Safety behaviors can exert their negative effects through several different pathways. These pathways are not mutually exclusive, meaning a safety behavior could maintain anxiety through one, several, or all the pathways.
1. SAFETY BEHAVIORS MAINTAIN THE SENSE OF THREAT RELATED TO A FEAR/ANXIETY
The first and likely most commonly cited pathway that safety behaviors maintain anxiety by preserving or maintaining the sense of threat related to particular stimuli. In other words, they prevent an individual from learning that a particular situation, place, activity, or thing is not actually dangerous (or is less dangerous than it feels). It does this through the safety behavior attribution or near miss phenomenon. The safety behavior attribution when we attribute the lack of a feared occurrence to engaging in the safety behavior. The near miss phenomenon is when we process multiple cues of threat and possible danger though vigilance or monitoring, which is what we remember after the event or situation. Both of these keep the feeling of danger alive.
2. SAFETY BEHAVIORS PREVENT THE DEVELOPMENT OF SELF-CONFIDENCE
Safety behaviors can prevent a person from developing confidence as it relates to one’s ability to handle stressful situations and possible threats. Therefore, the person feels like they cannot handle something successfully and effectively without the safety behavior. In this way, safety behaviors can act like a crutch, and if a crutch is used, the person learns that the crutch is effective, not themselves.
An example can be seen in a research study. The researchers divided participants in two groups. The first group was supposed to stare at a stove nob and repeatedly check (mentally) that it was turned off. The second group was asked to just look once and then look away. The researchers then asked participants how confident they were in their memory that the stove was turned off. The study found that the group of participants who repeatedly checked had less confidence in their memory about whether the stove was turned on or off. This illustrates how safety behaviors prevent confidence from developing.
3. SAFETY BEHAVIORS INCREASE THE LIKELIHOOD OF THE FEARED CONSEQUENCE OCCURRING.
Another way that safety behaviors increase anxiety is they can actually increase the likelihood of a feared consequence occurring. For instance, individuals with social anxiety fear negative judgements and evaluations by others. As a result, they will be more reserved, avoid eye contact, not talk about themselves, cut conversations short, and leave situations early. Guess what type of reaction these safety behaviors elicit from others? Unfortunately, they result in being perceived as less warm, less friendly, perhaps even aloof and detached…that is, negative judgement. It is important to note, that research has shown that it is the presence of safety behaviors, and not social anxiety itself, that is the cause for these negative reactions. Thus, safety behaviors can create a type of paradoxical self-fulfilling prophecy, which reinforces individuals negative beliefs about how they are perceived by others.
4. OUR MINDS INFER THREAT AND DANGER FROM THE PRESENCE OF SAFETY BEHAVIORS
Our minds are exquisite at threat detection. Our ability to detect danger has been refined through millions of years of evolution. So, it should not be too surprising to learn that our minds automatically infer threat or danger from the mere presence of safety behaviors. As far as our mind is concerned, if a safety behavior is being used, there must be danger present. If I smell smoke, there must be fire. If wash my hands, there must be germs. If I check the locks and windows there must be danger lurking.
5. SAFETY BEHAVIORS CAN INCREASE ANXIETY IN THE MOMENT AND OVER TIME
Certain safety behaviors are well known to increase anxiety in the moment. For example, it is well known, the monitoring and vigilance related safety behaviors increase anxiety and arousal in the moment (even though they are designed to reduce it). Think of body vigilance and fear of physical symptoms such as having a heart attack. As bodily vigilance is deployed, more physical symptoms and sensations will be detected. As frightening symptoms and sensations are detected, anxiety and arousal will increase (“why is my chest hurting”). As anxiety and arousal increases, so to do physical symptoms and sensations, which in turn, feed back into bodily vigilance. Thus, a cycle of increasing vigilance and anxiety ensues.
6. SAFETY BEHAVIORS PREVENT THE PROCESSING OF FEARS/TRAUMATIC MEMORIES
In order to process of fear or trauma memory we have to spend time with it. Safety behaviors prevent us from spending time with a fear which in turn does not allow for our minds to decatastrophize the fear or process the trauma. While it is a natural things to push away things that hurt and cause fear, by doing so it does not allow our mind to “heal.”
