Reducing Safety Behaviors In Social Anxiety Via Text Message Reminders

Safety behaviors in social anxiety are actions taken to prevent feared outcomes in social situations, such as avoiding eye contact or rehearsing sentences before speaking.

Safety behaviors can help alleviate social anxiety in the short term but can maintain and exacerbate it in the long run for several reasons:

1. They prevent directly testing fears. By relying on safety behaviors, the socially anxious person never gets to truly test if their feared negative outcomes would actually occur. This prevents learning that the fears are exaggerated or inaccurate.
2. They can become self-fulfilling prophecies. The safety behaviors themselves, like staying quiet in meetings, can actually cause the feared outcomes like a boss getting frustrated.
3. If fears don’t come true, the safety behavior gets falsely credited. This increases dependence on the behaviors, when in reality the feared outcome may not have occurred even without the safety behavior.
4. They increase self-focused attention. Monitoring one’s own thoughts and behaviors takes attention away from the social interaction at hand. This self-consciousness fuels more anxiety.

Dropping safety behaviors allows individuals to fully engage in social situations and test their negative predictions.

Over time, this can lead to increased social confidence as people learn they can handle social interactions without relying on safety aids. Reducing safety behaviors is an important target in cognitive-behavioral therapy for social anxiety.

Cougle, J. R., Mueller, N. E., McDermott, K. A., Wilver, N. L., Carlton, C. N., & Okey, S. A. (2020). Text message safety behavior reduction for social anxiety: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 88(5), 445–454. https://doi.org/10.1037/ccp0000494

Key Points

• The primary methods of reducing safety behaviors in social anxiety in this study included sending text message reminders to avoid using safety behaviors or focusing on the present.
• Compared to present-focused texts, safety behavior elimination texts led to lower safety behavior frequency at post-treatment and lower social anxiety at 1-month follow-up.
• Factors like psychiatric medication history did not significantly affect the relationship between treatment condition and social anxiety outcomes.
• The research, while enlightening, has limitations such as lack of a waitlist control condition and relatively short follow-up period.
• The findings support the importance of safety behaviors in social anxiety and suggest text-based interventions can be an accessible treatment approach.

Rationale

Effective treatments exist for social anxiety disorder, but many socially anxious individuals do not access them due to treatment barriers (Ruscio et al., 2008). Technology-based interventions like internet-delivered cognitive behavioral therapy (CBT) show promise but require substantial time and effort, with low rates of full adherence (Dryman et al., 2017).

Contemporary models propose that safety behaviors, actions intended to prevent feared outcomes, are key maintaining factors in social anxiety (Clark & Wells, 1995; Hofmann, 2007).

Studies manipulating safety behaviors in the context of exposure therapy or CBT have shown their importance (Morgan & Raffle, 1999; Taylor & Alden, 2010; Wells et al., 1995). However, no studies have examined safety behavior reduction as an isolated treatment strategy.

The current study evaluated a text message intervention solely targeting safety behavior reduction in socially anxious individuals. This low-cost, low-effort, accessible approach could meet the need for scalable interventions.

Comparing it to a credible control condition (present-focused texts) allowed the examination of safety behavior reduction’s specific effects.

The findings provide novel evidence for the causal role of safety behaviors in social anxiety and the potential of targeting them through a simple remote protocol.

Method

Randomized controlled trial comparing two 1-month text message interventions:

1. Safety behavior reduction
2. Present-focused (control condition)

Procedure

• Screened interested individuals for eligibility online
• Eligible participants completed baseline measures online and were randomly assigned to condition
• Sent 16 text messages every other day for 1 month, reminding participants to avoid safety behaviors (SB condition) or focus on the present (control)
• In SB condition, personalized texts based on participants’ self-reported safety behaviors
• Completed measures at mid-treatment, post-treatment, and 1-month follow-up online

Sample

• 94 individuals with elevated social anxiety were recruited from across the U.S.
• Ages 18-61, predominantly female (85%), racially/ethnically diverse
• No significant baseline differences between conditions except for medication history

Measures

• Social Phobia Inventory (SPIN): self-report measure of social anxiety severity
• Subtle Avoidance Frequency Examination (SAFE): self-report measure of safety behavior frequency
• Cognitive and Affective Mindfulness Scale-Revised (CAMS-R): self-report measure of mindfulness
• Credibility/Expectancy Questionnaire (CEQ): self-report measure of treatment credibility and expectancy

Statistical Analysis

• Multiple regression controlling for baseline scores to compare conditions
• Within-subject effects over time examined using Wald tests
• Reliable change index to assess clinically significant change

Results

It was predicted that, compared to the control condition, the safety behavior reduction condition would lead to lower safety behaviors and social anxiety at post-treatment and follow-up.

