Reducing Safety Behaviors In OCD Treatment
Overcoming OCD includes identifying and reducing safety behaviors.
Safety behaviors are the things we do to try to suppress thoughts, reduce anxiety, lessen uncertainty, and feel safe. Much of the time, safety behaviors momentarily make us feel better. But, as anyone with OCD knows, that momentary relief isn’t permanent. Sometimes the relief might not even last five minutes. The unwanted, distracting, and painful thoughts and feelings always come back, leaving us trapped in the OCD cycle.
In this post, we’ll review:
What safety behaviors are
Why they maintain OCD (and can contribute to OCD worsening over time)
Why reducing safety behaviors is a key part of treatment
What Are Safety Behaviors?
Safety behaviors are actions, physical and mental, that those of us with OCD use to feel better, suppress thoughts, and prevent harm. Examples of safety behaviors in OCD include:
Checking repeatedly (doors, locks, stoves, pets, reassurance from others, etc.)
Using google or ChatGPT to research
Counting or repeating phrases in your mind
Avoiding situations that trigger obsessions and anxiety
Mentally arguing / worrying to suppress thoughts
Repetitive behaviors until something feels “just right”
Many more…
A safety behavior isn’t defined by what the behavior looks like. A safety behavior is defined by the function of completing the behavior. If the behavior’s function is to suppress thoughts, reduce anxiety, and/or prevent a feared outcome related to our obsessional content, then that behavior is a safety behavior.
Danielle’s Safety Behaviors:
Danielle is a mom of three young children. Although Danielle has numerous OCD “theme areas”, one of the most troubling is the thought that, somehow, one of her children might get locked outside of the house. If one of her children was locked outside the house, Danielle imagines many terrible things that might happen, like her child being kidnapped or freezing to death.
Every night, Danielle feels compelled to complete multiple rituals (safety behaviors) to make sure her kids are all in the house. This includes specific, rigid conversations with each of her children while her children are seated on the couch in the living room. During this conversation, Danielle would repeat in her head (sometimes 50 or 60 times), “I see Mary. I see Mary. I see Mary. I see Dylan. I see Dylan. I see Dylan. I see Max. I see Max. I see Max. Mary is next to Dylan and Dylan is next to Max. Mary is next to Dylan and Dylan is next to Max. All three kids are on the couch. All three kids are on the couch.”
If anything about this ritual isn’t completed correctly, Danielle feels compelled to start over from the beginning. The ritual often takes more than an hour (sometimes a lot more). These safety behaviors are time consuming, painful, and disruptive to Danielle’s children and husband.
Danielle told me that she “knew” that it was “extremely unlikely” that she wouldn’t realize that one of her children was locked outside. She also told me she believed it was “crazy” that she “didn’t trust [her] perception or memory”. That is, when she was having conversations with her children in the living room, she “knew” that she could see her children directly in front of her. But even though she could see her children directly in front of her, she continued to have thoughts like:
· What if I’m not seeing my children correctly?
· What if, later tonight, I worry I didn’t see my children correctly and then I feel anxious and compelled to do more safety behaviors?
· What if, somehow, I’m making a mistake and then something terrible happens?
Danielle told me that, when she was traveling away from home, she didn’t have any concern that her husband would leave a child outside. She reported she frequently relied on reassurance from her husband even after completing her rituals (e.g., repeatedly asking her husband something like “You saw all the kids inside, right?”).
On the other hand, Danielle dreaded the times her husband travelled for work. During the times her husband was away, she almost always asked family or friends to come spend the night at her house (so that the friend or family member could ensure the kids were inside). In the rare instances family or friends weren’t available, she told me she’d stay up all night.
This brought us to Danielle’s reports about her sleep even when her husband was home. Danielle’s sleep had been disrupted for years. Frequently, in the middle of the night, Danielle would wake up, immediately have the thought “What if one of my kids is locked outside”, immediately feel anxious, and then instantly check on the kids in their rooms to “make sure” they were in their beds. These checks were almost never just a quick glance. Sometimes Danielle would be staring at each of her kids for 15 or 20 minutes to “be certain” they were tucked in their beds.
