Recent study shows that safety behaviors are partially ok in CBT for OCD

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Rachman, S., Shafran, R., Radomsky, A. S., & Zysk, E. (2011). Reducing contamination by exposure plus safety behaviour Journal of behavior therapy and experimental psychiatry, 42(3), 397–404.

One article published as early as 1966 demonstrated that fears in animals can be treated by exposing them repeatedly to the fear stimuli while they are restricted in a lab chamber. This has been further explored in humans and the standardized treatment of OCD nowadays is exposure with response prevention i.e. repeatedly exposing the patient to fear-evoking stimuli and preventing any safety behaviors that neutralizes the anxiety. In this study, the authors tested the specific effect of exposure with response prevention vs. exposure with safety behaviors. Exposure with response prevention group did training as implemented in standardized CBT protocols. Exposure with safety behaviors were given additional instructions to use a hygienic wipe to clean away any contamination after each trial of touching the contaminant.

Results showed that both exposure with response prevention as well as exposure with safety behaviors produced large reductions in anxiety and did not differ between the conditions. See results in the graph below (the red line is exposure with safety behaviors).

What is new in this article?

The role of safety behaviors has not been sufficiently empirically tested. This article actually disputes what many CBT therapist learn during their training (i.e. the patient should NOT engage in safety behaviors during the exposure). The authors conclude: “In many circumstances safety behaviour is anti-therapeutic, but we now have examples in which safety behaviour can facilitate treatment…It is conceivable that as more emphatically cognitive treatments are developed, some of the problems encountered in using ERP will be circumvented.”.

How is this relevant to clinicians?

We managed to get an interview with Prof. Rachman who is one of the authors:

– Our recent experiment, and replicated by van den Hout et al. (in the same issue of JBTEP), is part of our programme of re-considering the concept of safety behvaiour, and drawing attention to the uncritical rejection of all forms of S.B. (See Rachman et al. “Safety behaviour: A Re-consideration” in Behaviour Research and Therapy.) “There is bad cholesterol and good cholesterol, and there is bad safety behaviour and good safety behaviour.”

Adam Radomsky who is also one of the authors says:

– The first, and perhaps most important comment is that we do not recommend that clinicians start using the protocol described in the article as much work still needs to be done (on clinical populations, over a larger number of sessions, over a significantly long follow-up period) before we can recommend its use.  That said, the work has the potential to deliver a treatment just as effective as exposure with response prevention, but with markedly enhanced acceptability.  In our view, treatment drop outs and refusals are the greatest obstacle to individuals seeking evidence-based care, and we hope that exposure treatment with safety behaviors will eventually provide another option for therapists wishing to enhance the acceptability, and perhaps effectiveness of their interventions.

Dr. Radomsky

Read the full text article here