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Aversive therapy revisited
Journal of Subslance Abuse Treatment, Printed in the USA. All rights reserved.
Vol.7,pp.75-76,
1990 Copyright 0
074C-5472/90 $3.00 + .oO 1990 Pergamon Press plc
EDITORIAL
Aversive Therapy Revisited ment administered. These include job stability, living with a relative, absence of a criminal record, and living in a rural community. In the Seattle study there was no control group that did not receive conditioning therapy. It is possible that this select group of patients, many having characteristics that favor a good outcome, would have done as well without conditioning. Furthermore, in conditioning treatments, motivation is important. Treatment is voluntary and involves acute physical discomfort, so presumably few would consent to undergo the therapy who were not strongly motivated to stop drinking. The Seattle study makes this point graphically clear. Those who came back for booster sessions did better than those who didn’t, but another group did better still: those who wanted to come back but couldn’t because they lived too far from the hospital. All of these people remained abstinent. Many years have passed since the initial encouraging reports by the Seattle group (Voegtlin, 1940; Lemere & Voegtlin, 1940; Voegtlin, Lemere, & Broz, 1948). Chemically induced aversive conditioning of alcoholics has been virtually ignored in the literature since then. Now, in this issue, Smith and Frawley (1990) publish an outcome study of patients who received aversion therapy as part of their treatment in an inpatient program in 1983. From a randomly selected sample of 200 patients, 80% were located and interviewed by telephone. Between 13 and 25 months had passed since their discharge from the hospital (mean 20.5 months). Abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment, and current abstinence. The abstinence rate for the first 12 months was 71% and 65% for the total period. The current abstinence rate was 78%. Rarely do follow-up studies of alcoholism treatment report abstinence rates of this magnitude. How should they be interpreted? First, the self-reports of abstinence were probably fairly reliable. Other studies indicate that people are more accurate in reporting whether they are abstinent than in reporting gradations of consumption. This is particularly true when nothing bad happens to them if they report nonabstinence. Second, as in the original Seattle studies, the patients by and large had good prognostic features. At time of admission, more than half were married and
that if dogs repeatedly heard a bell before eating, eventually bells alone would make them salivate. And if you shocked the dog’s foot every time he heard a bell, he would soon respond to bells in the same way he did to shock-by withdrawing the foot. For many years attempts have been made to condition alcoholics to dislike alcohol. Alcoholics are asked to taste or smell alcohol just before a preadministered drug makes them nauseated. Repeated pairing of alcohol and nausea results in a conditioned response after a while alcohol alone makes them nauseated. Thereafter, it is hoped, the smell or taste of alcohol will cause nausea and discourage drinking. Instead of pairing alcohol with nausea, other therapists have associated it with pain, shocking patients just after they drink, or they have associated it with the panic experience from not being able to breathe by giving them a drug that causes very brief respiratory paralysis. Others have trained patients to imagine unpleasant effects from drinking, hoping to set up a conditioned response without causing so much actual distress. Does it work? Some degree of conditioning is usually established, but it is uncertain how long the conditioning lasts. The largest study that involved conditioning alcoholics was conducted 50 years ago in Seattle, Washington (Voegtlin, 1940). More than 34,000 patients conditioned to feel nauseated when exposed to alcohol were studied 10 to 15 years after treatment. Sixty-six percent were abstinent, which is an impressive recovery rate compared to other treatments. The patients who did best had booster sessions- that is, they came back to the clinic after the initial treatment to repeat the conditioning procedure. Of those who had booster sessions, 90% were abstinent. Based on this study, the nausea treatment for alcoholism would seem an outstanding success. Why hasn’t it been universally accepted? One reason is that the results can be attributed to factors other than the conditioning. The patients in the study were a special group. Generally, they were well educated, had jobs, and were well off financially. They may not have received the treatment otherwise, since the clinic where they were treated was private and cost money. Studies of alcoholics have often shown that certain subject characteristics are more predictive of successful treatment outcome than the type of treatPAVLOV FOUND