Danielle reported she doesn’t like completing her safety behaviors. But, when I asked Danielle what it would be like for her not to complete her safety behaviors, she told me that she would get stuck with the thought that one of her children might be stuck outside, and that she’d get stuck with extremely painful feelings of anxiety and guilt.
Why Are Safety Behaviors A Problem?
Anxiety isn’t bad. Worry isn’t bad. Both anxiety and worry are important in human life. We’d be lost without them. If Danielle was at a park with her children, and Max began running toward a street busy with traffic next to the park, it’s important that Danielle feel anxious. This anxiety will motivate Danielle to immediately run to Max and keep Max from entering the road.
Like running after Max to stop him from entering the road, safety behaviors have their own logic. If we experience a thought we don’t like, or if we’re afraid something terrible might happen, the most natural thing in the world is to do something, anything, to protect the things we care about and make the unwanted thoughts and feelings go away.
A lot of the time, our safety behaviors do stop a thought or reduce anxiety. Or they cause us to believe that we’ve protected something we care about which, in turn, helps us feel safe.
This doesn’t mean completing the safety behavior is enjoyable. It just means that we prefer completing the safety behavior (even if the safety behavior is time consuming and unpleasant) compared to what we think it will be like, or what will happen, if we don’t complete the safety behavior.
However, within OCD, anxiety and worry are far disproportional to the “risks”. As our OCD develops, anxiety and worry grow and grow, until much of (or all) our day is consumed by them.
This is why those I work with almost always come to agree that there are two levels of their anxiety.
The first level of anxiety is that the feared outcome will occur, such as one of Danielle’s children getting locked outside and then something bad happening. The second level of anxiety is that Danielle will get stuck with unwanted, uncontrollable, distracting, and painful thoughts and feelings for an indefinite amount of time.
Getting stuck with unwanted, uncontrollable, distracting, and painful thoughts and feelings is scary. It’s scary because when we’re stuck with those experiences, it really is painful, it really is distracting, and it really does get in the way of us being present and enjoying our lives. And it’s a constant reminder that we can never be 100% sure that the things we care about are safe.
This distinction between levels of anxiety is very important. It’s very rare for someone to work with me if they fully believe their obsessions. If they fully believed their obsessions, they wouldn’t feel the need for psychotherapy. If they fully believed their obsessions, they believe that something about the outside world is the problem.
But, in OCD treatment, we transition from thinking that something about the outside world is the problem to recognizing that it’s something about our internal world that’s the problem. That is, Danielle will transition from thinking:
· My problem is that my kids might get locked out of the house
To:
· My problem is that I constantly get stuck with unwanted, uncontrollable, distracting, and painful thoughts and feelings related to the possibility that my kids might get locked out of the house
Before Danielle and I began collaborating, her strategy to control her unwanted, uncontrollable, distracting, and painful thoughts and feelings was to do her best to rigidly control her external world. She lived her life trying to maintain control of her internal world (her unwanted thoughts and feelings) by obsessively and compulsively controlling her external world (the doors to her house, the physical location and behaviors of her children).
It's not a crazy strategy. Almost everyone with OCD tries this strategy. Sometimes for years. Sometimes for a lifetime.
But it’s a strategy that won’t work long-term. Long-term, we can’t directly control our thoughts and feelings. And the more we try, the more we’ll see for ourselves that all our attempts are doomed to fail.
So, what do we do instead?
Why Abstaining From Safety Behaviors Is So Important In OCD Treatment:
In ERP treatment for OCD, we deliberately face situations, thoughts, and feelings that activate discomfort without performing safety behaviors. When we first begin abstaining from our safety behaviors, it’s typically distracting and painful. However, with practice, we see for ourselves some very important things. We see:
We can tolerate distress even when our thoughts and feelings are very painful
We can meaningfully engage in our lives even in the presence of unwanted thoughts and feelings
The more we see these things for ourselves, the less and less our unwanted thoughts and feelings show up. When they do show up, they bother us much less. And this leaves us free to enjoy and be present in our lives without feeling like our internal world is constantly out of control.