Safety Behaviors have been categorized in many different ways. Some of the category systems have stuck around and are accepted by most researchers…others have not made the same splash. Like other safety behavior researchers, I have my own system for categorizing safety behaviors. There is nothing new or unique about my system, it just provides a mental frame work for organizing different safety behaviors, and thereby hopefully allowing for more recognition and insight into your safety behaviors. If you happen to read my treatment workbook on safety behaviors, the first chapter covers the different categories and examples in much more detail. Here is my safety behavior category system:
1) Checking and reassurance seeking*
2) Escape & evade behaviors
3) Attention safety behaviors (Vigilance, monitoring; worry, and planning)
6) Withdrawal and avoidance*
7) alcohol/drugs/medications, companions and safety aids:
8) Impression management:
Those with an *asterisk can be both internal and external
All the categories of safety behaviors (with the exception of impression management – usually social anxiety) are typically seen in more than one condition.
Speaking in very broad and general terms, each category of safety behaviors can be thought to have the following function:
Checking and reassurance: To make ourselves feel better (reduce our anxiety)
Escape and evade: To limit contact with things/people that make us feel anxious
Attention safety behaviors: Keep us safe and prevent mistakes
Suppression: To reduce or not feel anxiety
Withdrawal and avoidance: prevent future anxiety or discomfort
Impression management: to incur positive favor with others
Rumination: To analyze or figure out current problems
I’d be interested in any feedback about ways to improve my categorization system
It may be helpful to read through these different conditions and the common safety behaviors associated with them to identify what you are going through. Each condition includes a description of the symptoms, the safety behaviors, and then a fictional example of a person suffering from the condition.
GAD is characterized by worry, tension, a sense of looming apprehension, and difficulty tolerating uncertainty. The core feature of GAD is worry, which is a sense of looming apprehension about something (future catastrophe) that may or may not happen. The sense of apprehension is associated with attempts to prevent the catastrophe through problem solving. While everyone worries, in GAD the worry is excessive and uncontrollable. GAD also includes several physical symptoms such as: muscle tension, fatigue, feeling keyed up or on edge, difficulty concentrating, sleep problems, and irritability. Worry in GAD can revolve around several themes, including future, health, mental health, relationships, safety, finances, and everyday life activities. GAD also involves thinking patterns that perpetuate anxiety, including expecting the worst and catastrophizing. Thus, future catastrophes are perceived to be likely and severe in nature. Simultaneously, a person’s perceived ability to handle potential threats and related anxiety is diminished. This results in a state of perceived vulnerability and sense of danger, which is where safety behaviors come into play.
GENERALIZED ANXIETY DISORDER (GAD) AND SAFETY BEHAVIORS
When a person feels anxious and vulnerable, they begin to engage in safety behaviors, which are designed to reduce anxiety and/or the likelihood that a feared outcome will occur. These often include: over-planning, reassurance, checking behaviors monitoring the clock, control strategies, and of course, and worry itself. These safety behaviors may decrease anxiety in the short run (and increase a person’s sense of control in the moment), but over time they maintain (and usually increase) anxiety. This occurs because new learning about the likelihood of the feared outcome does not occur (most things we worry about never happen). Neither does a person learn that they are able to cope with anxiety around the possibility of the feared outcome occurring. This in part, is because individuals attribute the lack of the feared occurrence to the safety behaviors and come to rely on them to manage their anxiety. Finally, individuals are likely to view their safety behaviors as valuable and helpful, it increases the likelihood they rely on these strategies and thereby maintaining their anxiety. Let’s look at a clinical example of safety behavior use in generalized anxiety disorder.
Don suffers from generalized anxiety and persistent and chronic worry. One of his primary worries is that that he will get fired from work, eventually leading to being homeless and alone on the streets. This worry persists despite mountains of evidence of the contrary. The actual facts are that he has been at his job for several years, he has always gotten good performance ratings, he is well-respected, and he has even gotten raises and promotions. His work history is completely devoid of any formal disciplinary actions. Also, the company he works for has a lengthy procedural process to go through when they terminate an employee that includes numerous written and verbal warnings and remediation planning.
