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Electrical aversion therapy with alcoholics: An analogue study
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS: AN ANALOGUE STUDY PETERM. MILLER*, MICHEL HERSEN, RICHARD M. EWB
and DIANA P. HEMPHILL
Veterans Admin~st~t~on Center, and University of ~~ss~ss~pp~ Medical Center* Jackson, Mississippi, U.S.A.
(Received 14 March 1973)
Summary-Chronic alcoholic patients matched on age, education and length of problem drinking were assigned to one of three treatment conditions, with 10 subjects in each group: (1) Electrical Aversion Conditioning (high shock paired with alcohol sips); (2) Control Cond~t~o~i~ (very low shock paired with alcohol sips); and (3) Group Therapy (confrontation psychotherapy). Groups 2 and 3 were included to control for possible ‘attention-placebo’ and expectancy factors involved in the conditioning procedures. Subjects in each group were given instructions designed to produce high expectancy for therapeutic success, Rre-post measures of alcohol consumption and attitudes toward alcohol were obtained using an analogue ‘taste test’ assessment procedure. No statistically significant differences in reduced alcohol consumption or attitudes toward alcohol were found among the groups. Trends in the data support the contention that effects of electrical aversion may be more related to such factors as therapeutic instructions, expectancy, specificity of the procedure or experimental demand characteristics than to ~ndit~on~ng factors.
USE OF electrical aversion therapy in the treatment of alcoholism has been criticalIy reviewed by Miller and Barlow (1973). Evaluation of the efficacy of this procedure is difficult since very few well designed experimental studies ~mplo~ng adequate control groups have appeared in the literature. Recently, Vogler et af. (1970) compared electrical aversion conditioning, pseudoconditioning (random shock delivery), sham conditioning (no shock) and routine hospital care in the treatment of 51 chronic abohohcs. While relapse took significantly longer for the aversion conditioning subjects, proportion of relapses for this group did not differ significantly from the controfs. Outcome data indicating statistical superiority of a booster conditioning follow-up group cannot be properry evaluated since these subjects were not assigned randomly to this e~~r~rnenta~ condition. HalIam et alT. (1972) examined attitudinal and physiological effects of both electrical aversion therapy and general psychiatric care (group psychotherapy, AA meetings, drug therapy) with alcoholics. The aversion group showed no evidence of having developed heart rate or skin resistance responses to fantasies and photographic slides of alcohol. While signi~cant physiological and attitudinal changes were related to successful therapeutic outcome (in terms of abstinence), they did not correspond to type of treatment administered. The Hallam et al. (1972) study represents a trend toward more objective assessment of the efficacy of electrical aversion therapy. In evaluating the success of this technique with alcoholics, most studies have used either the patient’s self-report or reports from relatives,
*Requests for reprints should be sent to P. M. Miller, Veterans Mississippi 38216, U.S.A.
