Aversion Therapy for Alcoholism: Chemical, Electrical, or Verbal Imaginary?

Abstract

Aversion therapy approaches to alcoholism treatment and related experiments using nonhuman subjects have been critically reviewed. The traditional goal of such aversion therapy has been the induction of total abstinence through the development of conditioned aversions to alcoholic beverages. Toward this end, alcohol has been paired with a variety of aversive stimuli including chemically-induced illness, painful faradic stimulation, and drug-induced respiratory arrest. In addition to these abstinence-oriented efforts, recent innovations have rejected total abstinence as a necessary goal for all alcoholics and have attempted to convert alcoholics into controlled drinkers. The status of abstinence-oriented treatments will be summarized first and consideration will then be given to controlled drinking approaches.

Historically, aversion therapy for alcoholism has emphasized the pairing of alcohol with chemically-induced nausea or emesis. Results of some such attempts were encouraging, but rigorous experimental evaluations have not been reported. However, because of numerous practical considerations, aversive shock has replaced chemical-induced nausea as the usual basis of aversion therapy. Unfortunately, mounting comparative data now indicate that flavor aversions are readily based on nausea, but difficult to establish through shock. In addition, recent animal data also strongly suggest that some unsuccessful applications of chemical aversion therapy were consequences of inappropriate backward conditioning procedures which delayed alcohol ingestion until after the onset of nausea. In addition to its general inefficiency, it now appears that such backward conditioning, in direct opposition to the desired effect, might have actually increased the reward value of alcohol. These findings in conjunction with the unimpressive results of attempts to experimentally evaluate the effectiveness of alcoholism therapy based on shock apparently suggest a reemphasis of chemical aversion therapy. However, emetic therapy is beset with disadvantages and a more promising alternative is provided by a recently developed technique, variously designated as covert sensitization or verbal aversion therapy, which pairs imaginary alcohol with nausea induced through verbal suggestion. This innovative approach uses a biologically appropriate noxious stimulus, eliminates problems associated with chemically-induced nausea, facilitates discrimination training, and provides a self-control procedure reported to reduce anxiety in alcoholics simply by its availability. Although few reports have appeared, results of well-implemented clinical and experimental applications are quite encouraging. Methodological differences in covert sensitization and verbal aversion therapy have been critically evaluated and specific research needs have been emphasized in an effort to stimulate additional development and scientific evaluation of covert sensitization as a potentially important component in the successful treatment of many alcoholics.

There have been several attempts to condition therapeutically effective aversions by following alcohol exposure with succynilcholine chloride-induced paralysis and respiratory arrest. An initial clinical report of this apneic conditioning was promising, but subsequent clinical and experimental results have ranged from negative to marginal. Available data provide little basis for optimism that this treatment will prove to be as effective as either well-implemented emetic therapy or covert sensitization. In addition, apneic conditioning is extremely traumatic, and many patients report an overwhelming fear of death during respiratory arrest followed by a proneness to nonspecific anxiety. Apneic conditioning cannot be recommended for clinical use.

Despite the prevalent view that all alcoholics are necessarially separated from social drinkers by a lifetime inability to control alcohol ingestion short of total abstinence, much recent evidence indicates that some alcoholics can and do modify their intake in accord with environmental contingencies. Consistent with these findings, two experimental attempts to teach alcoholics to drink within socially acceptable limits have produced very encouraging results. Both studies paired excessive drinking with painful shock. However, success was apparently not dependent on conditioned alcohol aversions of the type produced by effective emetic conditioning or covert sensitization treatment. Instead of reporting conditioned aversions, most patients simply reported a loss of desire or taste for alcoholic beverages after several drinks. In fact, presently available data is insufficient to determine if painful shock in particular or aversive consequences in general are even critical to successful treatment. Nevertheless, these experiments clearly support recurrent clinical observations that some alcoholics can practice moderate drinking most of the time over extended intervals. This promising area of research demands vigorous pursuit. With a sufficient research effort it is conceivable that in the not too distant future many alcoholics can be offered controlled drinking or total abstinence as alternate treatment goals. An alcoholic will then be able to elect treatment compatible with his personal belief structure and pattern of available social reinforcement. If he is unsuccessful in his initial objective, the second goal will remain a viable alternative. Such options would probably be attractive to many problem drinkers who strongly assert that they can, in fact, gain control of their drinking and steadfastly refuse to involve themselves in treatment when success is defined strictly in terms of total abstinence.