So, what keeps Don worry about losing his job despite all of the evidence? Of course, the answer is safety behaviors. Specifically, Don has a habit of seeking reassurance from supervisors and co-workers. He seeks reassurance about decisions he makes, about the possibility of mistakes, and how others perceive his performance. He is also vigilant to any signs that his supervisors or co-workers y may be dissatisfied with any aspect of his work. He recounts conversations with others for any clues that he may have done or said something wrong or incorrect. He also checks and rechecks his work for any mistakes in content, grammatical, or appearance. Even casual emails are re-read several times. He also makes extensive lists of all the tasks he has to complete and spends considerable time reorganizing, and reprioritizing tasks on this list. He also extensively plans around deadlines attempting to figure out exactly how each task will be completed in time. All these safety behaviors leave Don feeling tense, worn-down, overwhelmed, and irritable and focused on the worst possible outcome despite the fact that he is highly successful in his career.
In this case, many of Don’s safety behaviors may actually contribute to positive job performance. Additionally, many of Don’s safety behaviors may be congruent with his values of hard-work and responsibility. Also, some of these safety behaviors are needed to complete his job. These are some of the most difficult safety behaviors to address as they appear to be adaptive (at least on the surface). However, at the same time, Don’s anxiety is overwhelming and his has a very low level of job satisfaction. Don will need to make a decision about his willingness to try to reduce some of his safety behaviors. IF he is able to do so, Don and his therapist will have to identify “normal” levels of checking, planning, reviewing and preparing and begin to practice. For example, it may be normal to review an email one time before sending. However, it may also be important to learn that a catastrophe will not happen if Don does not check at all. Thus, Don may then be encouraged to send an email without any checking. Don may also have to learn that mistakes are not the end of the world. As such, Don may then be encouraged to purposefully make a minor mistake in an email. Mistake making exposures are powerful learning tools. This is the typical progression of safety behavior elimination. Other of Don’s safety behaviors can be eliminated completely, such as reassurance seeking. With this safety behavior, be prepared to identify and counter very subtle (often automatic) ways of seeking reassurance.
SOCIAL ANXIETY DISORDER AND SAFETY BEHAVIORS
Social anxiety is characterized by fears of negative judgment, evaluation, or embarrassment. Concerns about negative judgment are often fueled by fears such as, being perceived as stupid, boring, awkward, offensive, generally unattractive, unappealing, etc. To avoid such judgments, individuals with social anxiety avoid social situations and engage in a host of different safety behaviors. Common safety behaviors include: impression management, monitoring of self and others, attempting to hiding anxiety, avoiding eye contact, leaving events early, and pretending not to recognize or see people. Of course, these safety behaviors prevent a person from learning that their fears are unlikely and/or overblown. Additionally, social anxiety related safety behaviors often result in negative judgment and evaluation from others, even though this is what they are designed to prevent. Additionally, social anxiety safety behaviors increase anxiety in the moment often through monitoring of self and others. Below is a clinical description of social anxiety and safety behaviors.
Adam suffers from social anxiety. He struggles with fears or embarrassment and anxiety about being negatively judged or evaluated in many social situations. In general, he fears awkwardness in conversations and believes he is not well-liked by others. He also avoids situations that trigger his social anxiety. As indicated above, safety behaviors play an integral role in maintaining social anxiety. In Adam’s case, his safety behaviors begin long before he actually enters a social situation. Prior to social events, Adam experiences high levels of anticipatory anxiety. During these periods he often has images of mishaps, embarrassments, and rejections. IN response to these, he prepares a head of time by identifying and rehearsing things he will talk about. For example, Adam practices how he will introduce himself and different topics he can discuss. Since he feels more anxious alone, he often reaches out to friends to try to attend social gatherings with them. Unfortunately, despite these anticipatory safety behaviors (or better stated, because of his anticipatory safety behaviors) his anxiety continues to increase as the social event approaches.