As hypothesized, the safety behavior condition led to significantly lower safety behaviors at mid-treatment and post-treatment compared to the control condition.

This effect was marginally significant at follow-up (p=.061). Both conditions showed significant reductions in safety behaviors from pre- to mid-treatment.

The safety behavior condition also led to lower social anxiety than the control condition at post-treatment, though this was a nonsignificant trend (p=.053).

At 1-month follow-up, the safety behavior condition had significantly lower social anxiety, a medium effect size. Both conditions experienced significant and substantial decreases in social anxiety from pre- to post-treatment (d=1.96 for safety behavior, d=1.34 for control).

There were no significant effects of the condition on mindfulness. However, both conditions reported substantial pre-to-follow-up improvements in mindfulness comparable to a mindfulness intervention.

Lastly, clinically significant change in social anxiety symptoms (assessed by reliable change index) did not significantly differ between conditions. Assuming drop-outs were non-responders, 39.6% of the safety behavior and 28.3% of the control condition achieved clinically significant improvements.

Insight

This study provides compelling evidence for the importance of safety behaviors in maintaining social anxiety symptoms.

Simply sending text messages reminding socially anxious individuals to reduce a few key safety behaviors led to lower social anxiety one month after the intervention ended compared to sending general reminders to focus on the present.

While both conditions produced substantial improvements, personalizing the texts to target specific safety behaviors used by each individual seems to have made the safety behavior intervention more potent.

These findings build on previous research embedding safety behavior reduction in exposure therapy or CBT packages. Showing the effects of safety behavior reduction as a standalone strategy implies it may causally influence social anxiety severity.

The fact that such a simple, low-intensity intervention produced symptom improvements is noteworthy. Text-based interventions require minimal time, effort and cost on the part of recipients and providers.

They are highly scalable and accessible, able to reach many undertreated socially anxious people who face barriers to traditional psychotherapy.

Interestingly, though the control condition aimed to cultivate mindfulness, both groups improved comparably on the mindfulness measure.

This may reflect poor measurement or indicate the control intervention had unintended therapeutic effects, perhaps by promoting approach behaviors. Additional control conditions could help clarify the change mechanisms.

Overall, this study spotlights safety behaviors as a prudent treatment target in social anxiety. Efficiently targeting these behaviors through technology could enhance and expand treatment options. Examining more intensive digital interventions and longer-term effects are fruitful avenues for further research.

Strengths

The study had many methodological strengths that bolster confidence in the findings:

First, the randomized controlled design with an active comparison condition enhances internal validity. Rather than merely comparing to no intervention, the control condition provided generic text messages framed as fostering mindfulness. This credible control allows stronger conclusions about the specific effects of the safety behavior messages.

The sample was relatively large for a randomized trial and recruited from across the United States. Participants were screened for elevated social anxiety to ensure relevance of the intervention. The diversity in age, gender, and racial/ethnic background enhances generalizability.

Importantly, the study achieved high retention, with 73% completing the post-treatment assessment and over 60% completing 1-month follow-up. Attrition did not differ between conditions. This high retention is impressive for a multi-assessment trial with no financial compensation, supporting acceptability of the intervention.

Using well-validated measures of social anxiety, safety behaviors, and mindfulness allows comparison to other research. Assessing outcomes at mid-treatment, post-treatment, and follow-up provides a glimpse at the time course of effects.

The safety behavior intervention was personalized based on participants’ self-reported behaviors, increasing relevance. It was fully automated, eliminating therapist confounds. Both conditions were perceived as equally credible, suggesting results were not driven by expectancy effects.

Finally, beyond evaluating statistical significance, the authors present effect sizes and examine rates of clinically significant change. Reporting multiple gauges of impact provides a fuller picture of the practical importance of the findings.

While no single study is definitive, the sound methodology and multi-faceted results of this trial render a meaningful contribution to the literature on treating social anxiety.

Limitations

Despite the notable strengths, some limitations temper the conclusions and point to directions for further investigation:

First, while the sample was relatively diverse, it was still predominantly female (85%), constraining generalizability. A more gender-balanced sample would increase confidence that the effects generalize across genders.

Additionally, the sample size, while respectable, was not large enough to provide adequate power for detecting smaller effects or subgroup differences.

