Behav. Res. & Therapj.

1975. Vol. 13. pp. 309-319. Pcrpmon

Press. Punted in Great Bntam

AVERSIVE AND POSITIVE CONDITIONING TREATMENTS OF HOMOSEXUALITY* N. MCCONAGHY School of Psychiatry.

University of New South Wales. Kensington. and Behaviour Prince Henry Hospital. Little Bay. N.S.W.. Australia (Received 25 September

Therapy

Unit

1974)

Summary-Thirty-one male homosexual patients were randomly allocated to receive either aversive therapy. in which unpleasant shocks were associated with pictures of nude males; or positive .conditioning, in which pictures of nude women were associated with similar pictures of men and later with pictures of heterosexual relationships. The patients were further randomly allocated to receive either procedure according to a forward or backward conditioning paradigm. Before, 3 weeks and 1 yr following 5 days of treatment. the patients were shown a film containing at I-min intervals IO-set segments of pictures of nude women or men. During this and all treatment procedures their penile volume responses were measured. The positive conditioning technique proved ineffective and hence acted as a placebo treatment control for the aversive therapy. Patients reported significantly greater reduction in homosexual feelings and behaviour following the latter. After both the aversive and the positive conditioning technique, patients showed significantly less penile volume increase to the pictures of men. There was no trend for this change to be greater following aversive therapy. It was concluded that this therapy reduced the secondary reinforcement value of homosexual stimuli but did not alter sexual orientation.

Therapists who developed aversive techniques for treating homosexuality had as a basic aim not only reduction of the patients’ homosexual feelings and behaviour but also the establishment of or increase in their heterosexual feelings and behaviour. Commonly, techniques additional to the aversive procedure were employed in the hope of achieving this. Freund (1960) followed a series of trials associating homosexual stimuli and nausea produced by apomorphine, with giving his patients 10 mg testosterone and 7 hr later showing them films of nude or semi-nude women. In each treatment session of the aversion-relief procedure of Thorpe et al. (1964) a series of homosexual stimuli were administered, each associated with a painful electric shock. These were followed by a heterosexual stimulus which was not associated with a shock. The expectation was that the relief produced by the appearance of this stimulus would give it a positive quality. This use of heterosexual stimuli during the aversive procedure to signal the onset of a period during which electric shocks would not be administered, was also an important part of Feldman and MacCulloch’s (1965) technique, aimed at increasing the patient’s heterosexual orientation. In a series of studies, McConaghy et al. (1969. 197Oa, 1972, 1973) compared the procedures of Thorpe et al. and of Feldman and MacCulloch with the apomorphine aversive phase only of the treatment introduced by Freund, and with an aversive procedure based on classical conditioning, in which homosexual stimuli were associated with painful electric shocks. There were no significant differences between the changes in heterosexual feelings or behaviour following the four treatments. This suggests that the association of heterosexual stimuli with periods of freedom from shock during an aversive procedure does not increase heterosexual behaviour. In these studies an attempt was made to develop an objective measure of change in sexual feelings. Before and after treatment, the penile volume changes of all patients were recorded while they were shown a film containing moving pictures of nude women and men. After treatment the summed penile volume responses of the patients to the pictures of the nude women were greater than those before treatment. This was due to the fact that almost half the homosexual patients showed a mean negative penile volume response to the pictures of women before treatment. Following treatment, this negative response was * This study was made possible by the National Health and Medical Research provided a grant for the salary of a research assistant, Mr. A. Blaszczynski. 309

