You’ll enjoy this. No, really. Let me be clear: you will enjoy this. Otherwise there could be unpleasant consequences.
Arranging unpleasant consequences for people who do not behave in desired ways is a basic behaviour modification technique, basic behaviour therapy. The technical term for the unpleasant consequences is punishment, but this term is not used in any moral sense, only to denote a type of consequence for certain behaviour, that causes the behaviour to decrease — if you are punished, you do it less.
When this kind of behaviour therapy was more popular, it was known as aversion therapy. Therapists would arrange for undesirable behaviours, or thoughts about undesirable behaviours, to be associated with various forms of unpleasantness.
A Clockwork Orange
A commonly-used form of unpleasantness was nausea, deliberately created by drugs. This kind of aversion therapy using nausea was the subject of Anthony Burgess’ 1962 novel A Clockwork Orange, which was made into a film a few years later.
The book’s hero is addicted to violence, including sexual violence. He is arrested and convicted, and agrees to have aversion therapy. The therapy involves his taking a nausea-inducing drug and then watching violent and sexual films. As he learns to associate violence and sexuality with nausea, his behaviour changes. He becomes non-violent, even when attacked, and he loses interest in sex. Success!
Electric shocks were another form of unpleasantness that was used in a similar way. A 1964 paper in the British Medical Journal (BMJ) describes how easy and cheap it is to make the equipment: Aversion Therapy by Electric Shock: a Simple Technique (free registration required).
Here’s the list of components:
|1 push-button switch||1s. 6d.|
|1 4-8-volt buzzer (miniature type)||5s. 0d.|
|1 small transformer, about 50 : 1 ratio||7s. 6d.|
|(The above three items are such as are used for a house door-bell)|
|1 grid-bias battery, 9 volts||1s. 9d.|
|1 potentiometer, 2 megohms, log. track||2s. 6d.|
|1 knob for above||9d.|
|1 box (cigar box ideal)||—|
|1 armband with electrodes||—|
1s (one shilling) became 5p when UK currency changed in 1971 (and 1d, a penny, was a twelfth of a shilling), so the total cost is 95p in today’s notation. Allowing for inflation, this would be around £15 today. It is perhaps surprising that armbands with electrodes were once as common as cigar boxes, and could be obtained at no cost.
The resulting contraption looked like this:
And here’s how it was used:
Treatment Procedure.—The use of the apparatus follows classical conditioning technique. The stimulus to which aversion is to be produced is presented, often by having the patient imagine the stimulus, and then a shock is administered…The strength of the shock should be adjusted so that it is as painful as the patient can bear.
The paper includes six brief case studies of the treatment. Here’s an extract from one of them:
A female schoolteacher of 37 who had smoked since the age of 18 was smoking 40 cigarettes a day… She was seen several times a day and on each occasion was asked to smoke a cigarette in her usual way. She was given a shock as soon as inhalation was complete.
…she has now had none for six months and has no difficulty in abstaining.
The paper caused some controversy in the letters pages of subsequent issues of the BMJ. For example, one correspondent, Clifford Allen of London W1, wrote:
In our wish to treat our patients effectively we are often faced by difficult decisions in which humanity and common sense should be our guide. It is not easy to see how this intention is furthered by submitting patients to electric shocks “as painful as they can bear”… I submit that electric shocks are in the same category as the flogging, ducking, and cannon-firing of the past, and that good intentions do not justify the means employed.
However, other correspondents supported the technique and contributed their own success stories.
The present day
All that was nearly half a century ago. We have moved on from those primitive ideas about changing people’s behaviour. Or have we?
Aversive elements in present-day treatments can still be found. That is, patients are still deliberately exposed to unpleasantness if they display symptoms. The basic logic, that a symptomatic behaviour leads to an unpleasant consequence, remains the same as in nausea therapy or electric shock therapy. The difference today is that the unpleasantness is never acknowledged as aversive.
If the patient’s behaviour changes, some other feature of the treatment is given credit. In this way, aversion therapy may be in common use today without ever being documented.
One example of unpleasantness that might have an aversive effect is the kind of bullying that sometimes occurs in therapy groups. Patients who find the group unpleasant may become conditioned to suppress their symptoms in order to avoid the unpleasantness — if you are punished, you do it less. The apparent improvement in these patients would be wrongly attributed to the overt content of the group sessions.
Bullying as an aversion therapy need not be a group effect. It could be administered by staff. For example, in a unit where the nursing culture tends towards authoritarianism, subtle bullying of patients who display symptoms could easily go unnoticed, and the resulting aversion would make for an apparent improvement in the unit’s results.
A devious unit could go further by selecting patients who have a history of being victims of bullying, and who can therefore be expected to be more vulnerable to it. The unit would then be able to publish a series of research papers documenting the success of whatever treatment they are overtly administering, while being careful to avoid mentioning their unofficial aversion sessions.
Another subtle form of bullying can occur in individual therapy, where the therapist establishes power over the patient and uses that power to cause deliberate suffering.
Research findings are vulnerable to a wide range of distortions of this kind, and the process of peer review that is meant to protect us from dodgy research findings does little good in practice.
As The Last Psychiatrist pointed out earlier this year in an excellent article about evidence based medicine in psychiatry, strangely titled, The Massacre Of The Unicorns II, much of the research that is done in psychiatry relies on questionnaires (known as ‘scales’) that are only indirect measures of patients’ troubles. He uses the example of a common scale for measuring depression (original emphasis):
Using this scale, a patient who sleeps too much and eats too much is less depressed than someone who sleeps too little and has lost weight. And, any drug that fixes sleep and makes you gain weight has an advantage over drugs that don’t. In fact, a third to half of the improvement on the [scale] could be accomplished by improved sleep and appetite alone.
The wider effect of using scales is that a research group does not have to cure anyone in order to get fantastic results, leading to fame and funding. They only have to influence limited factors that happen to be picked up by the scale they are using.
This makes it easy for a research project to get good results just by persuading patients to tick the right boxes in whatever scale the project uses to measure success. The means of persuasion does not have to be an actual cure — it could be any kind of behaviour modification.
Ironically, a research project that uses aversion to train patients to tick the right boxes will be rewarded in the form of a published paper, a trip to a conference, an increase in funding. The project team will become conditioned by these rewards to continue with clandestine aversion therapy.
Consent and suffering
Patients who have not consented to aversion therapy should be able to expect treatment that does not cause them deliberate suffering. Therapeutic regimes that do cause deliberate suffering may sometimes be rewarded by apparent success, which would tend to make the perpetrators continue in the same way.
So anyone who is made to suffer as a consequence of having symptoms, or who sees this happening to other patients, would be well advised to keep notes of the facts, make a formal written complaint as soon as they can, and pursue the matter until certain that the mistreatment of patients has been stamped out. Shocks, bullying and other aversive methods might be horrific for the victims, but they can be very rewarding for the perpetrators.