75
D. W. Goodwin
76
had some college education. Nearly 80% were employed. They could afford a private hospital. In short, having characteristics that favor a good outcome, they might have done as well without conditioning. There was no control group that did not receive aversion therapy. Moreover, the inpatient program involved more than aversive conditioning. It included many ingredients found in other treatment programs, including group and individual counseling, a family program and aftercare plan, and Alcoholics Anonymous. The patients received only 5 aversion treatments over a lo-day period, plus 5 pentothal interviews on alternate days. The latter were intended to gather diagnostic information and “monitor the development of aversion” to alcohol. It is not clear whether these goals were met, but in any case narcotherapy is an unusual feature in any alcoholism treatment program and may contribute to the encouraging outcome results. One finding in this latest report closely resembles the finding of the original studies: the importance of booster sessions. One month and three months after discharge, the patients were asked to return for “reinforcement treatments.” These consisted of two-day hospitalizations that included one aversion treatment and one narcotherapy treatment, plus counseling. Just as in the original studies, those who returned for the booster sessions had a remarkably good outcome. In fact, the most powerful predictor of abstinence was the number of reinforcement treatments utilized by the patients. Those taking two reinforcement treatments had a 1Zmonth abstinence rate of 70%. Those who took only one had a 44% rate and those who had no reinforcement had only a 27% rate. Seven percent took more than two reinforcement treatments and had a phenomenal 12-month abstinence rate of 92%. The importance of reinforcement sessions may reflect motivation on the part of the patient, actual Pavlovian conditioning, or both. Unfortunately, the paper does not tell whether the patients developed a true conditioned response to alcohol at any time. Information about this would help dissect nonspecific motivational factors from actual conditioning. On the other hand, the authors are to be commended for a well-designed study. A control group would have been helpful. This could have been achieved by randomly omitting the aversive therapy component of the program. Within its limitations, however, the study was a careful and methodologically sound assessment of outcome using the most conservative outcome measure of all: total abstinence. Let me conclude with a personal note. During my
residency days I had a 30-year-old patient whom I was convinced was hopeless. I predicted he would die from alcoholism within a year. Nothing had workedrepeated exposure to AA, prolonged hospitalizations, even ECT for presumed depression. A decision was made to try aversive therapy. Orders were written for emitine, apomorphine, and a room with a toilet. In those days we were encouraged to make the patient repeatedly nauseated over several hours while exposing him or her to the taste and smell of various alcoholic beverages. There was much vomiting involved and it was a horrific experience for both patient and therapist. Multiple sessions were conducted and the patient was finally released from the hospital. Within a few days he was drinking again. However, according to rumor, a conditioned response had been produced. He became ill whenever he saw me! (The patient, by the way, did not die within a year. Five years later I went into an automobile dealership to buy a car and he was the sales manager- happy, healthy, and dry for four years. He was married to a fellow AA member and they had recently toured Europe without touching a drop. Moral: no alcoholic is hopeless.) None of this is said to disparage aversive therapy. The outcome figures reported by Smith and Frawley are too impressive to be ignored. We all tend to don our ideological straight jackets and take absolutist views regarding treatment. This should not discourage the pragmatists among us from looking data in the face and deciding that if something works, something good must be going on. Donald
W. Goodwin,
MD
REFERENCES Lemere, F., & Voegtlin, W.L. (1940, December). Conditioned reflex therapy of alcoholic addiction: Specificity of conditioning against chronic alcoholism. California and WesternMedicine. 53(6), 1-4. Smith, J.W., & Frawley, P.J. (1990). Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program. Journal of Substance Abuse Treatment, I, 11-82. Voegtlin, W.L. (1940, June). The treatment of alcoholism by establishing a conditioned reflex. American Journal of Medical Sciences, 199, 802-10. Voegtlin, W.L., Lemere, F., & Broz, W.R. (1948, December). Conditioned reflex therapy of alcoholic addiction III: An evaluation of present results in the light of previous experiences in this method. QuarterlyJournal of Studies on Alcohol, l(3), 501-16.