Council

of Australia,

which

310

N. MCCCXAGHI

significantly reduced. There was no increase in the penile volume response to the pictures of women in the patients who showed a positive response to these pictures prior to treatment. The significance of the negative penile volume response to pictures of the non-preferred sex is not established. It has been found in most heterosexuals (McConaghy, 1970b; Barr and McConaghy, 1971) and was interpreted as evidence of a negative sexual reaction. Freund et al. (1973) found no difference in the penile volume response of both heterosexual and homosexual subjects to pictures of nudes of the non-preferred sex compared with those to colour slides of landscapes. but did not make clear whether the responses were negative. They concluded that there is no aversion to pictures of nudes of the non-preferred sex. These findings require replication but if correct suggest that the reduction in the negative penile response of homosexual patients to pictures of women following aversion therapy does not indicate a decrease in aversion. It could be due to habituation of a response to a novel stimulus, i.e., the nude or a landscape, which would be expected when the material is viewed a second time. Penile volume increase to pictures of nude women is associated with heterosexual feelings (Freund, 1963; McConaghy, 1967). The failure of patients following aversive therapy to show augmentation ofthisresponse suggests that the procedure does not increase heterosexual feelings. However, in the studies by McConaghy rr al., reported above. following the various forms of aversive therapy, approximately half the patients reported an increase in heterosexual feelings, and one quarter an increase in the frequency of heterosexual intercourse. These latter patients usually had experience of heterosexual intercourse prior to treatment. Less than 10 per cent of patients treated initiated such sexual behaviour in the year following treatment. It was suggested (McConaghy and Barr, 1973) that aversive therapy did not produce an increase in heterosexual feeling. but a reduction in homosexual feeling. This led to patients being more aware of and activated by their previously existing heterosexual feeling, which they therefore experienced as being increased. If aversive therapy does not increase heterosexual feeling. it is of no value to the patient with little or no feelings of this nature who seeks treatment primarily in order to establish them. The development of behavioural treatments which can accomplish this is therefore indicated. Barlow (1973) has reviewed studies in this area but finds no convincing evidence yet advanced that the techniques used were effective. One of these was the pairing of heterosexual with homosexual stimuli in a classical conditioning procedure. This has so far been used in only a few patients, and Barlow considers that it is likely to be effective. In the present study a technique of this nature is compared with a classical aversive procedure. METHOD

Thirty-one homosexual patients referred for behavioural treatment were randomly allocated to receive either aversive therapy or classical positive conditioning. Some patients expected to receive aversion therapy. All were informed that the aversive procedure had in previous studies not increased heterosexual feelings as much as was hoped and an alternative therapy was being investigated with the expectation that it would shift the patients’ sexual feelings from a homosexual towards a heterosexual orientation. They were informed that if they wished to accept treatment they would be allocated without choice to one of the two procedures, and also to either receive or not receive &monthly booster treatments. They could terminate the treatment at any stage but would be expected to return 1 yr following its commencement for follow-up interview and assessment. If they accepted these conditions they were to pay a bond of 530.00 which would be returned to them at the completion of the follow-up interview. Also at this interview they would be informed of what had been learned as to the value of the two treatments. If they wished and it seemed appropriate they could then receive the alternative treatment. Each patient was admitted to hospital for 5 days for initial investigations and treatment.

The patient first viewed the film referred to, containing moving pictures of nude men and women. Pictures of circles precede those of the women and of triangles those of the

Conditioning treatments of homosexuality

211

men. Conditioned responses occur to these figures, from which a measure of each patient’s appetitive conditionability is derived (McConaghy. 1970b). A procedure measuring aversive conditionability was then administered. During both these investigations and throughout ail treatment procedures, the patient’s penile volume and galvanic skin response were continuously recorded on a Grass 5B polygraph. Details of the investigations and method of scoring the responses have been described previously (McConaghy. 1967; Barr and McConaghy, 1972).