491
Adminis~tion
Center,
Jackson,
492
PETER M. MILLER,MCHEL
HERSEN,RICHARD
M. EISLER
and DIANA P. HEMPHILL
Summers (1970) and Guze et al. (1962) demonstrated that both of these subjective measures are of questionable validity and reliability. While attempts to utilize more objective measures of drinking behavior have occasionally been reported (Morosko and Baer, 1970; Chapman, Burt and Smith, 1972), systematic use of these procedures is infrequent. Miller and Hersen (1972a, 1972b) developed a quantitative analogue measure of alcohol consumption that is presented to subjects in the guise of a ‘taste test’ experiment. Subjects were asked to rate a variety of alcoholic and nonalcoholic beverages on a semantic differential scale, and ratings obtained for each beverage were used as an index of the subject’s attitude. Amount of alcohol consumed during the ‘taste test’ serves as pre-post measure of treatment success. In the present study the effects of electrical aversion therapy with hospitalized chronic alcoholics were assessed in a matched-subjects, pre-post design using the above-described measure. An electrical aversion group (high shock paired with sips of alcohol) was compared with control conditioning (low shock paired with sips of alcohol) and group psychotherapy conditions. On the basis of conditioning theory, it was hypothesized that subjects in the electrical aversion group would demonstrate significantly greater attitudinal and alcohol consumption changes than those in the control groups. METHOD Subjects Thirty males hospitalized on the Alcoholism Treatment Unit at the Veterans Administration Center, Jackson, Mississippi, were used as subjects. All subjects were undergoing treatment on a voluntary basis. Those with current evidence of organic brain disease, cardiovascular disorder and other major medical problems were excluded from the study. Subjects were assigned to one of the following three conditions, with 10 subjects in each group: (1) Aversion Conditioning; (2) Control Conditioning; (3) Group Psychotherapy. Subjects were matched on age, education and length of problem drinking. Means of these subject characteristics for the three groups are presented in Table 1. Examination of these variables in separate simple analyses of variance failed to reveal significant differences among the experimental and the control groups. TABLE~.&JEUECTCHARACTERISTICS
Subject characteristics Mean age Mean length of problem drinking Mean years of education
FORTHETHREEGROUPS
Electrical aversion
Control conditioning
Group therapy
44.6
44.1
47.3
10.3 13.7
12.6 10.4
12.7 12.3
Apparatus A Grason-Stadler shock generator model 700 was used to provide electrical stimulation. Electrical aversion therapy was conducted in a small room equipped with the shock generator, a table and two chairs. The experimenter remained behind the subject while operating the shock generator. ‘Taste Test’ Measure The ‘taste test’ measure (Miller and Hersen, 1972a, 1972b) for quantifying alcohol consumption was initially adapted from a procedure used by Schachter (1971) in his studies
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS
493
on obesity. Subjects were requested to participate in a ‘taste experiment’ being conducted by the Veterans Administration Psychology Division. During the ‘experiment’ each subject was seated before a table on which were placed six beverages, with exactly 100 cm3 of liquid in each glass. Glasses were opaque in order to avoid making the constant amount conspicuous. Three of the beverages were alcoholic(30cm3 ofbourbonorvodka in70cm3 ofwater and 100 cm3 of beer), whereas three were nonalcoholic ( 100cm3 each of coke, water andgingerale). Each subject was presented with semantic differential rating sheets and given the following instructions : “This is a taste experiment. We want you to judge each beverage on the taste dimensions (sweet, sour, etc.) listed on these sheets. Some of the drinks are alcoholic, and some are nonalcoholic. Taste as little or as much as you want of each beverage in making your judgments. The important thing is that your ratings be as accurate as possible.” Each subject was allowed 10 min to taste the beverage and complete the rating sheet for each drink. After the subject left the room, two sets of data were collected: (1) the total number of cm3 consumed from each glass, and (2) the score of the ratings on the evaluative scale of the semantic differential for each beverage. This latter measure provides a quantitative assessment of attitude towards the particular beverage. Measurement sessions were held for each subject at the same time of day. Order of presentation of the beverages was randomly rotated from session to session. Procedure In the aversion conditioning, control conditioning and group therapy conditions, the ‘taste test’ measure was administered once a day for three consecutive days before and after treatment. Subsequent comparisons of these pre- and post-test measures provided an assessment of inpatient treatment efficacy. A lo-day period intervened between pre- and post-tests for all three groups. Subjects in all conditions were informed that the specific technique being administered was a standard treatment for alcoholism and would result in a reduction of their drinking behavior. This latter instruction served to equate expectancy effects for each group. Subjects in the Electrical Aversion Conditioning Group were scheduled for treatment sessions twice daily for 10 days. During these sessions electrodes were attached to the ventral surface of the subject’s left forearm. Shock intensity was initially set at two mA and was increased until the subject reported pain and a distinct flexion of the arm was observed. Shock intensity for all subjects ranged from three to eight mA. Increasing adjustments were made in the intensity if, on the basis of arm flexion or verbal report, the subject appeared to be adapting to shock. The subject was seated at a table on which was placed a glass containing one of three alcoholic beverages and a metal pan. The subject’s preferred alcoholic beverage (in terms of amount consumed on the pre-test) was used for 50 per cent of the conditioning trials during each session. The two other alcoholic beverages on the ‘taste test’ measure were alternately used for the remaining 50 per cent of the trials. An escape paradigm (Blake, 1965) was used, and the subject was instructed to sip the drink but to avoid swallowing it. An electric shock was delivered to the forearm contiguously with the sip. Shock was terminated as soon as the subject spit the alcohol into the pan. Thirty pairings of alcohol sips with shock were administered during each session. Conditioning sessions and ‘taste test’ ratings were scheduled in different places, and instructions were geared to minimize the possibility that subjects would associate the two procedures. Each subject received 20 sessions of electrical aversion consisting of a total of 500 trials.