Vol.7,pp.75-76,
1990 Copyright 0
074C-5472/90 $3.00 + .oO 1990 Pergamon Press plc
EDITORIAL
Aversive Therapy Revisited ment administered. These include job stability, living with a relative, absence of a criminal record, and living in a rural community. In the Seattle study there was no control group that did not receive conditioning therapy. It is possible that this select group of patients, many having characteristics that favor a good outcome, would have done as well without conditioning. Furthermore, in conditioning treatments, motivation is important. Treatment is voluntary and involves acute physical discomfort, so presumably few would consent to undergo the therapy who were not strongly motivated to stop drinking. The Seattle study makes this point graphically clear. Those who came back for booster sessions did better than those who didn’t, but another group did better still: those who wanted to come back but couldn’t because they lived too far from the hospital. All of these people remained abstinent. Many years have passed since the initial encouraging reports by the Seattle group (Voegtlin, 1940; Lemere & Voegtlin, 1940; Voegtlin, Lemere, & Broz, 1948). Chemically induced aversive conditioning of alcoholics has been virtually ignored in the literature since then. Now, in this issue, Smith and Frawley (1990) publish an outcome study of patients who received aversion therapy as part of their treatment in an inpatient program in 1983. From a randomly selected sample of 200 patients, 80% were located and interviewed by telephone. Between 13 and 25 months had passed since their discharge from the hospital (mean 20.5 months). Abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment, and current abstinence. The abstinence rate for the first 12 months was 71% and 65% for the total period. The current abstinence rate was 78%. Rarely do follow-up studies of alcoholism treatment report abstinence rates of this magnitude. How should they be interpreted? First, the self-reports of abstinence were probably fairly reliable. Other studies indicate that people are more accurate in reporting whether they are abstinent than in reporting gradations of consumption. This is particularly true when nothing bad happens to them if they report nonabstinence. Second, as in the original Seattle studies, the patients by and large had good prognostic features. At time of admission, more than half were married and
that if dogs repeatedly heard a bell before eating, eventually bells alone would make them salivate. And if you shocked the dog’s foot every time he heard a bell, he would soon respond to bells in the same way he did to shock-by withdrawing the foot. For many years attempts have been made to condition alcoholics to dislike alcohol. Alcoholics are asked to taste or smell alcohol just before a preadministered drug makes them nauseated. Repeated pairing of alcohol and nausea results in a conditioned response after a while alcohol alone makes them nauseated. Thereafter, it is hoped, the smell or taste of alcohol will cause nausea and discourage drinking. Instead of pairing alcohol with nausea, other therapists have associated it with pain, shocking patients just after they drink, or they have associated it with the panic experience from not being able to breathe by giving them a drug that causes very brief respiratory paralysis. Others have trained patients to imagine unpleasant effects from drinking, hoping to set up a conditioned response without causing so much actual distress. Does it work? Some degree of conditioning is usually established, but it is uncertain how long the conditioning lasts. The largest study that involved conditioning alcoholics was conducted 50 years ago in Seattle, Washington (Voegtlin, 1940). More than 34,000 patients conditioned to feel nauseated when exposed to alcohol were studied 10 to 15 years after treatment. Sixty-six percent were abstinent, which is an impressive recovery rate compared to other treatments. The patients who did best had booster sessions- that is, they came back to the clinic after the initial treatment to repeat the conditioning procedure. Of those who had booster sessions, 90% were abstinent. Based on this study, the nausea treatment for alcoholism would seem an outstanding success. Why hasn’t it been universally accepted? One reason is that the results can be attributed to factors other than the conditioning. The patients in the study were a special group. Generally, they were well educated, had jobs, and were well off financially. They may not have received the treatment otherwise, since the clinic where they were treated was private and cost money. Studies of alcoholics have often shown that certain subject characteristics are more predictive of successful treatment outcome than the type of treatPAVLOV FOUND
75
D. W. Goodwin
76