Importantly, social anxiety disorder diagnosis was not confirmed with a clinical interview. The sample had severe levels of self-reported social anxiety, but some participants may not have met the full diagnostic criteria. Replicating the effects in a sample with confirmed diagnoses would enhance clinical relevance.

The control condition, while a credible placebo, also produced surprisingly large improvements in social anxiety and mindfulness. Including a waitlist control would have helped disentangle effects of the control messages from natural symptom course. The lack of a no-intervention control clouds interpretation of within-group changes.

Measurement limitations include omitting measures of depression, functioning, and quality of life to gauge broader impact. The mindfulness scale may have inadequately captured the construct targeted by the control texts. Behavioral measures could have augmented self-reports to assess actual safety behavior use.

The 1-month follow-up, while longer than many studies included, is still a relatively brief window into sustained effects. Examining the maintenance of gains several months out would strengthen clinical utility.

Finally, the intervention itself could be enhanced. Personalization to additional safety behaviors and more interactive elements may increase potency. Supplementing with therapist guidance or in-person instruction could boost adherence and effectiveness for some clients.

These limitations, while constraining conclusions, lay the groundwork for future studies to replicate and extend the promising findings.

Implications

The results of this study have significant implications for social anxiety treatment. Demonstrating the impact of a brief, standalone safety behavior reduction intervention spotlights its potential as a treatment mechanism.

Existing cognitive-behavioral therapies for social anxiety may be optimized by sharpening the focus on eliminating safety behaviors.

Even more impactful, the success of the automated text-based format highlights new avenues for intervention. With such high prevalence and low treatment rates, social anxiety is ripe for scalable interventions.

A simple, low-cost program that does not require therapist involvement could vastly expand access to care. Many socially anxious people who are unwilling or unable to attend traditional therapy may be open to a self-guided digital tool.

This prototype could be refined into a smartphone app, enabling interactive features and responsive tailoring. An app could provide a broader menu of safety behaviors to target, gather real-time data to reinforce progress, and supply on-demand help in triggering situations.

Such an app may serve as a transitional step toward face-to-face therapy or an adjunctive tool to maintain gains afterward.

Considering the heterogeneity of social anxiety, safety behavior reduction alone will not suffice for all sufferers. Those with severe or treatment-resistant symptoms may need more intensive therapies.

However, this study suggests reducing safety behaviors offers meaningful benefits for many, laying groundwork for a stepped care approach.

Beyond social anxiety, the concept may extend to other disorders maintained by safety behaviors, like panic disorder, OCD, and PTSD. Efficiently targeting these behaviors via technology could be a transdiagnostic treatment element.

As digital mental health expands, this study points to the value of precisely translating theory-driven mechanisms into accessible interventions.

References

Primary references

Cougle, J. R., Mueller, N. E., McDermott, K. A., Wilver, N. L., Carlton, C. N., & Okey, S. A. (2020). Text message safety behavior reduction for social anxiety: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 88(5), 445–454. https://doi.org/10.1037/ccp0000494

Other references

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69 –93). New York, NY: Guilford Press.

Dryman, M. T., McTeague, L. M., Olino, T. M., & Heimberg, R. G. (2017). Evaluation of an open-access CBT-based Internet program for social anxiety: Patterns of use, retention, and outcomes. Journal of Consulting and Clinical Psychology, 85, 988 –999. http://dx.doi.org/10.1037/ccp0000232

Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications. Cognitive Behaviour Therapy, 36, 193–209. http://dx.doi.org/10.1080/16506070701421313

Keep Learning

Here are some suggested Socratic questions for students to critically analyze and discuss this research paper further:

1. How might socially anxious individuals personalize this type of intervention to target their own unique safety behaviors? What elements would make a safety behavior reduction app most helpful?
2. The control condition produced significant improvements, possibly by inadvertently encouraging approach behaviors. How could future studies tease apart the active ingredients driving change in this type of intervention? What would be an optimal control condition?
3. Safety behaviors are also common in other anxiety-related disorders. What other conditions might benefit from a similar intervention approach? How would you need to modify the protocol to fit the specific safety behaviors of those disorders?
4. This study focused on treating social anxiety at a clinical level. Could a similar intervention be useful for preventing social anxiety in high-risk groups (e.g., shy adolescents)? What additional elements might you include for a prevention program?
5. Digital mental health tools like this one have the potential to increase access to care, but they also have drawbacks compared to in-person therapy. What are the key pros and cons of mobile interventions for social anxiety? How could the benefits be maximized and the limitations minimized in real-world use?