494
PETER M. MILLER,MI~HEL HERSEN,IUCMD
M.EISLER and DIANAP. HEMPHILL
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS
495
Procedures in the Control Conditioning Group were identical to those in the Electrical Aversion Conditioning Group, with the exception of the level of shock intensity. For these subjects the shock generator was set at 0.05 milliamps and remained at that level for all conditioning trials. The majority of subjects reported that they could feel no sensation at this intensity. A few subjects reported feeling a very slight ‘tingling sensation’ that was barely perceptable. However, this was not reported to be painful. This group was included to control for the possible influence of ‘expectancy’ or ‘attention-placebo’ variables active in the Electrical Aversion Conditioning Condition. In the Group Therapy Condition, subjects received six treatment sessions on alternate days during a IO-day period. Subjects met in a group consisting of 10 patients and a therapist. Each session lasted 1 hr and was oriented toward a better understanding of the social and emotional precipitants of excessive alcohol consumption. Emphasis was placed on confronting subjects with respect to their inappropriate or deficit behaviors. RESULTS Means and Standard deviations for cc consumption of alcohol and for evaluative scores on the pre-test and post-test measures are presented in Table 2. Mean cm3 consumption of alcohol for the pre-test was computed by adding the total consumption for the 3 days and then dividing by three. Post-test data were computed in identical fashion. Mean evaluative scores (high scores indicate a positive attitude toward alcohol) on the semantic differential measure for pre- and post-tests were computed by obtaining a mean for the three trials per day and then a grand mean for the 3 days of pre-test or post-test. Pre-test mean cc consumption of alcohol and pre-test mean evaluative scores for the three groups were examined in simple 1 x 3 analyses of variance.* The resulting F ratios were not significant, thus indicating initial comparability on these measures for the three groups. An examination of Table 2 reveals extremely large standard deviations for the three groups on the alcohol consumption measure. Therefore, a square root transformation was performed both on pre- and post-test data, and these scores were examined in a 1 x 3 simple analysis of variance for change scores. The resulting F was not significant. Mean cc consumption data were subsequently evaluated by examining the three groups with respect to percentage of change from pre- to post-test. In those cases where an increase in drinking occurred on the post-test, a 0 per cent score was arbitrarily assigned. Means of percentage change scores for the three groups are presented in Table 3. A simple 1 x 3 analysis of variance for percentage change scores was performed and yielded a nonsignificant F. Pre- and post-test consumption data were finally examined in terms of number of subjects in each group drinking 50 per cent less on the post-test than pre-test measure. Five of 10 subjects drank 50 per cent less in the Electrical Aversion Conditioning Group, TABLE 3. MEANS FOR PERCENTAGE OF PRE-POST REDUCTION IN Cm’ ALCOHOL CONSUMPTION Group
Electrical aversion Control conditioning Group therapy
36 37 30
*Constants were added in all three groups where minus scores occurred to facilitate computation analysis of variance.
of the
496
PETERM.
