How to use aversion therapy effectively

Some hypnotherapists frequently use mildly aversive techniques such as 'fork in the road' or stronger ones such as asking those who wish to quit smoking to imagine their own deathbed scene. Others use aversion techniques sometimes, or never.

It seems unethical to deliberately upset your clients or scare them witless unless there's evidence to prove it's helping them, so I went looking for this evidence. I found very little, but what I did find might surprise you.

What is aversion therapy?

Aversion therapy means associating an unwanted behaviour (like smoking) with unpleasant experiences so that it's easier to stop. So, how is this supposed to work?

Behavioural psychology tells us that if we do something and the consequences are pleasant, we'll more than likely want to do it again. If we do something and the consequences are unpleasant, we'll probably try to avoid a repeat. Of course, there is much more to behaviourism than that, but I'm sure you get a general idea.

The Mayo Clinic[1] says that nicotine increases the release of dopamine, a neurotransmitter that makes you feel good. Smokers also associate smoking with specific activities, relaxing, socialising, 'me time' and so on, which make it a pleasant experience for them. These create positive associations with smoking which helps make it hard to quit*.

(*Before anyone goes scrolling straight down for the comments box, I appreciate that there are many more factors involved, and that the 'enjoyment' may only be perceptual: as with behaviourism, space here demands a fairly reductionist argument. Anyway, in the end, isn’t it the client's perception that matters?)

 

Does aversion therapy work?

Firstly I have to admit I couldn’t find any studies comparing hypnotherapy that included or did not include aversion techniques. That's an idea for someone who fancies doing some research, I suppose. However, there are some studies on aversion therapy used with smokers in other therapeutic modalities. Generally, these involve either rapid smoking or pairing smoking with mild electric shocks, nausea or both.

In 2011, Hajek and Stead[2] searched the Cochrane Tobacco Addiction Group specialised register for studies that looked at aversive smoking cessation methodologies. They, unfortunately, decided that there was a "relative absence of small studies with negative results … most trials had a number of serious methodological problems likely to lead to spurious positive results" (p3-4). In other words, most of the studies were biased or too badly designed to be reliable. However, outside of that particular resource, there are a few studies that show more useful results.

• According to Nigel Barber in Psychology Today[3], "after the After Shick-Shadel aversion therapy (Ed: a combination of electric shocks and nausea), 52.5 per cent of 327 people were still off tobacco after a year … Other studies of aversion therapy produced more modest results."
   
• In June 2012 a meta-analysis study published in The American Journal of Medicine[4] reported that when compared to smokers attempting to quit without any therapeutic or chemical assistance (NRT etc), alternative quit-smoking treatments improved the success rate by factors of:
  • Acupuncture 3.53
  • Hypnotherapy 4.26
  • Aversion therapy 4.55

The use of aversion techniques within a hypnotherapy session wasn't recorded but this does give some credibility to the idea that it can help our clients.

 

How much aversion does it take?

I've always felt - and told my students - that if you are going to use aversion based hypnotherapy with smoking clients, you really have to go for it. Don’t pussyfoot around but make it as strong as you can. This is based on my own feeling that smokers must be pretty good at ignoring negative messages about smoking, since they are on every pack and most of the TV ads. I am gratified to say that I found some evidence to support this.

• The 2011 Hajek and Stead report mentioned above cited an efficacy figure of 14% for rapid smoking and 7% for "milder versions of aversion smoking" (page 6). Although they were not confident that the figures were reliable the difference is big enough that it probably does indicate that stronger methods have more effect.
   
• Dinh-Williams et al (2015)[5] compared MRI scans of smoker's brains when they were exposed to aversive images about smoking, aversive images about other issues and images likely to trigger an appetite to smoke. They found that their brains were less stimulated by the aversive smoking images than by the other two types.

 

Should hypnotherapists use aversion therapy?

Hajek and Stead seem to me to support my theory that you are better using strong aversive stimuli than milder ones. The Dinh-Williams study offers one explanation of why this might be; that smokers seem to react less to smoking-related aversion than they do to other kinds of aversion or (most importantly for us) the triggers that encourage them to smoke. It also makes sense that it would be easier to apply this insensitivity to milder forms of aversion than stronger ones.

As hypnotherapists, we, therefore, need to consider our aversion approach carefully.

• The goal of aversion therapy is to create explicit negative associations with smoking which are powerful enough to overcome any positive ones smokers already have
• Strong aversion is probably more effective than milder forms because smokers are insensitive to negative messages about smoking
• It needs to be combined with other, non-aversive ways of dissociating smoking from pleasure, which may avoid the barriers which protect smokers from taking in negative information about smoking

  

So, will I be changing my policy and using strong aversion for everyone? I have to say it, no. I don’t think there is any technique which suits literally every client. Each quit smoking session should be unique to the client you are working with, including as many elements of their lives as possible - their hopes and dreams as well as their fears. But I now have some facts on which to base what was, before, only an intuitive decision.

 

Now, hypnotherapists, over to you.

How do you use aversion? Always? Sometimes? Never? Just for smokers or for other issues too? Does this article change any of your thoughts? What’s your go-to aversive technique?
Please post in the comments box.

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Author: Debbie Waller is Senior Tutor At Yorkshire Hypnotherapy Training, which offers multi accredited hypnotherapy practitioner training in Wakefield and York, along with taster days and foundation levels. Debbie has written a chapter on working with IBS in The Hypnotherapy Handbook, aimed at students and newly qualified hypnotherapists and also offers supervision and continuous professional development (CPD) for those in practice. Please contact Debbie to find out more.

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References:
 
[1]   Butler, Alia. (2015) 'Aversion Therapy and Smoking'. Livestrong.com http://www.livestrong.com/article/131926-aversion-therapy-smoking/, accessed Dec. 2015
[2] Hajek P, Stead LF. 'Aversive smoking for smoking cessation.'  Cochrane Database of Systematic Reviews  2001, Issue 3. Art. No.: CD000546. DOI: 10.1002/14651858.CD000546.pub2.  http://www.ncsct.co.uk/usr/pub/aversive-smoking-for-smoking-cessation.pdf, accessed Dec. 2015
[3] Barber, Nigel (2010) 'Smoking: Most effective quitting technique little known.' Psychology Today Blog https://www.psychologytoday.com/blog/the-human-beast/201002/smoking-most-effective-quitting-technique-little-known, accessed Dec. 2015
[4] Carol (2012) 'Alternative Acupuncture & Hypnosis Can Help You Quit Smoking' Addiction Rehab Now,  http://addictionrehabnow.com/acupuncture-hypnosis-helps-quitting/, accessed Dec. 2015
[5] Dinh-Williams Laurence, Mendrek, Adrianna, Bourque, Josiane, & Potvin, Stéphane (2014) "Where there's smoke, there's fire: The brain reactivity of chronic smokers when exposed to the negative value of smoking." Progress in Neuro-Psychopharmacology and Biological Psychiatry Volume 50, 3 April 2014, Pages 66–73 http://www.sciencedirect.com/science/article/pii/S0278584613002881 accessed Dec. 2015