Aversion therapy is a form of behavior therapy in which an aversive (causing a strong feeling of dislike or disgust) stimulus is paired with an undesirable behavior in order to reduce or eliminate that behavior.
As with other behavior therapies, aversion therapy is a treatment grounded in learning theory—one of its basic principles being that all behavior is learned and that undesirable behaviors can be unlearned under the right circumstances. Aversion therapy is an application of the branch of learning theory called classical conditioning. Within this model of learning, an undesirable behavior, such as a deviant sexual act, is matched with an unpleasant (aversive) stimulus. The unpleasant feelings or sensations become associated with that behavior, and the behavior will decrease in frequency or stop altogether. Aversion therapy differs from those types of behavior therapy based on principles of operant conditioning. In operant therapy, the aversive stimulus, usually called punishment, is presented after the behavior rather than together with it.
The goal of aversion therapy is to decrease or eliminate undesirable behaviors. Treatment focuses on changing a specific behavior itself, unlike insight-oriented approaches that focus on uncovering unconscious motives in order to produce change. The behaviors that have been treated with aversion therapy include such addictions as alcohol abuse, drug abuse, and smoking; pathological gambling; sexual deviations; and more benign habits—including writer's cramp. Both the type of behavior to be changed and the characteristics of the aversive stimulus influence the treatment—which may be administered in either outpatient or inpatient settings as a self-sufficient intervention or as part of a multimodal program. Under some circumstances, aversion therapy may be self-administered.
A variety of aversive stimuli have been used as part of this approach, including chemical and pharmacological stimulants as well as electric shock. Foul odors, nasty tastes, and loud noises have been employed as aversive stimuli somewhat less frequently. The chemicals and medications generate very unpleasant and often physically painful responses. This type of aversive stimulation may be risky for persons with heart or lung problems because of the possibility of making the medical conditions worse. Patients with these conditions should be cleared by their doctor first. Often, however, the more intrusive aversive stimuli are administered within inpatient settings under medical supervision. An uncomfortable but safe level of electric (sometimes called faradic) shock is often preferred to chemical and pharmacological aversants because of the risks that these substances involve.
In addition to the health precautions mentioned above, there are ethical concerns surrounding the use of aversive stimuli. There are additional problems with patient acceptance and negative public perception of procedures utilizing aversants. Aversion treatment that makes use of powerful substances customarily (and intentionally) causes extremely uncomfortable consequences, including nausea and vomiting. These effects may lead to poor compliance with treatment, high dropout rates, potentially hostile and aggressive patients, and public relations problems. Social critics and members of the general public alike often consider this type of treatment punitive and morally objectionable. Although the scenes were exaggerated, the disturbing parts of the Stanley Kubrick film A Clockwork Orange that depicted the use of aversion therapy to reform the criminal protagonist, provide a powerful example of society's perception of this treatment.
Parents and other advocates for the mentally retarded and developmentally disabled have been particularly vocal in their condemnation of behavior therapy that uses aversive procedures in general. Aversive procedures are used within a variety of behavior modification strategies and that term is sometimes confused with the more specific technique of aversion therapy. Aversive procedures are usually based on an operant conditioning model that involves punishment. Advocates for special patient populations believe that all aversive procedures are punitive, coercive, and use unnecessary amounts of control and manipulation to modify behavior. They call for therapists to stop using aversive stimuli, noting that positive, non-aversive, behavioral-change strategies are available. These strategies are at least as, if not more, effective than aversive procedures.
A patient who consults a behavior therapist for aversion therapy can expect a fairly standard set of procedures. The therapist begins by assessing the problem, most likely measuring its frequency, severity, and the environment in which the undesirable behavior occurs. Although the therapeutic relationship is not the focus of treatment for the behavior therapist, therapists in this tradition believe that good rapport will facilitate a successful outcome. A positive relationship is also necessary to establish the patient's confidence in the rationale for exposing him or her to an uncomfortable stimulus. The therapist will design a treatment protocol and explain it to the patient. The most important choice the therapist makes is the type of aversive stimulus to employ. Depending upon the behavior to be changed, the preferred aversive stimulus is often electric stimulation delivered to the forearm or leg. This aversive stimulus should not be confused with electroconvulsive therapy (ECT), which is delivered to the brain to treat depression. Mild but uncomfortable electric shocks have several advantages over chemical and pharmacological stimuli. A great many laboratory research studies using animal and human subjects have used electrical shock and its characteristics are well known. In addition, it has been widely used in clinical settings. Electric shock is easy to administer, and the level of intensity can be preselected by the patient. The stimulation can be precisely controlled and timed. The equipment is safe, battery-powered, suitable for outpatients, portable, easy to use, and can be self-administered by the patient when appropriate.