MILLER,
MiCHEL
HERSEN,
RICHARD
M. EISLER
and
DIANA
P. HEMPHiLL
three of 10 in the ~~~~~#~C~~d~ti~~i~g Gpoztp, and none ia the Grcwp T~~~~~~ ~~~t~~~. However, despite a trend in the expected direction, an evaluation of these data in a 2 x 3 contingency table failed to yield a significant chi-square. Change scores for pre-post mean evaluative scores were examined in a simpie 1 x 3 analysis of variance, but the resulting F was not significant, thus indicating no differential change in attitude for the three groups. DISCUSSION Significant differences were not obtained in reduced consumption or attitudes toward alcohol when comparing electrica aversion therapy with control conditioning and group PsyGhot~erapy. It should be noted that percentage reductions in alcohol consumption were relatively similar for each group (36, 37 and 30 per cent, respectively). The most clinically relevant finding (~though not statistically signi~~ant) involves the number of subjects that decreased their alcohol consumption by 50 per cent or more on the post-test drinking measure. However, as a relatively equal number of subjects evidenced changes of this magnitude from both the electrical aversion and control aversion groups, it appears most unlikely that conditioning per se was the active ingredient inducing change. Despite identical instructions to all three groups (designed to equate high expectancy effects), specificity of the aversion procedures may have resulted in a more positive set on the part of these patients as compared with group psychotherapy controls, where no subjects evidenced a pre-post change of this magnitude. In summary, these data do not lend support to the conditioning explanation for the clinical success of electrical aversion therapy with alcoholics. EIallam et a/. (1971) were previously unabIe to tind evidence of condidoned physiological reactions in their alcoholic subjects when administering electrical aversion, Therefore, they concluded that therapeutic success obtained as a function of electrical aversion was more likely related to elements common to a variety of treatments (in&ding the nonbehavioral), rather than to specific elements underlying electrical aversion. Such elements might include ‘attention-placebo’, expectancy, social reinforcement by the therapist, therapeutic instructions, and demand characteristics of the situation (e.g. treatment being administered as an alternative to legal incarceration or fine). The theoretical implications of such findings have recently been discussed at length (Hallam and Rachman, 1972). A systematic analysis of these variables in relation to electrical aversion with alcoholic subjects now appears warranted. The empirical examination of therapeutic instructions should be of particular interest in light of their do~nmented significance with respect to treatment outcome (Agras el rrl., 1969; Barlow et ai., 1972). However, in most studies involving electrical aversion therapy, specific instructions given to subjects are usually omitted. By contrast to changes obtained on the consumption measure, tzo treizds were noted on the semantic differential scale. However, these findings are not surprising inasmuch as attitudes usually appear to lag behind motoric improvement in behavior modification analogue studies (Hersen, 1973; Hersen et al., 1973). REFERENCES ACRASW. S., IXKTENBERF H., BARLOW ID. N. and THOMPSON L. E. (1969) Knstructions and reinforcementin the modificationof neurotic behavior. Amex.J. P&z&t. X5,1435-1439. BARLOWD. H., L~-EN~~G H., AGRASW. S., CALLAZAN E. I_ md MOORER. C. (X972) The con~r~~~i~~~of therapeutic~~~fr~~ti~~s tocovertsensiti2ation.B~~~~. Res. & Tkempy %&41&-415.
