beliefs persist. Accordingly, we examined whether safety behaviours in response to unhelpful beliefs about intrusive memories might play a role in their maintenance. Eighteen high dysphoric (i.e., BDI-II⩾12) individuals who reported an intrusive negative autobiographical memory in the past week completed a battery of measures about their memory, associated negative beliefs and safety behaviours adopted in response to their beliefs. The most commonly endorsed beliefs reflected themes of wanting to control memories (e.g., ‘I should be able to rid my mind of this memory’) and self-deprecation about experiencing them (e.g., ‘Because I can’t control this memory, I am a weak person’). The beliefs prompted a range of safety behaviours, with cognitive distraction being the most common. The findings demonstrate that safety behaviours are common in response to maladaptive beliefs about intrusive memories. Treatment developments in this area are needed, and should incorporate strategies to challenge beliefs about memories, reduce the use of safety behaviours, and promote processing of intrusive memories.

The Role of Unhelpful Appraisals and Behaviours in Vulnerability to Psychotic-like Phenomena

Numerous research studies have found evidence of psychotic-like experiences in the general population which are unrelated to psychopathology. Recent cognitive models of psychosis have considered these findings and have taken a normalizing approach to psychosis. It is suggested that hallucinations and delusions are essentially “normal” but are interpreted and responded to in an unhelpful way by individuals who come into contact with services. A web-based cross-sectional survey was conducted in which 544 students completed measures of predisposition to psychotic phenomena, appraisals of hallucinations and delusions, the use of safety behaviours and thought control strategies and a measure of general health. Positive appraisals of psychotic-like phenomena were found to be associated with the frequency of such phenomena but no more so than negative beliefs. Negative appraisals were more strongly associated with distress than positive appraisals but when the frequency of psychotic-like phenomena was controlled for negative appraisals made only a small contribution to distress. Avoidant safety behaviours and punishment-based thought control strategies were found to be associated with both distress and the frequency of psychotic-like phenomena. These findings provide some support for recent cognitive conceptualizations of psychosis, but essentially they emphasize the multi-faceted nature of vulnerability to psychosis.

An open trial of cognitive therapy for chronic insomnia

We describe the development of a cognitive therapy intervention for chronic insomnia. The therapy is based on a cognitive model which suggests that the processes that maintain insomnia include: (1) worry and rumination, (2) attentional bias and monitoring for sleep-related threat, (3) unhelpful beliefs about sleep, (4) misperception of sleep and daytime deficits and (5) the use of safety behaviors that maintain unhelpful beliefs. The aim of cognitive therapy for insomnia is to reverse all five maintaining processes during both the night and the day. In an open trial 19 patients meeting diagnostic criteria for primary insomnia were treated with cognitive therapy for insomnia. Assessments were completed pretreatment, posttreatment and at 3-, 6- and 12-month followup. The significant improvement in both nighttime and daytime impairment evident at the posttreatment assessment was retained up to the 12 month followup.