The impact of safety behavior on exposure-based fear reduction: a meta-analytic review
Safety behaviours – the subtle things people do to prevent feared outcomes during exposure – are widely debated in clinical practice. Should clinicians discourage them entirely, or can they be used strategically? This meta-analytic review synthesises the experimental literature on the impact of safety behaviour on fear reduction during exposure therapy, offering a nuanced, evidence-based answer to a practically important clinical question.
Abstract
There is a longstanding debate whether allowing safety-seeking behaviors (SSBs) during cognitive-behavioral treatment hampers or facilitates the reduction of fear. In this meta-analysis, we evaluate the impact of SSBs on exposure-based fear reduction interventions. After filtering 409 journal articles, 23 studies were included for systematic review of which 20studies were coded for meta-analysis. For each study, the Standardized Mean Difference (SMD or Hedges’ g) of self-reported fear was calculated at post-intervention. Two comparisons were distinguished: I) exposure without safety-seeking behavior (SSB-) versus baseline behavior (BL), and II) exposure with safety-seeking behavior (SSB+) versus BL.
The results showed that average effect sizes were in favor of SSB-, (I: SMD=0. 31, 95% CI [-0. 04, 0. 66]), and in favor of BL, (II: SMD=-0. 13, 95% CI [-0. 37, 0. 11]). Neither of the effect sizes were statistically significant (I: Z=1. 75, p=. 08; II: Z=1. 07, p=. 28). The current meta-analysis could not provide compelling evidence supporting either the removal or addition of SSB during exposure. More systematic and statistically empowered replications, using comparable research methods, in (non-)clinical settings are needed. Novel insights from fear conditioning research may also shed light on the role of SSB in fear reduction.
Keywords: safety behaviour, exposure therapy, fear reduction, anxiety, meta-analysis, inhibitory learning
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Reference
Meulders, A., Van Daele, T., Volders, S., & Vlaeyen, J. W. S. (2016). The impact of safety behavior on exposure-based reduction of fear and anxiety: a meta-analytic review. Clinical Psychology Review, 45, 144–156. https://doi.org/10.1016/j.cpr.2016.02.002