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS
497
BLAKE B. G. (1965) The application of behavior therapy to the treatment of alcoholics. Eehau. Res. & Therapy 3, 75-85. CHAPMANR. F., BURT D. W. and SMITHJ. W. (1972) Electrical aversion conditioning to alcohol: Individual measurement. Paper presented at Western Psychological Association, Portland, Oregon. GUZE S. B., TUASONV. B., STEWARTM. A. and PICKENB. (1963) The drinking history: A comparison of reports by subjects and their relatives. Quart. J. Stud. Ale. 24, 249-260. HALLAMR. and RACHMANS. (1972) Theoretical problems of aversion therapy. B&au. Res. & Therapy 10, 341-353. HALLAMR., RACHMANS. and FALKOWSKIW. (1972) Subjective, attitudinal and physiological effects of electrical aversion therapy. Behau. Res. & Therapy 10, I-13. HERSENM. (1973) Self-assessment of fear. Behau. Therapy 4, 24-257. HERSENM., EISLERR. M., MILLER P. M., JOHNSONM. B. and PINKSTONS. G. (1973) Effects of practice, instructions, and modeling on components of assertive behavior. Behau. Res. & Therapy, in press. MILLER P. M. and BARLOWD. H. (1973) Behavioral approaches to the treatment of alcoholism. J. Nerv. Ment. Dis., in press. MILLER P. M. and HERSEN M. (1972a) Quantitative changes in alcohol consumption as a function of electrical aversive conditioning. J. C/in. Psychol. 28, 59&593. MILLER P. M. and HERSENM. (1972b) A quantitative measurement system for alcoholism treatment and research. Paper presented at Association for Advancement of Behavior Therapy, New York. MOROSKOT. E. and BAERP. E. (1970) Avoidance conditioning of alcoholics. In Control of Human Behavior. 2, pp. 170-176. (Eds. R. ULRICH, T. STACHNICHand J. MABRY) Scott, Foresman, Illinois. SUMMERST. (1970) Validity of alcoholics’ self-reported drinking history. Quart. J. Stud. Ale. 31, 972-974. V~GLERR. E., LUNDES. E., JOHNSONG. R. and MARTINP. L. (1970) Electrical aversion conditioning with chronic alcoholics. J. Coxwlt. Clin. Psychol. 34, 302-307.
and DIANA P. HEMPHILL
Veterans Admin~st~t~on Center, and University of ~~ss~ss~pp~ Medical Center* Jackson, Mississippi, U.S.A.
(Received 14 March 1973)
Summary-Chronic alcoholic patients matched on age, education and length of problem drinking were assigned to one of three treatment conditions, with 10 subjects in each group: (1) Electrical Aversion Conditioning (high shock paired with alcohol sips); (2) Control Cond~t~o~i~ (very low shock paired with alcohol sips); and (3) Group Therapy (confrontation psychotherapy). Groups 2 and 3 were included to control for possible ‘attention-placebo’ and expectancy factors involved in the conditioning procedures. Subjects in each group were given instructions designed to produce high expectancy for therapeutic success, Rre-post measures of alcohol consumption and attitudes toward alcohol were obtained using an analogue ‘taste test’ assessment procedure. No statistically significant differences in reduced alcohol consumption or attitudes toward alcohol were found among the groups. Trends in the data support the contention that effects of electrical aversion may be more related to such factors as therapeutic instructions, expectancy, specificity of the procedure or experimental demand characteristics than to ~ndit~on~ng factors.
USE OF electrical aversion therapy in the treatment of alcoholism has been criticalIy reviewed by Miller and Barlow (1973). Evaluation of the efficacy of this procedure is difficult since very few well designed experimental studies ~mplo~ng adequate control groups have appeared in the literature. Recently, Vogler et af. (1970) compared electrical aversion conditioning, pseudoconditioning (random shock delivery), sham conditioning (no shock) and routine hospital care in the treatment of 51 chronic abohohcs. While relapse took significantly longer for the aversion conditioning subjects, proportion of relapses for this group did not differ significantly from the controfs. Outcome data indicating statistical superiority of a booster conditioning follow-up group cannot be properry evaluated since these subjects were not assigned randomly to this e~~r~rnenta~ condition. HalIam et alT. (1972) examined attitudinal and physiological effects of both electrical aversion therapy and general psychiatric care (group psychotherapy, AA meetings, drug therapy) with alcoholics. The aversion group showed no evidence of having developed heart rate or skin resistance responses to fantasies and photographic slides of alcohol. While signi~cant physiological and attitudinal changes were related to successful therapeutic outcome (in terms of abstinence), they did not correspond to type of treatment administered. The Hallam et al. (1972) study represents a trend toward more objective assessment of the efficacy of electrical aversion therapy. In evaluating the success of this technique with alcoholics, most studies have used either the patient’s self-report or reports from relatives,
*Requests for reprints should be sent to P. M. Miller, Veterans Mississippi 38216, U.S.A.
