The importance of safety in psychotherapy is widely acknowledged, though not systematically explored. This paper addresses this gap by integrating the concept of safety across major psychotherapeutic paradigms. The authors argue that while a sense of safety is crucial for mental health and therapeutic progress, the literature lacks a unified understanding of its functions. Early developmental experiences of safety profoundly impact psychopathology, making its role in psychotherapy especially critical. The current understanding of safety is fragmented due to varying theoretical perspectives and terminological inconsistencies across different schools of thought. This study aims to provide a more integrated theoretical perspective on the functions of safety in both ontogenesis and clinical practice, focusing on psychodynamic, cognitive-behavioral, and humanistic approaches.

The authors review the concept of safety across different therapeutic schools. Psychodynamic literature, tracing back to Freud's notion of the ego's concern for safety, highlights safety's role in survival, homeostasis, and defense mechanisms. Key concepts such as attachment theory, the holding environment, and the secure base are discussed, emphasizing safety's importance in soothing and restoring a distressed organism. Cognitive-behavioral therapy (CBT) integrates evolutionary and neurobiological research, including the polyvagal theory, to understand safety as a neurobiological process involving the detection and differentiation of safety and danger cues. CBT therapies emphasize the reduction of safety behaviors and the promotion of safeness behaviors (curious exploration without defensive strategies). Humanistic approaches define safety as a need for a secure and predictable environment, linking it to concepts like ontological security and self-actualization. The authors highlight the contribution of humanistic therapy in defining relational qualities that foster safety in the therapeutic relationship, such as empathy, unconditional positive regard, and presence.

The study employed a qualitative, integrative review method. The authors conducted a panoramic overview of the concept of safety within psychodynamic, cognitive-behavioral, and humanistic psychotherapies. They analyzed literature from prominent authors within each school to identify commonalities and differences in how safety is conceptualized and its role in both ontogenesis and clinical practice. This involved comparing and synthesizing findings to identify the common functions of safety across different therapeutic orientations, examining how safety is perceived, explained, and utilized in therapeutic settings. The selection of these three approaches was based on their representation of major paradigms in contemporary psychotherapy, offering a solid ground for developing an integrative theoretical account. While acknowledging that other schools of thought exist, the authors justified their choice based on the representative nature of the chosen paradigms. The process involved a thorough review of literature, comparisons of the findings, and a synthesis to extract common themes and functions across therapeutic orientations.

The analysis revealed that safety, while central across schools, is a multifaceted and complex concept. The authors identified five fundamental functions of safety that are applicable across all therapeutic approaches: (1) securing survival and defense; (2) facilitating restoration; (3) promoting exploration and play; (4) sustaining risk-taking and coping with danger; and (5) enabling integration and balance. Psychodynamic theories highlight safety's importance in fostering trust, healing, and integration of the self through various relational concepts (containment, basic trust, mirroring). CBT emphasizes the neurobiological and cognitive aspects of safety, focusing on the regulation of the nervous system, the identification and management of safety and danger signals, and the reduction of reliance on safety behaviors. Humanistic therapies emphasize the relational aspects of safety, highlighting the role of empathy, unconditional positive regard, and presence in creating a secure therapeutic environment. The research showed that the optimal therapeutic environment is one that includes sufficient safety to promote trust and healing but also leaves space for the experience of tolerable frustration and risks needed for growth and resilience. Mismanagement of safety (lack, excess, mistiming, exploitation, misuse) can hinder healthy development and impede therapeutic progress. The authors also discuss the dialectical nature of safety, demonstrating that optimal development and treatment involve a balanced interplay between safety and the experience of necessary risk and challenges. The studies reviewed highlight the crucial role of the therapist's attachment style in creating a safe therapeutic environment and promoting successful outcomes. Furthermore, qualitative research supports the identified functions, indicating that clients often emphasize safety, reassurance, and support as core components of their positive therapeutic experiences.

The study's findings address the research question by providing an integrative theoretical framework for understanding the functions of safety in psychotherapy. The significance of these results lies in their contribution to bridging the gap between different therapeutic schools, highlighting common principles despite different theoretical approaches. The integration of neurobiological, relational, and developmental perspectives provides a more comprehensive understanding of safety's role in both ontogenesis and clinical practice. The authors’ proposed five functions of safety offer a framework for future research and provide a shared conceptual language for clinicians across different orientations. The emphasis on the dialectical nature of safety highlights the importance of finding a balance between safety and challenge to foster optimal therapeutic progress.

This paper offers a significant contribution to the field by providing an integrative theoretical perspective on the functions of safety in psychotherapy. The identification of five school-independent functions of safety provides a unifying framework across different therapeutic schools. The authors advocate for further research to explore the role of safety within additional therapeutic approaches and to connect their findings more explicitly with interpersonal neurobiology and affective neuroscience. Future research should focus on refining the assessment of safety through multiple measures, conducting process studies to explore the relationship between safety and clinical processes, and undertaking process-outcome studies to determine the predictive value of safety-related dynamics on treatment outcomes. The development of a comprehensive theory of safety in psychotherapy has broad implications for clinical theory, practice, and research, potentially fostering improved treatment tailoring and enhanced clinical efficacy.

The study's limitations include its reliance on a qualitative, integrative review method which may not account for all perspectives equally and may introduce bias in interpretation. The selection of only three major psychotherapeutic approaches limits the generalizability of the findings to other therapeutic orientations. Future research should incorporate quantitative methods and consider a wider range of therapeutic approaches. The findings are primarily based on existing literature and do not include new empirical data. The authors acknowledge that further research is needed to empirically validate the proposed functions of safety in psychotherapy and examine their interactions with different client characteristics and clinical contexts.