,c A patient who consults a behavior therapist for aver-

= sion therapy can expect a fairly standard set of proce-•7 dures. The therapist begins by assessing the problem, « most likely measuring its frequency, severity, and the environment in which the undesirable behavior occurs. Although the therapeutic relationship is not the focus of treatment for the behavior therapist, therapists in this tradition believe that good rapport will facilitate a successful outcome. A positive relationship is also necessary to establish the patient's confidence in the rationale for exposing him or her to an uncomfortable stimulus. The therapist will design a treatment protocol and explain it to the patient. The most important choice the therapist makes is the type of aversive stimulus to employ. Depending upon the behavior to be changed, the preferred aversive stimulus is often electric stimulation delivered to the forearm or leg. This aversive stimulus should not be confused with electroconvulsive therapy (ECT), which is delivered to the brain to treat depression. Mild but uncomfortable electric shocks have several advantages over chemical and pharmacological stimuli. A great many laboratory research studies using animal and human subjects have used electrical shock and its characteristics are well known. In addition, it has been widely used in clinical settings. Electric shock is easy to administer, and the level of intensity can be preselected by the patient. The stimulation can be precisely controlled and timed. The equipment is safe, battery-powered, suitable for outpatients, portable, easy to use, and can be self-administered by the patient when appropriate.

Case example #1: What would a treatment protocol look like for a relatively well-adjusted patient specifically requesting aversion therapy on an outpatient basis to reduce or eliminate problem gambling behavior? The therapist begins by asking the patient to keep a behavioral diary. The therapist uses this information both to understand the seriousness of the problem and as a baseline to measure whether or not change is occurring during the course of treatment. Because electric shock is easy to use and is acceptable to the patient, the therapist chooses it as the aversive stimulus. The patient has no medical problems that would preclude the use of this stimulus. He or she fully understands the procedure and consents to treatment. The treatment is conducted on an outpatient basis with the therapist administering the shocks on a daily basis for the first week in the office, gradually tapering to once a week over a month. Sessions last about an hour. A small, battery-powered electrical device is used. The electrodes are placed on the patient's wrist. The patient is asked to preselect a level of shock that is uncomfortable but not too painful. This shock is then briefly and repeatedly paired with stimuli (such as slides of the race track, betting sheets, written descriptions of gambling) that the patient has chosen for their association with his or her problem gambling. The timing, duration, and intensity of the shock are carefully planned by the therapist to assure that the patient experiences a discomfort level that is aversive and that the conditioning effect occurs.

After the first or second week of treatment, the patient is provided with a portable shocking device to use on a daily basis for practice at home to supplement office treatment. The therapist calls the patient at home to monitor compliance as well as progress between office sessions. The conditioning effect occurs, the discomfort from the electric shock becomes associated with the gambling behavior, the patient reports loss of desire and stops gambling. Booster sessions in the therapist's office are scheduled once a month for six months. A minor relapse is dealt with through an extra office visit. The patient is asked to administer his or her own booster sessions on an intermittent basis at home and to call in the future if needed.

Case example #2: What would the treatment protocol look like for an alcohol-dependent patient with an extensive treatment history including multiple prior life-threatening relapses? The patient who is motivated to change but has not experienced success in the past may be considered a candidate for aversion therapy as part of a comprehensive inpatient treatment program. The treating therapist assesses the extent of the patient's problem, including drinking history, prior treatments and response, physical health, and present drinking pattern. Patients who are physically addicted to alcohol and currently drinking may experience severe withdrawal symptoms and may have to undergo detoxification before treatment starts. When the detoxification is completed, the patient is assessed for aversion therapy. The therapist's first decision is what type of noxious stimulus to use, whether electrical stimulation or an emetic (a medication that causes vomiting). In this case, when the patient's problem is considered treatment-resistant and a medically-monitored inpatient setting is available, an emetic may be preferable to electric shock as the aversive stimulus. There is some research evidence that chemical aversants lead to at least short-term avoidance of alcohol in some patients. An emetic is "biologically appropriate" for the patient in that it affects him or her in the same organ systems that excessive alcohol use does. The procedure is fully explained to the patient, who gives informed consent.

During a ten-day hospitalization, the patient may receive aversion therapy sessions every other day as part of a comprehensive treatment program. During the treatment sessions, the patient is given an emetic intra venously under close medical supervision and with the help of staff assistants who understand and accept the theory. Within a few minutes following administration, the patient reports beginning to feel sick. To associate the emetic with the sight, smell and taste of alcohol, the patient is then asked to take a sip of the alcoholic beverage of his or her choice without swallowing. This process is repeated over a period of 30-60 minutes as nausea and vomiting occur. As the unpleasant effects of the emetic drug become associated with the alcoholic beverage, the patient begins to lose desire for drinking. Aversion therapy in an inpatient program is usually embedded within a comprehensive treatment curriculum that includes group therapy and such support groups as AA, couples/family counseling, social skills training, stress management, instruction in problem solving and conflict resolution, health education and other behavioral change and maintenance strategies. Discharge planning includes an intensive outpatient program that may include aversive booster sessions administered over a period of six to twelve months, or over the patient's lifetime.

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