491
Adminis~tion
Center,
Jackson,
492
PETER M. MILLER,MCHEL
HERSEN,RICHARD
M. EISLER
and DIANA P. HEMPHILL
Summers (1970) and Guze et al. (1962) demonstrated that both of these subjective measures are of questionable validity and reliability. While attempts to utilize more objective measures of drinking behavior have occasionally been reported (Morosko and Baer, 1970; Chapman, Burt and Smith, 1972), systematic use of these procedures is infrequent. Miller and Hersen (1972a, 1972b) developed a quantitative analogue measure of alcohol consumption that is presented to subjects in the guise of a ‘taste test’ experiment. Subjects were asked to rate a variety of alcoholic and nonalcoholic beverages on a semantic differential scale, and ratings obtained for each beverage were used as an index of the subject’s attitude. Amount of alcohol consumed during the ‘taste test’ serves as pre-post measure of treatment success. In the present study the effects of electrical aversion therapy with hospitalized chronic alcoholics were assessed in a matched-subjects, pre-post design using the above-described measure. An electrical aversion group (high shock paired with sips of alcohol) was compared with control conditioning (low shock paired with sips of alcohol) and group psychotherapy conditions. On the basis of conditioning theory, it was hypothesized that subjects in the electrical aversion group would demonstrate significantly greater attitudinal and alcohol consumption changes than those in the control groups. METHOD Subjects Thirty males hospitalized on the Alcoholism Treatment Unit at the Veterans Administration Center, Jackson, Mississippi, were used as subjects. All subjects were undergoing treatment on a voluntary basis. Those with current evidence of organic brain disease, cardiovascular disorder and other major medical problems were excluded from the study. Subjects were assigned to one of the following three conditions, with 10 subjects in each group: (1) Aversion Conditioning; (2) Control Conditioning; (3) Group Psychotherapy. Subjects were matched on age, education and length of problem drinking. Means of these subject characteristics for the three groups are presented in Table 1. Examination of these variables in separate simple analyses of variance failed to reveal significant differences among the experimental and the control groups. TABLE~.&JEUECTCHARACTERISTICS
Subject characteristics Mean age Mean length of problem drinking Mean years of education
FORTHETHREEGROUPS
Electrical aversion
Control conditioning
Group therapy
44.6
44.1
47.3
10.3 13.7
12.6 10.4
12.7 12.3
Apparatus A Grason-Stadler shock generator model 700 was used to provide electrical stimulation. Electrical aversion therapy was conducted in a small room equipped with the shock generator, a table and two chairs. The experimenter remained behind the subject while operating the shock generator. ‘Taste Test’ Measure The ‘taste test’ measure (Miller and Hersen, 1972a, 1972b) for quantifying alcohol consumption was initially adapted from a procedure used by Schachter (1971) in his studies
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS
493
on obesity. Subjects were requested to participate in a ‘taste experiment’ being conducted by the Veterans Administration Psychology Division. During the ‘experiment’ each subject was seated before a table on which were placed six beverages, with exactly 100 cm3 of liquid in each glass. Glasses were opaque in order to avoid making the constant amount conspicuous. Three of the beverages were alcoholic(30cm3 ofbourbonorvodka in70cm3 ofwater and 100 cm3 of beer), whereas three were nonalcoholic ( 100cm3 each of coke, water andgingerale). Each subject was presented with semantic differential rating sheets and given the following instructions : “This is a taste experiment. We want you to judge each beverage on the taste dimensions (sweet, sour, etc.) listed on these sheets. Some of the drinks are alcoholic, and some are nonalcoholic. Taste as little or as much as you want of each beverage in making your judgments. The important thing is that your ratings be as accurate as possible.” Each subject was allowed 10 min to taste the beverage and complete the rating sheet for each drink. After the subject left the room, two sets of data were collected: (1) the total number of cm3 consumed from each glass, and (2) the score of the ratings on the evaluative scale of the semantic differential for each beverage. This latter measure provides a quantitative assessment of attitude towards the particular beverage. Measurement sessions were held for each subject at the same time of day. Order of presentation of the beverages was randomly rotated from session to session. Procedure In the aversion conditioning, control conditioning and group therapy conditions, the ‘taste test’ measure was administered once a day for three consecutive days before and after treatment. Subsequent comparisons of these pre- and post-test measures provided an assessment of inpatient treatment efficacy. A lo-day period intervened between pre- and post-tests for all three groups. Subjects in all conditions were informed that the specific technique being administered was a standard