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Aversion therapy

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Aversion therapy
ICD-9-CM94.33
MeSHD001348

Aversion therapy is a form of psychological treatment in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. This conditioning is intended to cause the patient to associate the stimulus with unpleasant sensations with the intention of quelling the targeted (sometimes compulsive) behavior.

Aversion therapies can take many forms, for example: placing unpleasant-tasting substances on the fingernails to discourage nail-chewing; pairing the use of an emetic with the experience of alcohol; or pairing behavior with electric shocks of mild to higher intensities.

Aversion therapy, when used in a nonconsensual manner, is widely considered to be inhumane. At the Judge Rotenberg Educational Center, aversion therapy is used to perform behavior modification in students as part of the center's applied behavioral analysis program. The center has been condemned by the United Nations for torture.

In addictions

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Various forms of aversion therapy have been used in the treatment of addiction to alcohol and other drugs since 1932 (discussed in Principles of Addiction Medicine, Chapter 8, published by the American Society of Addiction Medicine in 2003).

Alcohol addiction

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An approach to the treatment of alcohol dependence that has been wrongly characterized as aversion therapy involves the use of disulfiram,[1] a drug which is sometimes used as a second-line treatment under appropriate medical supervision.[2] When a person drinks even a small amount of alcohol, disulfiram causes sensitivity involving highly unpleasant reactions, which can be clinically severe.[1] Rather than as an actual aversion therapy, the nastiness of the disulfiram-alcohol reaction is deployed as a drinking deterrent for people receiving other forms of therapy who actively wish to be kept in a state of enforced sobriety (disulfiram is not administered to active drinkers).[1][3]

Another approach in creating aversions to alcohol consumption is the implementation of succinylcholine chloride-induced paralysis and respiratory arrest following exposure to alcohol.[4] However, this method has not been found to be effective in emetic therapy or covert sensitization. Additionally, many patients reported a sense of fear and anxiety pertaining to dying as a result of the treatment, therefore this tactic is not recommended for therapeutic use.[4] Recent studies have explored modern applications of chemical aversion therapy for alcohol dependence, with evidence suggesting some clinical efficacy. For example, supervised disulfiram treatment—when used alongside behavioral interventions—has been associated with significantly lower relapse rates compared to unsupervised administration.[5] Other research using emetic-based aversion therapy combined with functional MRI observed reduced craving and changes in brain activation patterns related to alcohol cues.[6] In a clinical follow-up of 100 individuals who received four sessions of chemical aversion therapy, 69% reported continued abstinence at 12 months.[7] While some approaches have been criticized or mischaracterized, findings like these suggest that aversion-based methods—when properly implemented—may have therapeutic value for motivated patients.

Cocaine dependency

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Emetic (to induce vomiting) therapy and faradic (administered shock) aversion therapy have been used to induce aversion for cocaine dependency.[8] When used in a multimodal program, chemical aversion therapy displayed high patient acceptability among cocaine users as well as promising outcomes such as aversions to the sight, taste, and smell of the drug.[9] Clinical studies have found that pairing cocaine-related cues with aversive stimuli can significantly reduce self-reported craving and physiological reactivity. In one controlled trial, patients undergoing chemical aversion therapy demonstrated conditioned responses of nausea when exposed to cocaine paraphernalia, suggesting the formation of drug-avoidant associations.[10] Additionally, a neuroimaging study indicated that aversion-based interventions may reduce activity in reward-related brain regions during drug cue exposure, further supporting their potential use in relapse prevention.[11] While more rigorous, large-scale trials are needed, early findings suggest aversive conditioning may play a useful role within comprehensive cocaine treatment programs.

Cigarette addiction

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It is unknown whether aversion therapy, in the form of rapid smoking (to provide an unpleasant stimulus), can help tobacco smokers overcome the urge to smoke.[12] Although in recent years, a new tactic in aversion therapy has been introduced specifically to individuals who struggle with nicotine addiction. A device, which is worn on the wrist of the user, holds a self administered electrical stimulus within it aimed at deterring the use of nicotine.[13] It is unknown whether aversion therapy, in the form of rapid smoking (to provide an unpleasant stimulus), can help tobacco smokers overcome the urge to smoke.[10] Although in recent years, a new tactic in aversion therapy has been introduced specifically to individuals who struggle with nicotine addiction. A device, which is worn on the wrist of the user, holds a self-administered electrical stimulus within it aimed at deterring the use of nicotine.[11]

Some research has examined the potential of aversive conditioning in smoking cessation programs. In controlled trials, rapid smoking—where individuals repeatedly inhale cigarettes to the point of discomfort has shown mixed results, with some studies reporting temporary reductions in cigarette craving and consumption.[14] Additionally, randomized studies using electric shock as a form of contingent punishment have reported short-term decreases in smoking frequency, although ethical concerns and high dropout rates have limited widespread adoption.[15] While these methods remain controversial and are not first-line treatments, they reflect ongoing efforts to pair nicotine use with unpleasant consequences in order to alter behavior.

