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“Booster” sessions in aversion therapy: The permanency of treatment
BEHAVIORTHERAPY 8, 460-463 (1977)
"Booster" Sessions in Aversion Therapy: The Permanency of Treatment BARRY M . MALETZKY
Woodland Park Mental Health Center, Portland, Oregon Homosexual and exhibitionist patients were treated with "assisted" covert sensitization for a 6-month period. Subjects were then provided 12 months of follow-up care, with no active conditioning treatment. A further 12 months was devoted to "booster" sessions of active conditioning on a tapering basis. Although averaged data demonstrated the value of providing continuing, albeit infrequent, active conditioning sessions, not all subjects appeared to require such "boosters." Those who could adequately change life-style and avoid especially provocative situations seemed able to derive continuing benefit from aversive conditioning without "'booster" sessions.
How permanent are the behavioral treatments we administer? Longterm follow-ups for many behavioral techniques are pending, if only because so many techniques have only recently been developed. The advisability of "booster" sessions was recognized early (Wolpe, 1969), yet few studies have systematically examined whether behavioral treatment offers a permanent or a temporary improvement. In our experience with "assisted" covert sensitization (Maletzky, 1973, 1974a, b; Maletzky & George, 1973), a technique which employs aversive imagery and a noxious odor, maladaptive approach behaviors such as homosexuality, exhibitionism, and pedophilia could be successfully deconditioned. However, in many cases, "booster" sessions at increasing intervals were needed to perpetuate benefits of treatment. Frequently, the patient would encounter too potent a sexual stimulus in his ongoing treatment. A few "booster" sessions would then correct the situation. As there appears to be no study documenting the need for "booster" sessions, the present study was undertaken to determine whether such sessions were necessary after active treatment was terminated.
Send reprint requests to Barry M. Maletzky, Director of Research, Woodland Park Mental Health Center, 1345 S.E. Harney Street, Portland, OR 97202. 460 Copyright© 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
BRIEF NOTES
461
METHOD Eighteen homosexual and twelve exhibitionist patients were included and procedures of informed consent utilized. Several subjects have been included in prior reports (Maletzky & George, 1973; Maletzky, 1974). All homosexuals rated at least 4 on the Kinsey homosexuality scale (Kinsey, Pomeroy, & Martin, 1948). All subjects entered treatment voluntarily. The use of assisted covert sensitization has been described previously (Maletzky, 1973). A modified A - B - A design (Barlow & Hersen, 1973) was employed to determine the efficacy of " b o o s t e r " sessions for both homosexual and exhibitionist groups: Condition A: Active treatment of 10-12 bimonthly conditioning sessions using imagery, photographs, and a noxious odor, combined with 15-25 triweekly sessions at home using a noxious odor and tape recordings of scenes; also in vivo sensitizations where applicable. Condition B: Twelve months of no active conditioning; to control for the supportive effects of being seen by the therapist, monthly follow-up sessions were held in the office to collect data, promote life-style change, and offer support. Condition C: " B o o s t e r " sessions monthly for 3 months, thence conditioning sessions once each 3 months for 9 months; concomitantly, monthly conditioning sessions at home using a noxious odor and tape recordings for 12 months. Records were kept of subjects' and observers' reports of homosexual or exhibitionist overt behaviors (Maletzky & George, 1973; Maletzky, 1974).
RESULTS
For both groups, original behaviors could reappear and require additional, albeit infrequent, reconditioning (Fig. 1). Yet these averaged data obscure the fact that a goodly number of homosexual and exhibitionist patients did n o t require "boosters." Of the 18 homosexual and 12 exhibitionist subjects, the increase in maladaptive sexual behaviors occurring under condition B were attributable to just 7 of the homosexual and 4 of the exhibitionist subjects. The remainder stayed free of these behaviors despite the lack of "boosters" under condition B. Whether they would have continued free of these behaviors over longer periods without "boosters" cannot be answered by the present research.
JO
e~iTctive reotrnent
Follow-Up
"Booster"Sessions e--e HomosexuoI
~
~~
o - - o Exhibitionist
~
6 M0nfhs
12 Months
12
Months
FIG. 1. Average weekly frequency of overt homosexual or exhibitionist behavior during active treatment, follow-up, and " b o o s t e r " session conditions.
