Aversion therapy motivates behavior change through the formation of negative associations with a behavior. Medication, unpleasant smells or tastes and even electrical shocks are some of the methods used to create negative associations that discourage unwanted behaviors. While controversial, research suggests certain types of aversion therapy can be effective in the treatment of addiction and diseases related to lifestyle.
What Is Aversion Therapy and How Does it Work?
Aversion therapy is a psychological or medical treatment that uses negative physical and emotional associations to encourage behavior change. By pairing a problem behavior with something that creates physical or emotional discomfort, the positive association with the behavior is broken and a new, negative association is developed. This process is also referred to as “counterconditioning,” and is designed to encourage behavior change.7
Some of the methods used in aversion therapy to create unpleasant associations include:8
- Emetic methods: use of medication to induce nausea and vomiting
- Electrical methods: administering electric shocks
- Imaginal methods: use of unpleasant or upsetting mental images or thoughts
- Sensory methods: use of something with an unpleasant sensation (touch, taste or smell)
- Pharmacological methods: use of a medication which creates illness or discomfort when it interacts with a certain substance
Aversion therapy operates off of the principles of behaviorism, which encourages positive behaviors through rewards and discourages unwanted behaviors through punishments. Essentially, behaviorism is based on the idea that human behavior is motivated by natural urges to seek pleasure and avoid pain. Counterconditioning involves pairing behaviors or behavioral cues with painful, unpleasant or uncomfortable experiences to encourage future avoidance.1
Drugs and certain compulsive behaviors like sex, gambling or stealing are believed to activate reward centers in the brain, causing the release of dopamine and causing a pleasurable “high”. Over time, repeating the behavior causes reward or “addiction” pathways to form in the brain, resulting in strong urges to repeat the behavior and making it much harder to stop. Aversion therapy aims to reverse this process by interrupting the reward process and punishing the behavior to create a negative association.2,6,7
Aversion therapy is an umbrella term that actually includes a variety of different treatment methods. Some of these have more evidence to support their use and are more commonly used. For example, the use of pharmacological aversion treatments like Antabuse for alcoholism or orlistat for obesity are much more common than methods using electrical shock or sensory methods.
What Can Aversion Therapy Help With?
Aversion therapy can be used to treat a number of behavioral issues, lifestyle diseases, and addictions. In recent years, aversion therapy techniques are most commonly used to treat:1,5
- Drug and alcohol addiction
- Overeating and obesity
- Tobacco or nicotine use
- Compulsive Gambling
Less commonly, aversion therapy has a history of being used to treat:1,8
- Self-harming behavior (i.e. cutting)
- Nail biting or thumb sucking
- Trichotillomania (hair pulling)
- Excoriation (skin picking)
- Problem sexual behaviors
Aversion therapy is usually recommended only when other frontline treatments have been ineffective or when there are other factors complicating treatment. For example, aversion therapy has been used to help reduce self-harming and compulsive sexual behaviors in people who have an underlying brain injury or developmental disorder.2,8 In another example, a person with a history of serious drug use and multiple failed treatments is more likely to be recommended for aversion therapy than a person seeking treatment for the first time.
Aversion Therapy Examples
Aversion therapy has been a controversial treatment and there were many documented instances where its use was unethical and even inhumane. Because of this complicated history, aversion therapy is often misunderstood. The following are examples of aversion therapy as it is most commonly used today.
Aversion Therapy For Alcohol Use Disorder
The FDA-approved medication disulfiram (or Antabuse) is often prescribed to people with alcohol use disorders. Disulfiram is a medication that, when taken daily, causes an adverse response to alcohol by blocking enzymes in the liver. When people on this medication drink alcohol, they will develop uncomfortable symptoms like nausea and vomiting, headaches, changes in blood pressure, sweating, anxiety, and trouble breathing. Some people choose to take the medication to help safeguard against a relapse.3,9
Aversion Therapy For Obesity
Another FDA-approved medication used as a form of aversion therapy for obesity is the drug orlistat (brand names are Xenical and Alli). Orlistat reduces the amount of fat metabolized by the body by approximately 30% but the side effects of the drug are what classify it as a form of aversion therapy. When a person taking orlistat eats foods that are high in fat, they will experience diarrhea, gas, and even an inability to control the bowels. These unpleasant and embarrassing side effects are intentionally designed to create a negative association with eating fatty foods.4
Aversion Therapy For Nail Biting
Aversion therapy for nail biting is also relatively common. This technique is usually accomplished by painting the nails with a bitter substance like neem oil or a formula using a spicy ingredient like cayenne pepper. This at-home technique can be accomplished using products easily bought online or at a drugstore, and has two main functions. The first function is to help nail biters become more aware of the behavior and the second is to create a negative taste association.10
Cost of Aversion Therapy
The cost of aversion therapy varies greatly depending on the type of aversion therapy, whether it is being self-administered or professionally administered, and individual factors like the length of treatment. The most common types of professional aversion therapy are medications which can be prescribed by a primary care doctor or a specialist.
Costs for these pharmacological aversion treatments vary considerably. According to Good RX, the generic version of the drug Antabuse averages around $35 for a 30 day supply. Additional to this cost would be the cost of the actual visit or consultation with the prescribing professional.