All patients were shown 60 slides of nude or partially clothed male children. adolescents or adults. some with penile erections. Patients having positive conditioning were also shown 30 slides of nude or partially clothed young adult women. Each slide was shown for 10 sec. While viewing it, the patient scored his sexual response as marked. moderate. slight or none. At the same time his penile volume and galvanic skin reponse were recorded. For all patients.12 slides of males, and for those receiving positive conditioning 12 of females were selected to which the patient reported the greatest subjective response and showed the greatest penile volumeincrease. The 12 slides of males and females were randomly divided into three groups of 4. In each treatment session one set was used in turn, so that the same set of slides was shown in every fourth treatment session. Aversive treatment

The patients were randomly allocated to receive the treatment according to a forward or a backward conditioning paradigm. In each treatment session the patient was shown one of the selected sets of 4 slides of males. Each slide was shown for 10 set at approximately 3-min intervals. With the forward procedure, during the final second of exposure of each slide and for 1 set folowing, the patient received a painful electric shock to the fingers. With the backward procedure, the shock was also of 2 seconds’ duration but preceded the onset of the slide by 1 sec. Shocks consisted of I-msec pulses delivered from a Grass S4 stimulator at the rate of 100 pulses per set to the tips of the index and ring fingers of the left hand through 1.5cm solder electrodes coated with electrode jelly. The patient selected the level of shock used. and was instructed that it should be definitely unpleasant but not emotionally upsetting. Each was asked to rate its intensity on an imagined scale on which 0 was imperceptible and 10 unbearable. Most chose a level of shock which they rated as 7. Throughout the treatment they were regularly questioned concerning the intensity of the shock and reminded that it should conform to the above instruction. The level of shock used ranged from 30-100 V. Posirive co~7ditiafr~flg

The patients were randomly allocated to receive the treatment according to a forward or a backward conditioning paradigm. In the forward conditioning treatment sessions the patients were shown one of the selected sets of 4 slides of women. Each slide was shown for 10 set at approximately 3-min intervals. In the first seven treatment sessions these were immediately followed by a slide from the selected sets of 4 slides of men. Prior to the eighth treatment session a further slide selection procedure was carried out. The patients were shown 60 slides with heterosexual content, such as men and women fondling each other’s genitals. genital apposition in intercourse, heterosexual fellatio or an opened vulva. The 12 slides to which the patient reported the greatest subjective response and showed the greatest penile volume increase were then substituted for the slides of men in the next seven treatment sessions. This change was made with the hope of taking advantage of any arousal to heterosexual stimuli.which had been produced in the first seven sessions. The patients could respond both to the homosexual and heterosexual content of these slides. Also the introduction of new material was expected to reduce the effects of satiation from repeated viewing of the homosexual slides used in the first seven sessions. With backward conditioning the procedure was the same except that the pictures of the women immediately followed rather than preceded those of the men or of the heterosexual

312

N. MCCONAGHY

scenes. Two slide projectors and a special shutter were employed with both the forward and backward technique so that there would be no time interval between the paired slides. All patients received 14 sessions of treatment during the 5 days in hospital. They returned 3 weeks later for a further film assessment and interview. Those who were allocated to receive boosters and wished to continue treatment repeated the slide selection procedure and then received a treatment session similar to that given in hospital. They were asked to attend at monthly intervals for the next 5 months for further treatment sessions. Those not receiving boosters were asked to attend interviews at similar intervals. After 6 months all patients were asked to continue attending for interviews at 2-3 monthly intervals until their final assessment 1 yr following treatment when they had a third film assessment. At all interviews the patients were questioned about their current sexual feelings and behaviour. The interview was conducted in a supportive manner and no disapproval was shown if the patients reported homosexual experiences, except for discussing possible dangers, particularly legal ones, where these seemed likely. The basic aim was to help the patient clarify his own wishes about changes in his behaviour, rather than to encourage him necessarily to maintain the goals with which he entered treatment. All patients completed the sessions of treatment in hospital and attended the l-month follow-up assessment. Of the 16 patients allocated to receive boosters. 7 decided against this. Both had felt more tense and depressed since receiving treatment. The remaining 14 attended for an average of 4 booster sessions. only 5 receiving all 6. Of the total group of patients all but 3 attended the follow-up assessment at 1 yr. One of these was in Canada but wrote reporting his response at this time. The patient group