462
BRIEF NOTES
DISCUSSION For some subjects, "booster" sessions were necessary to maintain the effects of aversive conditioning. Most of these subjects described a recurrence of a strong setting which had evoked homosexual or exhibitionist behavior. Once a single such behavior occurred, it was easier for similar behaviors to follow in even less provocative environments. Yet, for many subjects, no such "boosters" were required. Reviewing characteristics of those subjects requiring "boosters" and those not, there was no distinguishing trait in terms of duration or frequency of problem, marital status, age, etc. which would allow us to predict who might need "boosters." It seemed, however, that many of those not requiring "boosters" had been able, by themselves or through therapy, to rearrange environments in such a manner that strong provocations did not frequently occur. If some conditioning patients require "boosters," for how long should they continue? Based on the present research this is unanswerable; yet, with the aid of tape recorders and home practice, it would be possible to promote "boosters" at infrequent intervals for many years to ensure safety against strong provocation. With the use of tape recorders for aversive imagery, the patient is given the means to carry on treatment when he feels the need. Treatment is thus viewed as an ongoing learning process, rather than a time-limited procedure controlled by treatment personnel. It would seem that aversive conditioning, such as is employed in assisted covert sensitization, can be successful to initiate a process of change which then must be pursued either by continued aversive conditioning ("boosters"), environmental change, or, preferably, both. To ensure continued effects of conditioning, our standard practice currently is to continue "boosters" over a long period of time and urge the patient to continue his own "booster" sessions at home. It would be of interest to determine how long patients can continue without any "booster" sessions. REFERENCES Barlow, D. H., & Hersen, M. Single-case experimental designs. Archives of General Psychiatry, 1973, 29, 319-325. Kinsey, N., Pomeroy, W. B., & Martin, C. E. Sexual behavior in the human male. Philadelphia: Saunders, 1948. Maletzky, B. M., & George, F. S. The treatment of homosexuality by "assisted" covert sensitization. Behaviour Research and Therapy, 1973, 11, 655-657. Maletzky, B. M. "Assisted" covert sensitization for drug abuse. International Journal of the Addictions, 1974, 9, 411-429. (a) Maletzky, B. M. "Assisted" cover sensitization in the treatment of exhibitionism. Journal of Consulting and Clinical Psychology, 1974, 42, 34-40. (b)
BRIEF NOTES
463
Maletzky, B. M., & George, F. S. The treatment of homosexuality by "assisted" covert sensitization. Behaviour Research and Therapy, 1973, 11, 655-657. Wolpe, J. The practice of behavior therapy. New York: Pergamon, 1962. RECEIVED" June 11, 1976; REVISED" June 11, 1976 FINAL ACCEPTANCE: June 26, 1976
"Booster" Sessions in Aversion Therapy: The Permanency of Treatment BARRY M . MALETZKY
Woodland Park Mental Health Center, Portland, Oregon Homosexual and exhibitionist patients were treated with "assisted" covert sensitization for a 6-month period. Subjects were then provided 12 months of follow-up care, with no active conditioning treatment. A further 12 months was devoted to "booster" sessions of active conditioning on a tapering basis. Although averaged data demonstrated the value of providing continuing, albeit infrequent, active conditioning sessions, not all subjects appeared to require such "boosters." Those who could adequately change life-style and avoid especially provocative situations seemed able to derive continuing benefit from aversive conditioning without "'booster" sessions.
How permanent are the behavioral treatments we administer? Longterm follow-ups for many behavioral techniques are pending, if only because so many techniques have only recently been developed. The advisability of "booster" sessions was recognized early (Wolpe, 1969), yet few studies have systematically examined whether behavioral treatment offers a permanent or a temporary improvement. In our experience with "assisted" covert sensitization (Maletzky, 1973, 1974a, b; Maletzky & George, 1973), a technique which employs aversive imagery and a noxious odor, maladaptive approach behaviors such as homosexuality, exhibitionism, and pedophilia could be successfully deconditioned. However, in many cases, "booster" sessions at increasing intervals were needed to perpetuate benefits of treatment. Frequently, the patient would encounter too potent a sexual stimulus in his ongoing treatment. A few "booster" sessions would then correct the situation. As there appears to be no study documenting the need for "booster" sessions, the present study was undertaken to determine whether such sessions were necessary after active treatment was terminated.
