One of my first memories from my deployment to Fallujah, Iraq was seeing the phrase “Complacency Kills” spray-painted in red on large concrete barriers and signs around the base. This simple phrase was a sober reminder to all who read it to be on guard at all times and men and women in theater rapidly internalized and adapted their behaviors to accommodate its warning. For many, it not only shaped their mindset and behaviors in theater, but continued to impact their post-deployment lives through the adoption of war-related safety behaviors.
What are safety behaviors?
Safety behaviors are anything a person does to avoid or reduce anxiety. The most common safety behavior is, of course, avoidance, simply staying away from situations that trigger anxiety. Since we cannot always avoid anxiety-provoking situations, people often develop and use alternative safety behaviors, actions, or activities that make it easier for them to tolerate the feared situation.
Safety behaviors may appear strange to an objective observer, but they usually make perfect sense to the person who is using them to reduce or avoid an anxiety-provoking experience. For example, consider a person with a severe driving phobia, who fears being in an accident. If they are unable to engage in the most extreme safety behavior (total avoidance of driving), they may engage in one or more of the following behaviors to feel safer while behind the wheel:
Safety behaviors tend to be effective in reducing anxiety for the person engaging in them. For example, each of the above behaviors would likely be effective in reducing some of the inherent risks of driving. However, if taken to the extreme, some of them can also increase the risk of an accident. For example, driving 10-20 miles per hour slower than other cars could frustrate other drivers, resulting in angry or aggressive behavior towards the anxious driver. This is a general danger of using safety behaviors: there is an inherent risk that they may increase or worsen the very things that they are intended to prevent. For a more thorough discussion of general information about safety behaviors, I encourage you to read Dr. Birman’s blog post.
What are some examples of safety behaviors in war-related PTSD?
While there is no comprehensive list of safety behaviors people develop post-deployment to a war zone, therapists treating Operation Iraqi Freedom/Operation Enduring Freedom veterans will recognize many of the ones listed below.
Living in a constant state of vigilance due to threat of ambush or attack may result in safety behaviors such as:
Those who participated in caravans or patrols at risk for improvised explosive devices (IED) in theater may engage in driving-related safety behaviors such as:
Individuals who experienced or feared attacks or sniper fire might still engage in safety behaviors such as:
Note that all of these all make sense in theater or if you have lived under these types of threatening conditions. Service members may continue to engage in safety behaviors long after the need for these precautions have passed. Individuals may view these behaviors as much more than habits and some Service members will attribute their survival during deployment to their successful use of these behaviors in a war zone. Understanding this context makes it easier to understand the longevity of these behaviors and why many Service members struggle to let them go once they return home.
How can safety behaviors impact treatment for PTSD?
As providers, it is important to understand how safety behaviors might impact treatment for war-related PTSD. The most salient examples of interference with treatment are a reduction in the effectiveness of exposure therapy, and difficulty in objectively measuring and assessing PTSD symptoms and level of impairment.
Reducing the effectiveness of exposure therapy. One of the main reasons for therapist to be aware of safety behaviors when treating someone with PTSD is that when patients use these behaviors it can reduce or eliminate the effectiveness of exposure therapy exercises. For example, consider a Soldier with PSTD who now avoids crowds altogether due to extreme anxiety. He and his therapist agree that as an exposure assignment the Soldier will make several hour-long visits to the local mall before the next session with the goal of helping the Soldier to realize that the mall is not an unsafe location. The Soldier goes to the mall four times and stays for the full hour each time, suggesting successful exposure trials. However, upon inquiring further, the therapist learns that the Soldier brought a knife for each visit and sat in a secluded corner near the mall entrance where he could observe every person entering or leaving and assess them for threats. The Soldier likely reports feeling safe due to the presence of the knife and the ability to observe and track the other individuals in the mall from a safe location. This scenario highlights the importance of therapist awareness and assessment of safety behaviors in this population. Once identified, therapists can systematically “fade” these safety behaviors as part of the patient’s exposure hierarchy.
Masking symptoms and levels of dysfunction. Another key reason for assessing whether your patient is using safety behaviors is that the use of these strategies can give the false impression of a reduction in symptom occurrence and/or severity. When patients use safety behaviors, they may also be more willing to enter into situations that they would normally avoid. This can lead to providers believing they have less social and occupational impairment than is actually the case. Returning to our example of the Soldier who fears crowds, if they are using an array of safety behaviors every time they go out in public, they may have artificially reduced their anxiety level and may appear more functional than they actually are.
To learn more about safety behaviors, consider attending CDP’s two-day course on Prolonged Exposure Therapy (PE).
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jeffrey H. Cook, Ph.D., is a clinical psychologist serving as the Director of Military Programs for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, he oversees several of the Center's training programs, including Deployment Behavioral Health Providers and the two week training course for military providers.