had some college education. Nearly 80% were employed. They could afford a private hospital. In short, having characteristics that favor a good outcome, they might have done as well without conditioning. There was no control group that did not receive aversion therapy. Moreover, the inpatient program involved more than aversive conditioning. It included many ingredients found in other treatment programs, including group and individual counseling, a family program and aftercare plan, and Alcoholics Anonymous. The patients received only 5 aversion treatments over a lo-day period, plus 5 pentothal interviews on alternate days. The latter were intended to gather diagnostic information and “monitor the development of aversion” to alcohol. It is not clear whether these goals were met, but in any case narcotherapy is an unusual feature in any alcoholism treatment program and may contribute to the encouraging outcome results. One finding in this latest report closely resembles the finding of the original studies: the importance of booster sessions. One month and three months after discharge, the patients were asked to return for “reinforcement treatments.” These consisted of two-day hospitalizations that included one aversion treatment and one narcotherapy treatment, plus counseling. Just as in the original studies, those who returned for the booster sessions had a remarkably good outcome. In fact, the most powerful predictor of abstinence was the number of reinforcement treatments utilized by the patients. Those taking two reinforcement treatments had a 1Zmonth abstinence rate of 70%. Those who took only one had a 44% rate and those who had no reinforcement had only a 27% rate. Seven percent took more than two reinforcement treatments and had a phenomenal 12-month abstinence rate of 92%. The importance of reinforcement sessions may reflect motivation on the part of the patient, actual Pavlovian conditioning, or both. Unfortunately, the paper does not tell whether the patients developed a true conditioned response to alcohol at any time. Information about this would help dissect nonspecific motivational factors from actual conditioning. On the other hand, the authors are to be commended for a well-designed study. A control group would have been helpful. This could have been achieved by randomly omitting the aversive therapy component of the program. Within its limitations, however, the study was a careful and methodologically sound assessment of outcome using the most conservative outcome measure of all: total abstinence. Let me conclude with a personal note. During my
residency days I had a 30-year-old patient whom I was convinced was hopeless. I predicted he would die from alcoholism within a year. Nothing had workedrepeated exposure to AA, prolonged hospitalizations, even ECT for presumed depression. A decision was made to try aversive therapy. Orders were written for emitine, apomorphine, and a room with a toilet. In those days we were encouraged to make the patient repeatedly nauseated over several hours while exposing him or her to the taste and smell of various alcoholic beverages. There was much vomiting involved and it was a horrific experience for both patient and therapist. Multiple sessions were conducted and the patient was finally released from the hospital. Within a few days he was drinking again. However, according to rumor, a conditioned response had been produced. He became ill whenever he saw me! (The patient, by the way, did not die within a year. Five years later I went into an automobile dealership to buy a car and he was the sales manager- happy, healthy, and dry for four years. He was married to a fellow AA member and they had recently toured Europe without touching a drop. Moral: no alcoholic is hopeless.) None of this is said to disparage aversive therapy. The outcome figures reported by Smith and Frawley are too impressive to be ignored. We all tend to don our ideological straight jackets and take absolutist views regarding treatment. This should not discourage the pragmatists among us from looking data in the face and deciding that if something works, something good must be going on. Donald
W. Goodwin,
MD
REFERENCES Lemere, F., & Voegtlin, W.L. (1940, December). Conditioned reflex therapy of alcoholic addiction: Specificity of conditioning against chronic alcoholism. California and WesternMedicine. 53(6), 1-4. Smith, J.W., & Frawley, P.J. (1990). Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program. Journal of Substance Abuse Treatment, I, 11-82. Voegtlin, W.L. (1940, June). The treatment of alcoholism by establishing a conditioned reflex. American Journal of Medical Sciences, 199, 802-10. Voegtlin, W.L., Lemere, F., & Broz, W.R. (1948, December). Conditioned reflex therapy of alcoholic addiction III: An evaluation of present results in the light of previous experiences in this method. QuarterlyJournal of Studies on Alcohol, l(3), 501-16.