Send reprint requests to Barry M. Maletzky, Director of Research, Woodland Park Mental Health Center, 1345 S.E. Harney Street, Portland, OR 97202. 460 Copyright© 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
BRIEF NOTES
461
METHOD Eighteen homosexual and twelve exhibitionist patients were included and procedures of informed consent utilized. Several subjects have been included in prior reports (Maletzky & George, 1973; Maletzky, 1974). All homosexuals rated at least 4 on the Kinsey homosexuality scale (Kinsey, Pomeroy, & Martin, 1948). All subjects entered treatment voluntarily. The use of assisted covert sensitization has been described previously (Maletzky, 1973). A modified A - B - A design (Barlow & Hersen, 1973) was employed to determine the efficacy of " b o o s t e r " sessions for both homosexual and exhibitionist groups: Condition A: Active treatment of 10-12 bimonthly conditioning sessions using imagery, photographs, and a noxious odor, combined with 15-25 triweekly sessions at home using a noxious odor and tape recordings of scenes; also in vivo sensitizations where applicable. Condition B: Twelve months of no active conditioning; to control for the supportive effects of being seen by the therapist, monthly follow-up sessions were held in the office to collect data, promote life-style change, and offer support. Condition C: " B o o s t e r " sessions monthly for 3 months, thence conditioning sessions once each 3 months for 9 months; concomitantly, monthly conditioning sessions at home using a noxious odor and tape recordings for 12 months. Records were kept of subjects' and observers' reports of homosexual or exhibitionist overt behaviors (Maletzky & George, 1973; Maletzky, 1974).
RESULTS
For both groups, original behaviors could reappear and require additional, albeit infrequent, reconditioning (Fig. 1). Yet these averaged data obscure the fact that a goodly number of homosexual and exhibitionist patients did n o t require "boosters." Of the 18 homosexual and 12 exhibitionist subjects, the increase in maladaptive sexual behaviors occurring under condition B were attributable to just 7 of the homosexual and 4 of the exhibitionist subjects. The remainder stayed free of these behaviors despite the lack of "boosters" under condition B. Whether they would have continued free of these behaviors over longer periods without "boosters" cannot be answered by the present research.
JO
e~iTctive reotrnent
Follow-Up
"Booster"Sessions e--e HomosexuoI
~
~~
o - - o Exhibitionist
~
6 M0nfhs
12 Months
12
Months
FIG. 1. Average weekly frequency of overt homosexual or exhibitionist behavior during active treatment, follow-up, and " b o o s t e r " session conditions.
462
BRIEF NOTES
DISCUSSION For some subjects, "booster" sessions were necessary to maintain the effects of aversive conditioning. Most of these subjects described a recurrence of a strong setting which had evoked homosexual or exhibitionist behavior. Once a single such behavior occurred, it was easier for similar behaviors to follow in even less provocative environments. Yet, for many subjects, no such "boosters" were required. Reviewing characteristics of those subjects requiring "boosters" and those not, there was no distinguishing trait in terms of duration or frequency of problem, marital status, age, etc. which would allow us to predict who might need "boosters." It seemed, however, that many of those not requiring "boosters" had been able, by themselves or through therapy, to rearrange environments in such a manner that strong provocations did not frequently occur. If some conditioning patients require "boosters," for how long should they continue? Based on the present research this is unanswerable; yet, with the aid of tape recorders and home practice, it would be possible to promote "boosters" at infrequent intervals for many years to ensure safety against strong provocation. With the use of tape recorders for aversive imagery, the patient is given the means to carry on treatment when he feels the need. Treatment is thus viewed as an ongoing learning process, rather than a time-limited procedure controlled by treatment personnel. It would seem that aversive conditioning, such as is employed in assisted covert sensitization, can be successful to initiate a process of change which then must be pursued either by continued aversive conditioning ("boosters"), environmental change, or, preferably, both. To ensure continued effects of conditioning, our standard practice currently is to continue "boosters" over a long period of time and urge the patient to continue his own "booster" sessions at home. It would be of interest to determine how long patients can continue without any "booster" sessions. REFERENCES Barlow, D. H., & Hersen, M. Single-case experimental designs. Archives of General Psychiatry, 1973, 29, 319-325. Kinsey, N., Pomeroy, W. B., & Martin, C. E. Sexual behavior in the human male. Philadelphia: Saunders, 1948. Maletzky, B. M., & George, F. S. The treatment of homosexuality by "assisted" covert sensitization. Behaviour Research and Therapy, 1973, 11, 655-657. Maletzky, B. M. "Assisted" covert sensitization for drug abuse. International Journal of the Addictions, 1974, 9, 411-429. (a) Maletzky, B. M. "Assisted" cover sensitization in the treatment of exhibitionism. Journal of Consulting and Clinical Psychology, 1974, 42, 34-40. (b)
BRIEF NOTES
463
Maletzky, B. M., & George, F. S. The treatment of homosexuality by "assisted" covert sensitization. Behaviour Research and Therapy, 1973, 11, 655-657. Wolpe, J. The practice of behavior therapy. New York: Pergamon, 1962. RECEIVED" June 11, 1976; REVISED" June 11, 1976 FINAL ACCEPTANCE: June 26, 1976