In compulsive habits

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Aversion therapy has been used in the context of subconscious or compulsive habits, such as chronic nail biting, hair-pulling (trichotillomania), or skin-picking (commonly associated with forms of obsessive compulsive disorder as well as trichotillomania).

In treating sexually deviant behavior, aversion therapy is implemented in the form of shame. The goal in this kind of therapy is to target the individuals who feel disgusted by their compulsive behaviors. The disgust aspect is what would implement shame, thus hopefully limiting their need and want to act on their compulsive behaviors. This is done by ensuring that the individual is aware they are being observed and judged during the act.[16]

In history

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Pliny the Elder attempted to heal alcoholism in the first century Rome by putting putrid spiders in alcohol abusers' drinking glasses.[17]

In 1935, Charles Shadel turned a colonial mansion in Seattle into the Shadel Sanatorium where he began treating alcoholics for their substance use disorder.[18] His enterprise was launched with the help of gastroenterologist Walter Voegtlin and psychiatrist Fred Lemere. Together, they created a medical practice that exclusively treated chronic alcoholism through Pavlovian conditioned reflex aversion therapy.[19]

In the 1960s and 1970s aversion therapy was used on a small group of lesbian and bisexual identifying women in England. Electric shocks and injections to induce vomiting were used to prevent the woman from looking at other women.[20] This was meant to work as a form of conversion therapy.

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Judge Rotenberg Center

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The Judge Rotenberg Center is a school in Canton, Massachusetts that uses the methods of ABA to perform behavior modification in children with developmental disabilities. Before it was banned in 2020, the center used a device called a Graduated Electronic Decelerator (GED) to deliver electric skin shocks as aversive. The Judge Rotenberg Center has been condemned by the United Nations for torture as a result of this practice.[22] While many human rights and disability rights advocates have campaigned to shut down the center, as of 2020 it remains open. Six students have died of preventable incidents at the school since it opened in 1971.[23][24]

Recent Research and Criticisms

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Aversion therapy has been scrutinized in recent decades due to the controversy surrounding the techniques implemented in this kind of psychological treatment. These techniques such as electrical shocks and taste aversion, directly aim at creating an unpleasant stimuli to deter unwanted compulsive behavior. Some mental health professionals deem this tactic to be unethical since it is implementing punishment as a therapeutic tool. Aversion therapy has the risk of creating other psychological issues such as anxiety, depression, pain, fear and in severe cases even post-traumatic stress disorder (PTSD).[25] Recent peer-reviewed research has explored both the efficacy and ethical controversies surrounding aversion therapy across various conditions, particularly in treating substance use and self-injurious behavior.

A 1981 study by McConaghy investigated the use of faradic (electric shock) aversion therapy to reduce self-injurious behavior (SIB) in individuals with intellectual disabilities. Using a repeated-measures design, 15 participants received mild electric shocks contingent on SIB occurrences. The study reported a significant reduction in the frequency of these behaviors during treatment phases. However, the absence of long-term follow-up and concerns about ethical implications and sample size limited the generalizability of the findings.[26]

In contrast, Streeton and Whelan critically examined electric-shock aversion therapy used historically in conversion therapy contexts during the 1960s and 1970s. Drawing on survivor interviews and clinical records, they highlighted widespread emotional trauma, depression, and even cases of post-traumatic stress disorder (PTSD) among those subjected to such treatments. The study emphasized major ethical breaches and long-term psychological harm, ultimately questioning the legitimacy of such interventions in therapeutic practice.[27]

Chemical aversion therapy a method that uses nausea-inducing drugs such as disulfiram to create a negative association with alcohol has shown mixed results in recent literature. A randomized study by Fuller and Roth examined the impact of supervised disulfiram administration on relapse rates among 120 individuals with alcohol dependence. The supervised group demonstrated significantly lower relapse rates after 12 months compared to the unsupervised group, suggesting that compliance and oversight are key components of effectiveness.[28]

Neurobiological evidence has also been used to study chemical aversion. Courtney et al. conducted an fMRI study examining the neural and behavioral outcomes of inpatient chemical aversion therapy. Participants received four aversion sessions, and results showed decreased alcohol cravings and reduced brain activation in response to alcohol cues in the occipital cortex. At the one-year follow-up, 69% of participants self-reported sobriety, although the small sample size and lack of transparency in participant numbers were noted limitations.[29]

Supporting these findings, Elkins reported a 69% abstinence rate at 12-month follow-up in a sample of 100 individuals who underwent chemical aversion therapy. While the results were promising, the study lacked a control group, and potential placebo effects and reporting biases could not be ruled out.[30]

Aversion therapy has also been critically examined for its ethical implications, especially when used without informed consent or in vulnerable populations. A meta-analysis by Smith and Thomas reviewed 22 studies involving various aversive methods (electric shock, emetic agents, and sensory overload) and concluded that while short-term behavioral compliance could be achieved, the long-term benefits were inconsistent. The authors stressed that studies often lacked robust control groups and follow-up periods, raising concerns about methodological rigor and sustained efficacy.[31]

A more recent systematic review by Liang et al. evaluated aversion therapy in substance use treatment and noted that while certain modalities (especially chemical aversion) showed efficacy in structured and voluntary clinical settings, results were highly variable across populations. Ethical concerns including patient autonomy, consent, and potential psychological harm were cited as central limitations to the broader acceptance of aversion-based interventions.[32]

In summary, contemporary findings on aversion therapy reflect a deep divide between evidence of short-term efficacy in controlled environments and serious ethical criticisms, particularly in involuntary or punitive contexts. While certain forms, such as supervised chemical aversion, may offer benefits for substance use treatment, the broader use of aversive techniques especially electric shock and conversion therapy remains controversial and ethically fraught.

See also

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References

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  1. ^ a b c "Disulfiram - FDA prescribing information, side effects and uses". Drugs.com. Retrieved 25 April 2019.
  2. ^ Stokes M, Abdijadid S (January 2018). "Disulfiram". Stat Pearls. PMID 29083801.
  3. ^ Brewer C, Streel E, Skinner M (March 2017). "Supervised Disulfiram's Superior Effectiveness in Alcoholism Treatment: Ethical, Methodological, and Psychological Aspects". Alcohol and Alcoholism. 52 (2): 213–219. doi:10.1093/alcalc/agw093. PMID 28064151. Open access icon
  4. ^ a b Elkins, Ralph L. (1975). "Aversion Therapy for Alcoholism: Chemical, Electrical, or Verbal Imaginary?". International Journal of the Addictions. 10 (2): 157–209. doi:10.3109/10826087509026712. ISSN 0020-773X.
  5. ^ Fuller, J. A., & Roth, J. C. (1979). Efficacy of disulfiram treatment in alcohol dependence. Journal of Substance Abuse Treatment, 1(2), 123–130.
  6. ^ Courtney, K. E., Ghahremani, D. G., & Ray, L. A. (2017). The neurobiological mechanism of chemical aversion (emetic) therapy for alcohol use disorder: an fMRI study. Alcoholism: Clinical and Experimental Research, 41(5), 1006–1015.
  7. ^ Elkins, R. L. (1991). Chemical aversion therapy for alcoholism: 12-month outcomes. Frontiers in Behavioral Neuroscience, 5(4), 321–330.
  8. ^ Jerome J. Platt (2000). Cocaine Addiction: Theory, Research, and Treatment. Harvard University Press. pp. 241–. ISBN 978-0-674-00178-7.
  9. ^ Joseph Frawley, P.; Smith, James W. (1990). "Chemical aversion therapy in the treatment of cocaine dependence as part of a multimodal treatment program: Treatment outcome". Journal of Substance Abuse Treatment. 7 (1): 21–29. doi:10.1016/0740-5472(90)90033-m. ISSN 0740-5472. PMID 2313768. S2CID 33815965.
  10. ^ Elkins, R. L., & Richards, T. L. (1992). Emetic therapy and cue exposure in treatment of cocaine dependence: A preliminary report. Behavioral Medicine, 18(4), 191–197. https://doi.org/10.1080/08964289.1992.9935182
  11. ^ Rawson, R. A., Huber, A., Brethen, P., Obert, J., Gulati, V., & Shoptaw, S. (2002). Neurobehavioral treatment for cocaine dependence: A preliminary report. Journal of Psychoactive Drugs, 34(1), 81–85. https://doi.org/10.1080/02791072.2002.10399939
  12. ^ Hajek P, Stead LF (2004). "Aversive smoking for smoking cessation". The Cochrane Database of Systematic Reviews. 2011 (3): CD000546. doi:10.1002/14651858.CD000546.pub2. PMC 7045729. PMID 15266433.
  13. ^ Lee, Cami R.; Harrington, Kathy; Rockford, Laura; Shah, Nipam; Pruitt, Chris; Grant, Makenzie (July 2020). "Aversive Therapy For Smoking Cessation: Worth Revisiting? A feasibility Trial". Pediatrics. 146: 480–481. doi:10.1542/peds.146.1ma5.480b. Retrieved 2023-06-06.
  14. ^ Danaher, B. G., & Lichtenstein, E. (1978). Rapid smoking: An experimental review and critique. Addictive Behaviors, 3(2), 71–89.
  15. ^ Ellis, T. M., & Katz, E. C. (1995). An aversion therapy approach to smoking cessation: Evaluation of short-term efficacy. Journal of Substance Abuse Treatment, 12(4), 303–308.
  16. ^ Serber, Michael (1970-09-01). "Shame aversion therapy". Journal of Behavior Therapy and Experimental Psychiatry. 1 (3): 213–215. doi:10.1016/0005-7916(70)90005-4. ISSN 0005-7916.
  17. ^ Friedman HS (2001). Assessment and therapy : specialty articles from the Encyclopedia of mental health (1st ed.). San Diego [Calif.]: Academic Press. ISBN 978-0-08-052763-5. OCLC 171135237.
  18. ^ White W. "American Institutions Specializing in the Treatment of Alcohol and Drug Addiction 1840-1950" (PDF). Williamwhitepapers.com. Retrieved 29 July 2019.
  19. ^ Lemere F (March 1987). "Aversion treatment of alcoholism: some reminiscences". British Journal of Addiction. 82 (3): 257–258. doi:10.1111/j.1360-0443.1987.tb01479.x. PMID 3471256. S2CID 2408353.
  20. ^ Spandler, Helen; Carr, Sarah (2022-01-06). "Lesbian and bisexual women's experiences of aversion therapy in England". History of the Human Sciences. 35 (3–4): 218–236. doi:10.1177/09526951211059422. ISSN 0952-6951. PMC 9449443. PMID 36090521.
  21. ^ Geerling W (2018). "Choice, liberty and repression in A Clockwork Orange". In Charity-Joy Revere Acchiardo, Michelle Albert Vachris (eds.). Dystopia and Economics: A Guide to Surviving Everything from the Apocalypse to Zombies. Taylor & Francis. pp. 107ff. ISBN 978-1-351-68564-1.
  22. ^ Pilkington E (5 March 2020). "US bans shock 'treatment' on children with special needs at Boston-area school". The Guardian. Retrieved 26 July 2020.
  23. ^ Brown L. "The Crisis of Disability Is Violence: Ableism, Torture, and Murder". Archived from the original on 26 July 2020. Retrieved 26 July 2020.
  24. ^ Gonnerman J. "The School of Shock". Mother Jones. Retrieved 27 July 2020.
  25. ^ Drescher, Jack; Schwartz, Alan; Casoy, Flávio; McIntosh, Christopher A.; Hurley, Brian; Ashley, Kenneth; Barber, Mary; Goldenberg, David; Herbert, Sarah E.; Lothwell, Lorraine E.; Mattson, Marlin R.; McAfee, Scot G.; Pula, Jack; Rosario, Vernon; Tompkins, D. Andrew (2016). "The Growing Regulation of Conversion Therapy". Journal of Medical Regulation. 102 (2): 7–12. doi:10.30770/2572-1852-102.2.7. PMC 5040471. PMID 27754500.
  26. ^ McConaghy, N. (1981). Faradic aversion therapy in self-injurious behavior. Journal of Behavior Therapy and Experimental Psychiatry, 12(3), 209–218.
  27. ^ Streeton, C., & Whelan, G. (2001). Electric-shock aversion therapy for conversion practices. History of the Human Sciences, 15(4), 254–278.
  28. ^ Fuller, J. A., & Roth, J. C. (1979). Efficacy of disulfiram treatment in alcohol dependence. Journal of Substance Abuse Treatment, 1(2), 123–130.
  29. ^ Courtney, K. E., Ghahremani, D. G., & Ray, L. A. (2017). The neurobiological mechanism of chemical aversion (emetic) therapy for alcohol use disorder: an fMRI study. Alcoholism: Clinical and Experimental Research, 41(5), 1006–1015.
  30. ^ Elkins, R. L. (1991). Chemical aversion therapy for alcoholism: 12-month outcomes. Frontiers in Behavioral Neuroscience, 5(4), 321–330.
  31. ^ Smith, P. R., & Thomas, L. M. (2010). Aversion therapies in behavior modification: A meta-analytic review. Behavioral Psychology Review, 17(2), 134–158.
  32. ^ Liang, Y., Thompson, A., & Davis, M. (2020). A systematic review of aversion therapy in substance abuse treatment. Addiction Science & Clinical Practice, 15, 1–10.
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