The Problems with Habituation as an Explanation for Exposure Treatment

The Problems with Habituation as an Explanation for Exposure Treatment

NOTE: This post is part of a larger series of on the theory, practice, and research on exposure therapy. If you are interested in other posts in this series, you can find them here.

 

As discussed in a previous post, it is clear that exposure, or the systematic confrontation with feared stimuli, seems to be a critical component of most therapies, particularly for the treatment of anxiety. However, the way in which exposure is conducted and theories about it why it works vary widely. For decades, one of the dominant concepts used to guide the conduct of exposure therapy was habituation.

In the context of exposure, habituation refers to reductions in fear over time as a person encounters fear-inducing stimuli. While it was originally a term that emerged from behaviorism, it seems to more recently be used to refer to any sort of a decrease in response to a stimulus. For example, you’ve probably had the experience of putting on sunglasses and eventually forgetting that you’re wearing them until you walk indoors and notice how dark everything looks. In these instances, you’ve habituated to feel of the glasses against your skin and the darkened tint of the lenses.

As a more personal example, after getting in a car accident, I remember feeling a sense of anxiety the first few of times I drove again. However, this subsided over time and now I rarely think about the accident when I’m driving. I wasn’t in therapy and didn’t approach this in a systematic way, but I recognized my reactions as minor posttraumatic stress symptoms that would eventually recede as I habituated to driving again. This is basically the same thing that happens in exposure therapy.

In a research context, habituation is often measured through objective physiological measures such as heart rate and skin conductance or through questionnaire measures of fear, such as the Subjective Units of Distress Scale (SUDS). (Instead of “distress,” I’ve also heard “discomfort” and “disturbance” used for the “D” in SUDS.)

Within-Session and Between-Session Habituation

There are two types of habituation in exposure therapy. Within-session habituation occurs when fear decreases during a therapy session as exposure is conducted. Between-session habituation occurs when fear decreases between therapy sessions.

Habituation doesn’t mean that fear goes away completely. Many people continue to experience a fear response when they encounter certain situations. For example, professional public speakers often say that they always feel at least a little nervous before a speaking engagement. However, they generally are often less nervous than they were when they first started (which is similar to between-session habituation) or they find their nervousness goes down more quickly when they begin speaking and become involved in what they’re doing (which is similar to within-session habituation).

The Old Guideline: Within-Session Habituation is Important

It used to be that habituation was used a primary guide for exposure treatment, particularly for treatment of PTSD and obsessive-compulsive disorder. Typical guidelines would be that the person should stay in contact with the feared stimulus until his or her fear went down. At that point, exposure might be discontinued. For example, here’s a diagram of the heart rate of a person doing exposure who is afraid of cats.

Often this happens naturally. If we don’t feed our anxiety by leaving the situation, it will often decrease on it’s own within about 45 minutes. Consequently, some exposure therapies specified that a person remain in an anxiety provoking situation for 30-60 minutes, or until anxiety decreased.

The New Guideline: Within-Session Habituation Doesn’t Matter

Although habituation has supplied thousands of clinicians with a measurable marker for beginning and ending exposure treatment, research hasn’t provided a lot of support for its reliability and validity. Using habituation isn’t necessarily a bad thing—it does provide a decent marker—but researchers haven’t found much of a relationship between within-session habituation and treatment success. There’s even some question whether between-session habituation matters, but that’s a little more controversial.

I’ll be going into this issue in more depth on subsequent posts, but for now, I’ll summarize. There’s evidence that clients may show physiological decreases in anxiety but continue to report high levels of fear, and vice versa. Put simply, it may not matter much whether people experience reductions in fear through exposure. The usefulness of exposure appears to be more about people getting used to their fear than changes in how strong it is. In sum, the research evidence for habituation doesn’t support its use in exposure therapy.

Look for future posts that go into greater detail on the problems with habituation.

UPCOMING TRAINING EVENTS

How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


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Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


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Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC