Habituation: Friend or Foe?

The methods of treatment for psychological disorders have typically drawn on research literature and theory generated by Pavlov, Thorndyke, Skinner and others. In the aggregate, both classical conditioning and operant conditioning models have been employed to reduce anxiety, eliminate phobias, lessen depression and improve self-control. Applications of these methods became common in domains very different from psychotherapy-management, advertising, education and personal growth. Our goal here is to briefly compare the occurrence of the phenomenon of habituation in the domains of structured psychotherapy and also in self-guided introspection.

Habituation is defined as “a form of non-associative learning in which an innate (non-reinforced) response to a stimulus decreases after repeated or prolonged presentation of that stimulus.” It is often considered equivalent to desensitization, “a treatment or process that diminishes emotional responsiveness to a negative, aversive or positive stimulus after repeated exposure to it,” according to the APA Dictionary.

In the treatment of combat-related PTSD and in the introspection on career satisfaction, the question will be posed: Habituation – friend or foe?

Treatment of the Combat Veteran: Friend (who tells you what you don’t want to hear)

My own experience treating veterans with PTSD began with a focus on male Vietnam veterans; this was the case in spite of the fact that they had been out of the war for thirty or forty years or more. Of course, the US Department of Veterans Affairs (VA) was also providing care for Iraq and Afghanistan vets, and more recently they have presented in far greater numbers as their symptoms have become entrenched and less easy to ignore. Still, it was remarkable to me that the preponderance of vets enrolled in the treatment program I coordinated at the Indianapolis VAMC in the period 2006-2013 were from the Vietnam War. It has been suggested that the stressor of retirement pushed many veterans into seeking treatment, since it stimulated the re-emergence of symptoms (nightmares, flashbacks, etc.) that had been dormant for many years (Foa & Kozak 1986).

It may seem odd to regard retirement as a stressor, since many of these same men had been anticipating this period as an opportunity for freedom and leisure. Yet, as we know, work life imposes structure on people. It dominates their lives and restricts their freedom, but it does give predictability, income and manageable social interactions. The veteran with chronic PTSD values predictability, not because it moves him along in the pursuit of happiness but rather because it reduces his overwhelming anxiety. He is a person who shuns novelty and avoids attendance at special events or any occasion involving a large number of people, whether he knows them or not.

If he is married, his spouse may have learned ways to protect him from stress and may have coached their children to do the same. Eventually, however, families become fatigued performing these protective and enabling duties, and they make known their need for a change.  The added pressure of a major life change (e.g., retirement) may motivate the veteran to present for treatment.

Even if he has been prescribed antidepressant or anti-anxiety medication in the past, his first encounter in actual psychotherapy moves him much further out of his comfort zone. He has a suspicion that he will be asked to relax some of his avoidance tendencies that have been so automatic in the past. If he receives treatment through a VAMC facility, the authorized therapeutic methods do, in fact, require some release of avoidance. This has not always been the case, however; prior therapeutic methods actually encouraged the practice of selective avoidance of “triggers” (sounds, sights, odors, memories) that might bring on an episode of acute anxiety.  By contrast, current authorized methods, Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE) both involve the neutralization of traumatic memories and triggers through habituation (Monson & Shnaider 2014; Foa, Hambree & Rothbaum 2007).

My preferred method of treatment, PE, requires gradual exposure to life experiences which, in themselves, were not traumatic or dangerous but over time had become anxiety- provoking through association. In addition, the patient is instructed to tell a narrative of the event he identifies as his index trauma; this is done repeatedly in session and also listened to in recorded form between sessions. Not surprisingly, patients are usually put off when they hear what is expected of them, and some patient education about the rationale of treatment is necessary. It requires some courage for the person who has avoided traumatic memories for years to revisit them week after week. Yet, I heard from veteran after veteran that their story had eventually become so desensitized that it became boring. This usually signaled the end of the therapy. Habituation had done its work.

The Successful Careerist: Foe (who promises much but doesn’t deliver)

In his piece in the March 2022 issue of The Atlantic, Arthur C. Brooks made me laugh out loud when he reported his daughter being amused watching “an old man dancing like a chicken and singing ‘(I Can’t Get No) Satisfaction.’” Dad was a bit offended that she couldn’t relate to the relevance of the song for his generation and for most of the rest of us. Her response after he expounded about the malaise of adulthood was, “that sucks.” He tried to soften the blow a bit by suggesting that all this unhappiness could be avoided by “making some difficult choices in the way we live.” (Brooks 2022).

Brooks had been giving this problem some thought, especially as he reflected on the bucket list of things he set up several years ago on his 40th birthday. Items on the list included being a tenured professor at a prestigious university, getting invited to give lectures at important venues, publishing widely acclaimed books in his field, etc. He stated that he had checked all the boxes on the list, but he also indicated that each accomplishment had a fairly short satisfaction shelf life (a day or a week, never more than a month). If this is typical, one wonders how long the satisfaction duration of a Nobel Prize would be (Brooks 2022).

The notion of hedonic treadmill was cited by Brooks to describe the ephemeral enjoyment of achievements and the need to recapture satisfactions that have lost their zest (Brickman & Campbell 1971). Curiously, Brooks notes the similarity between the careerist’s entrapment on the hedonic treadmill and the addict’s need to increase dosage just to maintain equilibrium and stave off withdrawal symptoms (Grisel 2019). If the dilemma for the addict and the careerist striver is similar, even when neurophysiological pathways differ, how can they be released from the hedonic trap? Do their concerns bear any resemblance to the PTSD survivor?

Recovery and Happiness (Maybe)

When the combat veteran entered treatment, he sought relief from misery and release from restrictions so numerous that he wasn’t even aware of many of them. The opening of a life free of trauma would seem a rather low bar when considering the pursuit of happiness, but a new awakening can offer the person possibilities that weren’t even considered before. 