Then when he gets to the social event his anxiety spikes and he often experiences strong physical symptoms of arousal. He feels hot, his face flushes, his chest is beating hard, and he starts sweating. He attempts to lessen these symptoms by positioning himself right next to a window or a cooling vent and somewhat away from the main crowd of people. He also tries to stay where the lights are dim and wears clothes that hide sweat. When friends attempt to call him over, he often declines because of his concern about his physical symptoms and others noticing them. At the first opportunity possible, Adam consumes alcohol to bring down his anxiety. After he feels the effect of the alcohol, he starts to engage in conversation and move around the party more freely. However, he continues to engage in safety behaviors. Since he does not want to come across as self-involved, he shares very little information about himself. When asked directly about himself he gives short answers and quickly asks about the other person. Adam also has difficulty maintaining eye contact and whenever there is a lull in the conversation he ends the conversation to avoid any awkwardness. Adam also monitors his conversations carefully and remains vigilant for cues to disapproval. This results in less fluent conversation and gives the perception that he not very interested in the conversation. Of course, all these behaviors have the opposite of their intended effect. That is, they leave others feeling as if Adam is not genuinely interested in talking with them, that he is somewhat disinterested and aloof. After more time passes with Adam continuing to feel anxiety, heusually decides to leave early. Adams early departure (along with his other safety behaviors) is also interpreted by others as him not being interested or motivated to spend time with them. As a result, the next time Adam runs into some of the partygoers they may act a bit more distant and uninterested, which of course will reinforce Adam’s belief that he was negatively judged and not well-liked by others.
The final stage occurs after he has left the party. While driving home, Adam rehashes conversations, comments, facial expressions, body language etc. Adam attempts to identify things that may have upset or offended others or times when others may have felt awkward. This is called post-event rehashing. Adam believes that post-event rehashing will help him to not have such problems again in the future. However, the more he rehashes the worse he feels about the evening. He becomes more convinced that others may have misinterpreted some of the things he said as offensive and that he made them feel uncomfortable and awkward. This rehashing lasts through the night and much of the next day and causes high levels of distress and anxiety. Later in the week, Adam may see some of the partygoers on the street. However, he pretends to not recognize them which greatly limits the likelihood to future positive interactions with these individuals. Overall, these behaviors serve to reinforce Adams belief that he is not well liked and catastrophize feelings of awkwardness in a conversation (which are actually quite normal). These behaviors also cause others to view Adam in a less favorable light, which becomes a self-fulfilling prophecy bringing to pass the very things he was trying to prevent.
SAFETY BEHAVIORS AND PANIC DISORDER
Panic disorder is characterized by recurrent panic attacks, catastrophic interpretations of physical symptoms, and avoidance of situations where panic attacks may occur. Common fears in panic attacks include fears of physical catastrophe, fears of losing control, fears of going crazy, fears of dying, and fears of fear. Common safety behaviors in panic disorder include: body vigilance/scanning for physical symptoms, arousal control strategies, checking pulse or HR, reassurance seeking, traveling with companions, carry medication, carry water bottles, stay on the outside of crowds, take it easy when exercising, avoiding stimulants or alcohol, etc. Below is a clinical description of safety behaviors in panic disorder.
Anne suffers from panic attacks. She is fearful of unusually bodily symptoms as well as situations that may trigger such symptoms and subsequent panic attacks. While she has entered into these situations many times, she continues to feel anxious and panicky. Likewise, while no physical catastrophe has occurred, she continues to be fearful of the symptoms. Why does this continue even when she has entered the situations repeatedly? Again, because of safety behaviors. For instance, Anne always carries a water bottle and anxiety medication. Additionally, when she starts to feel the physical symptoms, she slows down and takes care to not exert herself any more than necessary. As such, when Anne has gotten through the situation without incident, she attributes her safety (i.e., the absence of a catastrophe) to her safety behaviors, as opposed to reevaluating symptoms/situations and her ability to handle them. With the passage of time, Anne monitors her body more and more and becomes more sensitive to her internal experiences. Her vigilance becomes automatic and nearly constant. As soon as she senses a physical symptom she immediately attempts to reduce it through medication, leaving the situation, or taking it easy. She begins to avoid more and more situations and activities (e.g., alcohol, caffeine, heavy meals, exercise, etc.). Additionally, she regularly checks her pulse, looks up symptoms of the internet, and attempts to reassure herself that she is not in danger. Unfortunately, the more she does so the less safe she feels. As Anne continues to engage in safety behaviors, her anxiety around physical symptoms increases, while her life activities become more restricted.
PTSD AND SAFETY BEHAVIORS
PTSD is characterized by a sense of ongoing threat. This sense of threat stems from traumatic events that involved extreme danger to one’s physical or emotional self. Following exposure to a trauma, a constellation of symptoms develops, including intrusive recollections, avoidance, changes in beliefs about the world and others, changes in emotional functioning, and arousal. Most fears in PTSD revolve around fears of physical safety. PTSD is characterized by two types of safety behaviors: 1) vigilance; 2) thought suppression Common vigilance related safety behaviors include scanning, contingency planning, monitoring, checking for danger, locating exits, etc. Thought suppression usually takes the form of trying not to think about the traumatic event and pushing out memories and negative feelings. Below is a clinical description of PTSD related safety behaviors.
Joe has posttraumatic stress disorder (PTSD) which is characterized by vigilance related safety behaviors. One Saturday afternoon, Joe and his wife decide to go to Wall Mart. As the time to leave approaches, Joe starts to feel more uneasy and has some images of things that could go wrong while shopping and what he could do about each situation should it occur…. his sense of unease begins to grow. It’s time to leave, and he and his wife lock the front door and jump in the car. Before leaving, Joe jumps out of the car and checks the door to make sure it is locked. While he’s at it, he checks a couple of the windows just to make sure. Back in the car and Joe is driving. On the back streets he is scanning for debris and trash along the side of the road and when he sees some he swerves to miss it. He also notices cars that look out of place or may be driving erratically. His anxiety has increased a good bit by this point.
The couple arrive at the freeway and have to merge into fast moving traffic. Joe is continually scanning, looking for beat-up cars, trucks, or cars without license plates. When a car gets too close, he believes the driver may have hostile intent and he moves defensively to let the car pass. He feels a mixture of anxiety and rage at the car while it passes and has some fantasies about chasing him down. Joe also continues to scan the side of the road for debris and keeps away from the outside lanes. He also notices cars going too fast as well as those going to slow…but there are so many cars that it is difficult to track all of them. Joe is constantly looking in his rearview and side view mirrors and continues to formulate plans in case he is attacked or other cars lose control. He approaches a bridge and feels his heart begin to race and suddenly feels vulnerable and open to attack. He is sweating and feels like his head is on a swivel. There are so many cars to pay attention to and so much that could possibly go wrong. By the time Joe and his wife reach Walmart his anxiety is very high, he’s feeling tense, his breathing is rapid, and mind is racing.
The couple pull into the parking lot, but it is pretty full and he does not want to park close to other cars. Joe decides on parking near the far corner, which irritates his wife because she does not want to walk that far. Joe feels irritated that his wife does not understand how potentially dangerous this parking lot could be. While walking across the parking lot, he notices cars parked but with their engines idling, he notices cars with tinted windows, he notices cars with passengers sitting waiting in them and for each he forms a plan forwhat he would do if someone jumps out and attacks him. He feels vulnerable in the parking lot. By the time he gets into the store his anxiety is even higher.
