Further Support for the Acceptability-Enhancing Roles of Safety Behavior and a Cognitive Rationale in Cognitive Behavioral Therapy for Anxiety Disorders

By Levy, Hannah C.; Senn, Jessica M. et al. | Journal of Cognitive Psychotherapy, December 1, 2014 | Go to article overview

Further Support for the Acceptability-Enhancing Roles of Safety Behavior and a Cognitive Rationale in Cognitive Behavioral Therapy for Anxiety Disorders


Levy, Hannah C., Senn, Jessica M., Radomsky, Adam S., Journal of Cognitive Psychotherapy


It has been proposed that the judicious use of safety behavior may enhance the acceptability of cognitive behavioral therapy (CBT). Indeed, Milosevic and Radomsky (2013a) found that descriptions of CBT incorporating safety behavior were more acceptable than those that dis- couraged safety behavior. This study aimed to replicate and extend this work. Participants were 688 undergraduates who rated the acceptability of descriptions of CBT varying in safety behavior (judicious or discouraged) and rationale (cognitive or extinction). Consistent with Milosevic and Radomsky, CBT with safety behavior was significantly more acceptable than traditional CBT. Cognitively based CBT was preferred over extinction-based CBT. The effects of prior treatment and general distress were also examined. Overall, previous treatment and greater anxiety were associated with significantly lower acceptability ratings. Results support the acceptability-enhancing role of safety behavior in CBT and are discussed in terms of cog- nitive-behavioral theory and treatment of anxiety and related disorders.

Keywords: CBT; exposure; anxiety; safety behavior; treatment acceptability

Exposure therapy is one of the most effective and widely used treatments for anxiety and related disorders (Abramowitz, Deacon, & Whiteside, 2011; Deacon & Abramowitz, 2004; Olatunji, Cisler, & Deacon, 2010). It involves graded and prolonged experiences with feared stimuli to promote fear extinction and corrective learning. Although exposure is undoubtedly effective, a significant minority of treatment-seeking individuals refuse the treatment entirely or drop out prematurely (Bados, Balaguer, & Saldaña, 2007; Foa et al., 2005; Hembree et al., 2003). In fact, fear of cognitive behavioral therapy (CBT) is a commonly endorsed reason for treatment refusal and/or dropout among individuals with anxiety disor- ders (Mancebo, Eisen, Sibrava, Dyck, & Rasmussen, 2011). As such, a modification of current effective treatments to enhance their acceptability is critically needed.

It has been proposed that the judicious use of safety behavior (i.e., the careful and strategic implementation of safety behavior in the early and/or most challenging stages of treatment) may enhance the acceptability of exposure therapy (Parrish, Radomsky, & Dugas, 2008; Rachman, Radomsky, & Shafran, 2008). Safety behaviors are overt or covert strategies employed in feared situations to reduce anxiety and/or to minimize perceived threat (Salkovskis, 1991; Salkovskis, Clark, & Gelder, 1996). For instance, an individual with contamination fear may carry around hand sanitizer or hygienic wipes to use in the event of perceived contamination. Defined this way, the judicious use of safety behavior is functionally different from the traditional methods used to make exposure therapy more gradual (i.e., developing a hierarchy of feared situations in ascending order of difficulty) because it involves the intentional incorporation of safety behavior into a given exposure session. By contrast, traditional exposure therapy and hierarchy develop- ment are focused on the elimination of anxiety-reducing strategies (known as "response preven- tion") during exposure. According to cognitive theory, safety behavior prevents the acquisition of disconfirmatory evidence about feared situations because the individual attributes the nonoccur- rence of catastrophic outcomes to the presence of the safety behavior (Salkovskis, 1991; Salkovskis et ah, 1996). Alternatively, behavioral theory suggests that safety behavior interferes with fear ac- tivation during exposure, which is considered by some to be an important mechanism of change in exposure therapy (Foa & Kozak, 1986).

Numerous studies have shown that safety behavior interferes with both fear reduction and cognitive change in exposure-based treatments for anxiety disorders (Kim, 2005; McManus, Sacadura, & Clark, 2008; Powers, Smits, & Teich, 2004; Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999). …

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