treatment for alcoholism and would result in a reduction of their drinking behavior. This latter instruction served to equate expectancy effects for each group. Subjects in the Electrical Aversion Conditioning Group were scheduled for treatment sessions twice daily for 10 days. During these sessions electrodes were attached to the ventral surface of the subject’s left forearm. Shock intensity was initially set at two mA and was increased until the subject reported pain and a distinct flexion of the arm was observed. Shock intensity for all subjects ranged from three to eight mA. Increasing adjustments were made in the intensity if, on the basis of arm flexion or verbal report, the subject appeared to be adapting to shock. The subject was seated at a table on which was placed a glass containing one of three alcoholic beverages and a metal pan. The subject’s preferred alcoholic beverage (in terms of amount consumed on the pre-test) was used for 50 per cent of the conditioning trials during each session. The two other alcoholic beverages on the ‘taste test’ measure were alternately used for the remaining 50 per cent of the trials. An escape paradigm (Blake, 1965) was used, and the subject was instructed to sip the drink but to avoid swallowing it. An electric shock was delivered to the forearm contiguously with the sip. Shock was terminated as soon as the subject spit the alcohol into the pan. Thirty pairings of alcohol sips with shock were administered during each session. Conditioning sessions and ‘taste test’ ratings were scheduled in different places, and instructions were geared to minimize the possibility that subjects would associate the two procedures. Each subject received 20 sessions of electrical aversion consisting of a total of 500 trials.
494
PETER M. MILLER,MI~HEL HERSEN,IUCMD
M.EISLER and DIANAP. HEMPHILL
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS
495
Procedures in the Control Conditioning Group were identical to those in the Electrical Aversion Conditioning Group, with the exception of the level of shock intensity. For these subjects the shock generator was set at 0.05 milliamps and remained at that level for all conditioning trials. The majority of subjects reported that they could feel no sensation at this intensity. A few subjects reported feeling a very slight ‘tingling sensation’ that was barely perceptable. However, this was not reported to be painful. This group was included to control for the possible influence of ‘expectancy’ or ‘attention-placebo’ variables active in the Electrical Aversion Conditioning Condition. In the Group Therapy Condition, subjects received six treatment sessions on alternate days during a IO-day period. Subjects met in a group consisting of 10 patients and a therapist. Each session lasted 1 hr and was oriented toward a better understanding of the social and emotional precipitants of excessive alcohol consumption. Emphasis was placed on confronting subjects with respect to their inappropriate or deficit behaviors. RESULTS Means and Standard deviations for cc consumption of alcohol and for evaluative scores on the pre-test and post-test measures are presented in Table 2. Mean cm3 consumption of alcohol for the pre-test was computed by adding the total consumption for the 3 days and then dividing by three. Post-test data were computed in identical fashion. Mean evaluative scores (high scores indicate a positive attitude toward alcohol) on the semantic differential measure for pre- and post-tests were computed by obtaining a mean for the three trials per day and then a grand mean for the 3 days of pre-test or post-test. Pre-test mean cc consumption of alcohol and pre-test mean evaluative scores for the three groups were examined in simple 1 x 3 analyses of variance.* The resulting F ratios were not significant, thus indicating initial comparability on these measures for the three groups. An examination of Table 2 reveals extremely large standard deviations for the three groups on the alcohol consumption measure. Therefore, a square root transformation was performed both on pre- and post-test data, and these scores were examined in a 1 x 3 simple analysis of variance for change scores. The resulting F was not significant. Mean cc consumption data were subsequently evaluated by examining the three groups with respect to percentage of change from pre- to post-test. In those cases where an increase in drinking occurred on the post-test, a 0 per cent score was arbitrarily assigned. Means of percentage change scores for the three groups are presented in Table 3. A simple 1 x 3 analysis of variance for percentage change scores was performed and yielded a nonsignificant F. Pre- and post-test consumption data were finally examined in terms of number of subjects in each group drinking 50 per cent less on the post-test than pre-test measure. Five of 10 subjects drank 50 per cent less in the Electrical Aversion Conditioning Group, TABLE 3. MEANS FOR PERCENTAGE OF PRE-POST REDUCTION IN Cm’ ALCOHOL CONSUMPTION Group
Electrical aversion Control conditioning Group therapy
36 37 30
*Constants were added in all three groups where minus scores occurred to facilitate computation analysis of variance.