Aversion therapy is often recommended in combination with other treatments. For example, those taking the drug Antabuse for alcohol dependence are also recommended to see a professional counselor or addiction specialist. Often, prescribed medications and office visits are at least partially covered by health insurance. Visiting the insurers website or calling the number on the back of the insurance card is a good way to get detailed information about the cost of covered services and medications.
How To Find Aversion Therapy
Where to begin your search for aversion therapy greatly depends on the type of aversion therapy you are seeking, and the particular issue being addressed. Those who are seeking aversion therapy for health-related issues like weight loss or even smoking cessation can sometimes set up an appointment with their primary care doctor. Those who are looking for aversion therapy for addiction or compulsive gambling should search for an addiction counselor.
Many people begin their search for an addiction counselor by doing a google search or by using an online directory. Those with health insurance can often save money by selecting an in-network therapist. Reaching out to the insurance company or using their online portal can help identify a list of in-network therapists. Those who need addiction treatment should look for providers with secondary licenses or credentials to prove they are experienced in treating addiction.
Because aversion therapy is not very common, it may be difficult to find a counselor who specializes in this approach. There is not a formal designation or credential for aversion therapists, but calling around can sometimes lead to finding a counselor with specialized training in this area. Because of their education and training, most professional counselors are not able to prescribe medication, so those interested in pharmacological treatments should find a doctor or other prescribing professional.
What to Expect At Your First Appointment
Those who begin aversion therapy with a licensed counselor can expect to spend 60-90 minutes completing a detailed intake and assessment. During this appointment, clients are asked to fill out paperwork and are also asked a number of questions designed to help determine a clinical diagnosis. At the end of the appointment, the counselor will review the diagnosis and discuss options for further treatment.
If the first appointment is with a prescribing professional (like a doctor, physician’s assistant, or nurse practitioner), the first appointment will involve a less formal discussion of the issue. Those seeking pharmacological aversion therapy can expect for the practitioner to provide detailed information about the medication, purpose, and potential side effects.
When any medication is prescribed, a follow-up appointment is usually scheduled to determine whether the medication is having the desired effects after 2-6 weeks. If a person has adverse reactions or side effects prior to their follow-up, they are recommended to contact the doctor for advice on whether to continue the medication.
Is Aversion Therapy Effective?
Certain types of aversion therapy have more research to support their efficacy. Much of the research on aversion therapy is outdated, and was conducted when standards for research were less rigorous.
More current research on aversion therapy has proven it can be effective in treating the following issues:1,2,5,6,7,9,10,11
- Addictions to alcohol, cocaine, methamphetamines
- Obesity and weight loss (Orlistat)
- Self-harming behaviors (i.e. cutting)
- Nail biting
- Compulsive gambling
Brain imaging studies have provided evidence that counterconditioning does interrupt reward activity, suggesting that it can be effective in counteracting addiction pathways in the brain.6 It is also well documented that aversion therapy can reduce cravings but what is less clear is whether these results are lasting, as research on the topic has been mixed.2,11 Many of the medications used in aversion therapy will not have lasting impact. So if a patient decides to stop taking the prescription there will no longer be the negative “consequences” to the behavior being addressed.
Insufficient research exists on the use of aversion therapy for the following issues:1,8
- Excoriation disorder (skin picking)
- Trichotillomania (hair pulling)
- Sexually compulsive behaviors (pedophilia, exhibitionism)
- Smoking cessation (specifically aversive smoking which involves rapid chain smoking)
- Compulsive gambling
History of Aversion Therapy
The use of aversion therapy became prevalent in the 50’s and 60’s, building upon the work of behaviorists like Pavlov (Keller). It was used to treat drug and alcohol addictions, behavioral problems, and sexual perversion. At this time electrical aversion therapy was the most widely used, but emetics (medication that induce vomiting) were also sometimes used.
In the early years, aversion therapy was used in ways that were unethical and inhumane. For example, aversion therapy was often administered without a patient’s consent. Electrical shock treatments were much more rudimentary and could result in painful and dangerous electrocution. Aversion therapy was also inappropriately used to “cure” homosexuality, which was considered a disorder at that time.8
As controversy and criticism grew in the 70’s, aversion therapy became less common. Contemporary aversion therapy began to reemerge in the late 90’s but never gained the same popularity it had before. The most common forms of aversion therapy utilized today are pharmacological treatments for addiction and obesity.1
Controversy & Criticism of Aversion Therapy
Today, there are many ethical codes, laws, and safeguards that protect people seeking treatment for a physical or psychological problem. Unfortunately, this was not always the case. Much of the controversy surrounding aversion therapy stemmed from experimental psychological treatments done in the 50’s, 60’s and 70’s. At this time, electric shock treatment was the most commonly used technique, and unlike modern methods of electrical treatment, was painful and inhumane.8
Because of the controversy surrounding these techniques, aversion therapy was rarely used between the years of 1980-2000, and has only recently reemerged as a viable treatment option for addiction, lifestyle, and behavioral disorders. Still, some continue to raise ethical concerns about certain aversion techniques like the use of electrical shocks. There is also some research which suggests that counterconditioning in aversion therapy provides only short-term results as opposed to the more lasting results seen in other types of treatment.11
It should be pointed out that shock treatments for aversion therapy are different than elecroconvulsive therapy, which is still used for cases of treatment resistant depression.
