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

Abstract

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.

Introduction

Anxiety disorders are characterized by inaccurate appraisals of threat which often persist despite the habitual non-occurrence of feared outcomes (Clark, 1999). To explain why seemingly irrational fears seldom self-correct over time, cognitive-behavioral theorists (e.g., Salkovskis, 1991) have highlighted the role played by safety behaviors (i.e., actions taken to prevent, avoid, or escape a feared outcome) in the maintenance of pathological anxiety. Safety behaviors are thought to prevent anxious individuals from acquiring accurate threat-relevant information by promoting a misattribution of safety (Salkovskis, 1991) and by diverting attentional resources away from potentially disconfirming information (Sloan & Telch, 2002). To illustrate, an individual with panic disorder who sits down, breathes deeply, and ingests a high-potency benzodiazepine medication upon experiencing palpitations is unable to learn that such actions may not have been necessary to prevent a heart attack. The attention devoted to these behaviors may also rob the individual of the opportunity to observe the dissimilarity between his or her symptoms and those associated with a genuine heart attack.

Consistent with their hypothesized role as a maintenance factor, safety behaviors are often targeted for reduction or elimination in cognitive-behavioral therapy (CBT). Indeed, CBT involving exposure to feared stimuli and the prevention of safety behaviors is considered the treatment of choice for anxiety disorders such as obsessive–compulsive disorder, panic disorder, and specific phobias (Deacon and Abramowitz, 2004, Otto et al., 2005). From the perspective of emotional processing theory (e.g., Foa & Kozak, 1986), the goal of treatment is to provide anxious individuals with corrective information that disconfirms their inaccurate threat appraisals. Accordingly, exposure therapy is believed to be maximally effective when contexts that might interfere with threat disconfirmation, such as the utilization of safety behaviors during therapeutic exposures, are minimized or eliminated (see Powers, Smits, Leyro, & Otto, 2007, for a review).

Treatment studies have often found that exposure therapy in which safety behaviors are prohibited is more effective than exposure therapy in which patients are permitted to use safety behaviors (Parrish, Radomsky, & Dugas, 2008). For example, a study comparing variants of exposure therapy for panic disorder with agoraphobia (Salkovskis, Clark, Hackman, Wells, & Gelder, 1999) found that patients who dropped safety behaviors during treatment showed a greater decrease in anxiety and panic-related cognitions than patients who did not receive instructions to drop safety behaviors. Research conducted among individuals with high claustrophobic fear suggests that compared to standard exposure, worse outcomes are obtained when individuals are allowed to use safety behaviors during exposures (Sloan & Telch, 2002), even when the option to do so is declined (Powers, Smits, & Telch, 2004). Alternatively, exposure therapy appears more effective when patients deliberately forego their safety behaviors (Kim, 2005, Morgan and Raffle, 1999, Wells et al., 1995) or even act in an opposite manner by engaging in “fear antagonistic actions” (Wolitzky & Telch, 2009).

In contrast to the findings reviewed above, several investigations have found that giving patients permission to utilize safety behaviors during treatment does not diminish the benefits of exposure therapy. In an early investigation, Bandura, Jeffrey, and Wright (1974) found that snake phobic participants who were unable to perform an exposure task after it was modeled for them experienced greater fear reduction when they were able to use “response induction aids” (e.g., gloves) during exposures. Rachman and colleagues (Rachman et al., 1986, de Silva and Rachman, 1984) reported that agoraphobic patients who were allowed to leave the situation (i.e., escape) during in vivo exposures improved to the same extent as those who were not given such permission. Of interest, few patients actually chose to escape during exposures, and escapes were not followed by increases in avoidance or fear but rather by an improved sense of control. More recently, Milosevic and Radomsky (2008) examined the effects of allowing snake fearful participants access to “safety gear” (e.g., gloves, goggles) during a series of progressively more difficult exposures involving a live snake. Compared to participants who were not offered safety gear, those who were experienced large and comparable levels of improvement in fear and catastrophic cognitions. Moreover, participants offered safety gear more rapidly approached the snake. Taken together, these studies suggest that in some circumstances, allowing patients to use safety behaviors during exposure therapy is not associated with decreased efficacy and may even convey some therapeutic benefits.

Drawing on the available clinical research, Rachman, Radomsky, and Shafran (2008) argued that safety behaviors do not necessarily interfere with the benefits of exposure therapy. They suggested that the “judicious use” of safety behaviors, in which access to safety during exposure tasks is provided in the early stages of treatment but is subsequently faded, may facilitate exposure therapy by increasing its acceptability to patients without diminishing its potency with respect to fear reduction and cognitive change. The possibility that the judicious use of safety behaviors may improve upon traditional methods of conducting exposure therapy has important clinical implications. Despite the well-established efficacy of exposure-based CBT, many individuals with anxiety disorders do not benefit from this approach. For example, approximately 45% of patients with obsessive-compulsive disorder drop out, fail to respond acutely, or relapse following exposure and response prevention (Stanley & Turner, 1995). Modifications to exposure therapy that increase its efficacy, decrease its aversiveness, or both have the potential to increase the percentage of patients who can tolerate and benefit from this treatment.

The present study was conducted to examine the effects of augmenting exposure therapy with the judicious use of safety behaviors. Undergraduate participants with high claustrophobic fear were randomly assigned to undergo exposure therapy either with or without access to safety aids during initial exposure trials. Measures of claustrophobic-specific anxiety, catastrophic cognitions, and self-efficacy were assessed at pretreatment, posttreatment, and one-week follow-up. Ratings of treatment acceptability and aversiveness were obtained following each exposure trial. This methodology permitted us to test the following hypotheses, proposed by Rachman et al. (2008), regarding the effects of the judicious use of safety behaviors on exposure therapy:

• Safety behaviors will facilitate therapeutic progress.

• Safety behaviors will increase the acceptability and tolerability of treatment.

• Safety behaviors will provide an enhanced sense of control.

• Safety behaviors will be especially useful during the early stages of treatment.

• Safety behaviors will not preclude cognitive change.

• Safety behaviors will be more effective for individuals with more severe fears.