Of course the store is packed. As Joe walks in he has a sinking feeling that quickly turns into anxiety and near-panic. There is no way he can keep eyes on all of these people. HE is scanning their faces, their hands, their clothes, shoes, and looking for people that just seem to be out of place. He continues to formulate contingency plans in case he is attacked. He takes note of the exits and places he could use for cover if something went down. As he begins to walk the isles he continues to scan and notice all kinds of potential danger. He uses the shopping cart to keep a safe distance between he and other people. He takes wide turn when he turns into a new isle. He is bothered by people talking too loud. He is fully on guard and aware and expecting something to jump off any minute. He feels panicked and just wants to get out as soon as possible. His wife does not share this concern. IN fact, not only is she not in a hurry, but she decides this is a good opportunity to have a nice chat about their relationship and how great things are going. But Joe does not feel like talking. He is on guard and believes it will take his attention away from the potential danger. He also feels that his wife does not understand how dangerous this situation could be. His gives short, quick answers and does not look at his wife. This quickly irritates his wife and she asks him what is wrong with him. Joe can’t really explain what is going on so he remains quiet and focused on getting out of there as soon as possible. By the time the shopping trip is over, joe is wired, anxious, exhausted, and angry. Joe’s wife is somewhat confused and angry as well. The couple don’t talk much for the rest of the day.
That evening, joe has several intrusive memories about his combat experiences and the friends that he lost. The memories come and he feels anger, guilt, shame, anxiety, and rage. It completely throws him off. He does not want to talk with anyone, but rather wants to be alone. As the memories come, Joe tries to push them out of his mind, but he still feels terrible and the memories continue to linger. Joe then watches TV in attempts to distract himself. This does not really work and he is having a hard time concentrating. He tries getting up and going for a run, which works somewhat, but when he is still having memories. Joe feels desperate. He worries he may be going crazy or will never get over what he saw and experienced. He worries he will not be able to function and does not understand why these memories keep plaguing him. After 2 or 3 hours of this struggle, Joe starts drinking. He quickly feels better and so he keeps drinking. Finally, after a couple hours of drinking, Joe gets tired and goes to bed.
Not all safety behaviors are problematic. In fact, some safety behaviors are helpful. It is important to be able to distinguish between helpful and harmful safety behaviors. Generally speaking, outside of the context of anxiety, safety behaviors can actually reduce real and serious dangers. For example, fastening your seat-belt is a helpful safety behavior that reduces an objective threat.
There are the four questions you can ask in considering whether a safety behavior is truly helpful:
1. Does the safety behavior reduce an objective danger, or is the threat a false alarm
2. How Frequently is the Safety Behavior Performed?
3. What is the function of the safety behavior or is the safety behavior related to anxiety or threat?
The more I study and work with safety behaviors the more I see them as relevant to not just anxiety, but life as well. Safety behaviors are actions and mental strategies to reduce anxiety, uncertainty, and possible threat. This seems normal enough. The problem is, the more we try to reduce uncertainty, the more anxious we feel. Trying to control uncertainty is like trying to control the flow of a river. It is a futile endeavor that leaves us cold, wet, and exhausted. A similar principle applies to our emotions. Our emotions are designed to come and go (or flow like a river). The harder we work to control them (i.e., engage in safety behaviors) the deeper we sink into the sands of the river, until we are stuck, chest-deep and drowning in emotional distress. This same truism runs through life. The more we seek reassurance, the less confident we feel, the more we resist unpleasant internal experiences, the more they persist, the more we try to control others, the less influence we have, the harder we try to fall asleep, the more it alludes us, the more we try to impress, the worse we come off, the more we try to not fall, the more likely we are to take a tumble, the more we work to reduce danger, the more threatened we feel, and the more we try to protect our self from hurt, the more pain we experience.
This does not mean we should be recklessness or thoughtlessness in our actions and interactions. But it does mean that we need to accept a certain amount of risk in order to live life. We need to open ourselves to uncertainty and anxiety and fully embrace them. This, paradoxically, will result in less anxiety and greater self-confidence to deal with whatever comes our way. Our mantra when faced with uncertainty and anxiety should be “maybe so” or “it might happen but I can handle it.” Because in truth, it might, and we need to believe that we can handle things as the occur. This mantra should be followed by DOING NOTHING. Meaning not engaging in the safety behavior your anxiety is making you think is necessary. As we practice this we start to feel our confidence grow and our anxiety decrease.