The use of safety-seeking behavior in exposure-based treatments for fear and anxiety: Benefit or burden? A meta-analytic review

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 20 studies 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 = 031, 95% CI [-0.04, 0.66]), and in favor of BL, (II: SMD = 0.13, 95% CI [-037, 0.111). 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. (C) 2016 Elsevier Ltd. All rights reserved.