As in previous studies (McConaghy et al., 1970a, 1972, 1973) all persons conscious of homosexual feeling who wished to have this reduced or eliminated and who were not overtly psychotic were accepted for treatment. The majority were referred by other psychiatrists. Their ages ranged from 15 to 45, with a median of 23 yr. Five were married and one divorced. Three had been charged in the past with homosexual offences, two on 4 occasions. One was referred by his solicitor, but claimed he wanted treatment in any case. The 5 married men were having regular heterosexual intercourse, four with their wives and one, who was separated, with another woman. One of the 5 professed no interest in this sexual relationship and all 5 were having regular homosexual relations. Fourteen further patients had experienced heterosexual intercourse. In all but 5 this experience had not occurred in the year preceding treatment. Fourteen patients were having regular homosexual relations until commencing treatment and a further 7 had had such relations in the preceding 6 months. Three patients had never had homosexual relations and a further 6 none for over a year. These patients were all distressed by the intensity of their attraction to males.

RESULTS

Reported

subjective

response

to therapy

Table 1 summarizes the feelings and behaviour reported by patients at 3 weeks and 1 yr following the initial week of treatment. The estimation of change in heterosexual and homosexual desire was based on the patient’s awareness of the amount of sexual interest in men and women and the amount and nature of sexual fantasy, including masturbatory fantasy. Sexual relationships reported are those occurring in the 3 weeks following treatment and in the period 612 months following treatment. Relationships in the period up to 6 months after treatment were not included in the final assessment as some patients were continuing their booster treatments during this time. At 3 weeks following treatment there was little difference between the positive conditioning and aversive procedures in regard to the reported increase in heterosexual feelings or behaviour. At 1 yr the difference was still not marked, but the increase was greater following aversive therapy.

Conditioning

Table

I. Reported

subjective

treatments

responses

313

of homosexuality

at 3 weeks and I year after behaviour

therapy

KETZRCS_L Desire Inonassd

..

Possibly

incrcarrsd

Unchanged

. .

Possibly reduced

. .

1

..

2

. .

5

..

0

Reduced

. .

. .

0

unknc.vn

..

. .

0

*Relations since

treatment

Inersased

..

. .

“nchmged

. .

..

2 1

Reduced

..

. .

0 4

NolIe,

unclL¶n@cl

. .

None,

reduced

..

1

. .

0

“nknnm

. .

“O”csFmAL Desme Increased

. .

Possibly mcrasaed UllChllgd

. .

Possibly reduced

..

0

..

1

..

1

. .

I

Reduced

..

..

5

None

. .

..

0

. .

..

0

“tiam

sinca traatmant

lRelatio¶!s Increas*d

. .

. .

0

“IWlWlgd

. .

. .

2

Reduoed

..

..

0

None,

“nchanpd

. .

1

mm,

redu0.d

. .

5

. .

II

“n!ulnn

. .

At 3 weeks there was a statistically significant tendency for more patients to report a definite reduction in homosexual feeling following aversive as compared with the positive conditioning procedure (p = 0.05, Exact Test). This was paralleled by the former group of patients reporting less homosexual experience in the 3 weeks following treatment, though this trend is not statistically significant. At 1 yr the trend for more patients to report reduction in homosexual feeling after the aversive procedure as compared with positive conditioning was still present, but not statistically significant. Significantly more patients having homosexual relationships prior to treatment had reduced or ceased these by this time following the aversive as compared with the positive procedure (p = 0.05,Exact Test). More patients reported increased heterosexual feelings at 3 weeks following backward as compared with forward positive conditioning, but this trend was no longer present at 1 yr. There were no other marked differences between the response to these two procedures. Though there was little difference at 3 weeks following treatment. there was a trend at 1 yr for more patients to report an increase in heterosexual desire and behaviour and a reduction in homosexual feelings following forward compared with the backward

N. MCCONAGHV

314

aversive procedure. There was little difference this time between the two procedures.

