Ten safety behaviours worth tracking in PTSD therapy
- The SBAF-PTSD is a 10-item self-report scale of PTSD-specific safety behaviours, shortened from the 41-item Safety Behavior Assessment Form. Each item is rated Never, Sometimes, Often or Always, and the total ranges from 0 to 30.
- In 169 treatment-seeking US veterans, a one-factor model fitted the data (χ²(32) = 43.06, p = 0.09, CFI 0.979) and Cronbach's alpha was 0.84. Alpha was 0.83 in 139 undergraduates and 0.73 in a second student sample.
- In 66 veterans who completed Prolonged Exposure (24) or Trauma Processing and Safety Behavior Elimination (42), the mean SBAF-PTSD score fell from 20.8 to 12.4 and the mean PCL-5 score from 46.1 to 20.6.
- Change on the SBAF-PTSD accounted for an additional 29% of the variance in PCL-5 change (β = 1.16, p < 0.001). Adding the type of treatment did not improve the model (p = 0.83).
Most exposure hierarchies are built from what the client avoids. Fewer list what the client does to feel safe once inside the situation: the chair facing the door, the lap around the car park before going in. A group at the VA Salt Lake City PTSD Clinical Team has turned those behaviours into a short scale and printed it in full.
Ten items out of forty-one
The authors started from the 41-item Safety Behavior Assessment Form, took its seven vigilance items and added five that correlated with PCL-5 scores in clinic data. Two were dropped after the first study. The remaining ten cover scoping places before entering, sitting with one's back to the wall, perimeter checks around the home, contingency plans in case someone turns aggressive, letting a person walking behind pass, watching others for signs of danger and checking locks. Three social items – pretending not to recognise someone, cutting conversations short, leaving events early – form a separate Social Escape Index. The form and its instructions are in Appendix A of the open-access article.
Four samples, one of them in treatment
The first sample was 169 veterans at a VA PTSD clinic, 60% of them with a PTSD diagnosis; the next two were students. In the third, students screening positive for probable PTSD scored 13.8, against 11.2 without trauma. In the fourth, 66 veterans completed treatment and filled in the scale every one to three sessions.
From a score to a task list
The scale is more useful as a planning sheet than as a single number. At intake, every item marked Often or Always is a ready-made exposure task: take the seat with your back to the room, walk into the shop without scanning it first, check the lock once. Repeat the ten items every few sessions and you see whether that list is shrinking, which the PCL-5 does not ask. Most participants in the clinical samples were male veterans, so with civilian clients check that each item fits their daily routine.
Every safety behaviour a client marks as frequent is already an exposure task waiting to be scheduled.
Three of the four studies were cross-sectional, and all four samples came from the United States and were fairly homogeneous in race and ethnicity. The authors state that normative cut-offs have not yet been established.