When the hard driving careerist is liberated from the hedonic treadmill, he or she is able to enjoy the here and now instead of breathlessly pursuing the next professional conquest.  Similarly, the recovered addict enjoys freedom from fear of the agony of withdrawal and the tyranny of tolerance of the chemical. Whether habituation has acted as a friend or a foe in the case of the veteran, careerist or addict, it is true of all that some courage is needed to modify longstanding habits that have become problematic.

Arthur Brooks was able to make the decision to get off the hedonic treadmill on his own, presumably through lengthy introspection and with input from people he cares about. He describes his own liberation from the satisfaction trap as moving from “extrinsic” to “intrinsic” sources of happiness. Extrinsic sources would include reinforcements like praise, sensual pleasures and money; whereas, intrinsic sources would relate to spiritual or altruistic motives. In many respects, the distinction between extrinsic and intrinsic sources is strikingly similar to the dichotomy of Hedonic vs. Eudaimonic orientations in what has come to be called Happiness Studies (Ryan & Deci 2001). A person whose orientation is fundamentally hedonic would be totally invested in the pursuit of pleasure. But the person with a eudaimonic orientation would define happiness in terms of virtue and devotion to higher ideals.  

The notion of eudaimonia is taken from Aristotle’s Nicomachean Ethics, where the philosopher grants that while pleasure is desired by men, true happiness is attained only through Contemplative Speculation (eudaimonic pursuit of virtue and meaning). Although Aristotle identifies Contemplative Speculation as “co-extensive” with happiness, it is regarded as Practice, which eventually leads to virtue. In his view, contemplative speculation can be done continuously; this contrasts sharply with pleasure, since “…no one feels pleasure continuously.  One wearies. It pleases when new but afterward Pleasure is dulled.” (Aristotle tr. 1998).  Aristotle clearly anticipates modern psychology’s concept of habituation.

The examination of hedonic and eudaimonic orientations to well-being has been operationalized and factor analyzed for research use in the form of the Hedonic and Eudaimonic Motives for Activities (HEMI). This instrument has permitted study of various questions associated with well-being and happiness. Huta and Ryan (2010) found that hedonia produced more well-being benefits at short term follow-up. They conclude that a combination of hedonic and eudaimonic reinforcement may be necessary for overall well-being.

Luo et al (2018) reported evidence that hedonic affect is more prone to habituation than is eudaimonic affect. Chen and Zeng (2021) pursued a refinement of Luo et al (2018) and Huta and Ryan (2010) by examining the degree to which one prioritizes hedonic vs. eudaimonic goals.  Chen and Zeng’s (2021) study suggests that persons who prioritize hedonic goals over eudaimonic experience a dramatic reduction in overall experience of well-being; whereas, persons who prioritize eudaimonic over hedonic witness sustained gains in overall well-being.  In other words, there is a resistance to habituation. These data offer some laboratory support to Brooks’ decision to shift from seeking extrinsic/hedonic to intrinsic/eudaimonic life rewards.

Conclusion

Our initial question as to whether habituation is friend or foe is rendered moot. It is both and neither. But awareness of its power is highly relevant in therapy and in efforts for self-improvement. In that vein, it is interesting that the hedonia/eudaimonia debate remains active and has become amenable to international research. Perhaps Aristotle would be pleased that a growing number of people are interested in seeking virtue or “the best Principle.” He might smile to read of eudaimonia’s more robust resistance to habituation.

We need to recall that the British philosophers who wrote “(I can’t get no) Satisfaction” also wrote at a later date “You can’t always get what you want, but if you try sometimes, you get what you need.” (Jagger & Richards, 1965; 1969). It often takes some time for this realization to sink in. 

Addendum

In the April 2024 issue of The American Psychologist, Rubenstein and colleagues (2024) provided an examination and critique of Prolonged Exposure Therapy (PE). Although PE was described as the “gold standard” of treatment for PTSD, complaints concerning high dropout rates and poor treatment response have emerged, and a thorough examination of efficacy with comparison to treatment alternatives was provided by the authors.

Although I trained in both Cognitive Processing Therapy (CPT) and PE (the only authorized VA methods during my employment 2007-2013), my preference for the PE approach was clear at the outset, primarily because of its focus on emotional engagement. It seemed logical to me that a patient’s treatment had the highest likelihood of being effective by showing him (all male combat vets at that time) that he has other choices besides avoidance, which is the default mode for the combat veteran. If the therapist is successful in engaging the patient, there is a possibility of convincing the person that the current recollection of the trauma is different from the actual trauma, and he is now safe. Grounding in the present is considered by most to be a necessary condition for recovery from PTSD.

I always felt that I was ethically bound to provide patient education and obtain informed consent before starting treatment. A small number of veterans decided that revisiting traumatic memories was something they would not or could not do. In these cases, I respected their decision, and other treatment options were offered. I never considered them dropouts because PE was never started.

It is clear from Rubenstein et al (2024) that there are now several therapy modalities available that may remedy some of the problems experienced in PE. There are clearly many pathways to symptom reduction, and today’s panoply of choices for treatment is welcomed by the mental health community. I am not familiar with the details of these techniques, but they appear to involve cognitive reframing, broadening of the perceptual field, encouragement of inadvertent exposure, and acceptance of tolerance of distress, among others. I support this emphasis on personal agency. Although I feel that PE can be presented in this light, it may be that some of the residues from the harshness of flooding and implosion (Stampfl & Levis, 1967) contributed to PE being less preferred.

Of course, my goal in the present article was to explore different manifestations of habituation, rather than to advocate for PE, per se.