of the
496
PETERM.
MILLER,
MiCHEL
HERSEN,
RICHARD
M. EISLER
and
DIANA
P. HEMPHiLL
three of 10 in the ~~~~~#~C~~d~ti~~i~g Gpoztp, and none ia the Grcwp T~~~~~~ ~~~t~~~. However, despite a trend in the expected direction, an evaluation of these data in a 2 x 3 contingency table failed to yield a significant chi-square. Change scores for pre-post mean evaluative scores were examined in a simpie 1 x 3 analysis of variance, but the resulting F was not significant, thus indicating no differential change in attitude for the three groups. DISCUSSION Significant differences were not obtained in reduced consumption or attitudes toward alcohol when comparing electrica aversion therapy with control conditioning and group PsyGhot~erapy. It should be noted that percentage reductions in alcohol consumption were relatively similar for each group (36, 37 and 30 per cent, respectively). The most clinically relevant finding (~though not statistically signi~~ant) involves the number of subjects that decreased their alcohol consumption by 50 per cent or more on the post-test drinking measure. However, as a relatively equal number of subjects evidenced changes of this magnitude from both the electrical aversion and control aversion groups, it appears most unlikely that conditioning per se was the active ingredient inducing change. Despite identical instructions to all three groups (designed to equate high expectancy effects), specificity of the aversion procedures may have resulted in a more positive set on the part of these patients as compared with group psychotherapy controls, where no subjects evidenced a pre-post change of this magnitude. In summary, these data do not lend support to the conditioning explanation for the clinical success of electrical aversion therapy with alcoholics. EIallam et a/. (1971) were previously unabIe to tind evidence of condidoned physiological reactions in their alcoholic subjects when administering electrical aversion, Therefore, they concluded that therapeutic success obtained as a function of electrical aversion was more likely related to elements common to a variety of treatments (in&ding the nonbehavioral), rather than to specific elements underlying electrical aversion. Such elements might include ‘attention-placebo’, expectancy, social reinforcement by the therapist, therapeutic instructions, and demand characteristics of the situation (e.g. treatment being administered as an alternative to legal incarceration or fine). The theoretical implications of such findings have recently been discussed at length (Hallam and Rachman, 1972). A systematic analysis of these variables in relation to electrical aversion with alcoholic subjects now appears warranted. The empirical examination of therapeutic instructions should be of particular interest in light of their do~nmented significance with respect to treatment outcome (Agras el rrl., 1969; Barlow et ai., 1972). However, in most studies involving electrical aversion therapy, specific instructions given to subjects are usually omitted. By contrast to changes obtained on the consumption measure, tzo treizds were noted on the semantic differential scale. However, these findings are not surprising inasmuch as attitudes usually appear to lag behind motoric improvement in behavior modification analogue studies (Hersen, 1973; Hersen et al., 1973). REFERENCES ACRASW. S., IXKTENBERF H., BARLOW ID. N. and THOMPSON L. E. (1969) Knstructions and reinforcementin the modificationof neurotic behavior. Amex.J. P&z&t. X5,1435-1439. BARLOWD. H., L~-EN~~G H., AGRASW. S., CALLAZAN E. I_ md MOORER. C. (X972) The con~r~~~i~~~of therapeutic~~~fr~~ti~~s tocovertsensiti2ation.B~~~~. Res. & Tkempy %&41&-415.
ELECTRICAL AVERSION THERAPY WITH ALCOHOLICS
497
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