Case example #1 : What would a treatment protocol look like for a relatively well-adjusted patient specifically requesting aversion therapy on an outpatient basis to reduce or eliminate problem gambling behavior? The therapist begins by asking the patient to keep a behavioral diary. The therapist uses this information both to understand the seriousness of the problem and as a baseline to measure whether or not change is occurring during the course of treatment. Because electric shock is easy to use and is acceptable to the patient, the therapist chooses it as the aversive stimulus. The patient has no medical problems that would preclude the use of this stimulus. He or she fully understands the procedure and consents to treatment. The treatment is conducted on an outpatient basis with the therapist administering the shocks on a daily basis for the first week in the office, gradually tapering to once a week over a month. Sessions last about an hour. A small, battery-powered electrical device is used. The electrodes are placed on the patient's wrist. The patient is asked to preselect a level of shock that is uncomfortable but not too painful. This shock is then briefly and repeatedly paired with stimuli (such as slides of the race track, betting sheets, written descriptions of gambling) that the patient has chosen for their association with his or her problem gambling. The timing, duration, and intensity of the shock are carefully planned by the therapist to assure that the patient experiences a discomfort level that is aversive and that the conditioning effect occurs.
After the first or second week of treatment, the patient is provided with a portable shocking device to use on a daily basis for practice at home to supplement office treatment. The therapist calls the patient at home to monitor compliance as well as progress between office sessions. The conditioning effect occurs, the discomfort from the electric shock becomes associated with the gambling behavior, the patient reports loss of desire and stops gambling. Booster sessions in the therapist's office are scheduled once a month for six months. A minor relapse is dealt with through an extra office visit. The patient is asked to administer his or her own booster sessions on an intermittent basis at home and to call in the future if needed.
Case example #2 : What would the treatment protocol look like for an alcohol-dependent patient with an extensive treatment history including multiple prior life-threatening relapses? The patient who is motivated to change but has not experienced success in the past may be considered a candidate for aversion therapy as part of a comprehensive inpatient treatment program. The treating therapist assesses the extent of the patient's problem, including drinking history, prior treatments and response, physical health, and present drinking pattern. Patients who are physically addicted to alcohol and currently drinking may experience severe withdrawal symptoms and may have to undergo detoxification before treatment starts. When the detoxification is completed, the patient is assessed for aversion therapy. The therapist's first decision is what type of noxious stimulus to use, whether electrical stimulation or an emetic (a medication that causes vomiting). In this case, when the patient's problem is considered treatment-resistant and a medically-monitored inpatient setting is available, an emetic may be preferable to electric shock as the aversive stimulus. There is some research evidence that chemical aversants lead to at least short-term avoidance of alcohol in some patients. An emetic is "biologically appropriate" for the patient in that it affects him or her in the same organ systems that excessive alcohol use does. The procedure is fully explained to the patient, who gives informed consent .
During a ten-day hospitalization , the patient may receive aversion therapy sessions every other day as part of a comprehensive treatment program. During the treatment sessions, the patient is given an emetic intravenously under close medical supervision and with the help of staff assistants who understand and accept the theory. Within a few minutes following administration, the patient reports beginning to feel sick. To associate the emetic with the sight, smell and taste of alcohol, the patient is then asked to take a sip of the alcoholic beverage of his or her choice without swallowing. This process is repeated over a period of 30–60 minutes as nausea and vomiting occur. As the unpleasant effects of the emetic drug become associated with the alcoholic beverage, the patient begins to lose desire for drinking. Aversion therapy in an inpatient program is usually embedded within a comprehensive treatment curriculum that includes group therapy and such support groups as AA, couples/family counseling, social skills training , stress management, instruction in problem solving and conflict resolution, health education and other behavioral change and maintenance strategies. Discharge planning includes an intensive outpatient program that may include aversive booster sessions administered over a period of six to twelve months, or over the patient's lifetime.
Depending upon his/her customary practice, a therapist administering aversion therapy may establish a behavioral contract defining the treatment, objectives, expected outcome, and what will be required of the patient. The patient may be asked to keep a behavioral diary to establish a baseline measure of the behavior targeted for change. The patient undergoing this type of treatment should have enough information beforehand to give full consent for the procedure. Patients with medical problems or who are otherwise vulnerable to potentially damaging physical side effects of the more intense aversive stimuli should consult their primary care doctor first.
Patients completing the initial phase of aversion therapy are often asked by the therapist to return periodically over the following six to twelve months or longer for booster sessions to prevent relapse.
Patients with cardiac, pulmonary, or gastrointestinal problems may experience a worsening of their symptoms, depending upon the characteristics and strength of the aversive stimuli. Some therapists have reported that patients undergoing aversion therapy, especially treatment that uses powerful chemical or pharmacological aversive stimuli, have become negative and aggressive.
Depending upon the objectives established at the beginning of treatment, patients successfully completing a course of aversion therapy can expect to see a reduction or cessation of the undesirable behavior. If they practice relapse prevention techniques, they can expect to maintain the improvement.
Some clinicians have reported that patients undergoing aversive treatment utilizing electric shocks have experienced increased anxiety and anxiety-related symptoms that may interfere with the conditioning process as well as lead to decreased acceptance of the treatment. As indicated above, a few clinicians have reported a worrisome increase in hostility among patients receiving aversion therapy, especially those undergoing treatment using chemical aversants. Although aversion therapy has some adherents, lack of rigorous outcome studies demonstrating its effectiveness, along with the ethical objections mentioned earlier, have generated numerous opponents among clinicians as well as the general public. These opponents point out that less intrusive alternative treatments, such as covert sensitization , are available.
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Association for Advancement of Behavior Therapy. 305 Seventh Ave.—16th Floor, New York, NY 10001-6008. <http://www.aabt.org> .
John Garrison, Ph.D.