in the change

in homosexual

behaviour

at

Penile aolurne resporlse,folloM~ing therap~~ In assessing sexual orientation, 10 moving photos of women and 10 of men were shown to the subjects. It had been found previously (McConaghy. 1970a) that the most reliable measure of the resultant penile volume changes was that obtained by testing the difference between the 10 volume responses to the pictures of the men and the 10 to the women, using the Mann-Whitney U-test. This provided a U-score for the assessment of each patient’s responses which approached 100 the more his penile responses to the female photos exceeded those to the male photos. and approached 0 the more the responses to the male photos were greater. U-scores of 23 or less and 77 or more indicate a statistically significant difference at the 5 per cent level (two-tailed). Both at 3 weeks and 1 yr after treatment the U-scores of the patients who attended for assessment changed in the heterosexual direction to a statistically significant degree (P < 0.05, Wilcoxon test of paired replicates). The summed penile volume responses of each subject to the male nudes in the film assessment were significantly reduced at 3 weeks and 1 yr after treatment (p < 0.05, Wilcoxon). There was no significant change in the summed penile volume responses to the female nudes following treatment. When the patients were separated into those who showed a mean positive change to these nudes prior to treatment and those who showed a mean negative change, both these changes were significantly reduced following treatment. There was no significant difference between the change in U-scores either at 3 weeks or 1 yr following treatment in those patients who received aversive as compared with those who received positive conditioning. DISCUSSION

Comparison

of aversive treatment

and positive conditiorling

The response to aversive therapy in this study was similar to that found in the previous ones (McConaghy et al., 197Oa, 1972, 1973). At 1 yr following treatment. approximately half the patients reported a possible or definite increase in heterosexual feeling and a decrease in homosexual feeling and behaviour. Approximately one quarter reported an increase in heterosexual intercourse and a cessation of homosexual relations. There was no evidence that positive conditioning produced a greater increase in heterosexual feelings and behaviour than did the aversive treatment. In fact at 1 yr following treatment. there was a trend in favour of the latter therapy. More patients reported reduction of homosexual feelings and behaviour following the aversive as compared with the positive procedure. This trend was statistically significant as regards the reduction in feelings reported at 3 weeks and the reduction in homosexual relations reported at 1 yr following treatment. It would appear that the positive conditioning procedure produced no specific effect on sexual feelings and behaviour. It has been argued previously (McConaghy, Procter and Barr. 1972) that aversion therapy produces a reduction in homosexual feelings but no actual increase in heterosexual feelings. as after it patients do not show greater penile volume increase to pictures of nude women. The increase in heterosexual feelings and behaviour reported by patients following aversion treatment was attributed to their increased awareness of previously existing heterosexual feelings, when their homosexual feelings were reduced. If this is correct, then the fact that after the positive conditioning procedure the patients reported less increase in heterosexual feeling and behaviour than after the aversive procedure, indicates that the positive procedure does not specifically increase heterosexual feelings and behaviour and that the increase reported must be regarded as a placebo effect. This conclusion is consistent with the reported increase in heterosexual feeling and behaviour being no greater following the forward than the backward positive conditioning procedure. If these procedures were producing specific effects by conditioning, the forward

Conditioning

treatments

of homosexualit)

315

procedure should be more effective (Pavlov. 1927; Franks, 1958). Furthermore. there was no evidence of conditioning occurring with these two procedures. With the forward positive conditioning, the mean penile volume response of the 8 subjects to the first (unreinforced) presentation of the slide of a nude female was - 1.74; the mean of the responses to the last 12 (reinforced) presentations of these slides was -0.15. This change was not statistically significant. Though the trend was in the positive direction. only one of the 8 subjects in fact showed a mean positive penile volume at this time, as against two at the first presentation. What occurred was a reduction in both the positive and the negative penile volume changes to the pictures of nude women with repeated presentation. a change similar to that found in the second film assessment. as compared with the first, and presumably due to satiation. With backward conditioning there was also no significant change to the slides of nude women. The mean penile response of the 7 subjects to the presentation of the first slide was 0.62 and to the last 12 presentations, 0.5. Five of the 7 subjects allocated to backward conditioning showed mean positive penile volume changes to the first presentation of the slide of a nude woman. This could be due to the fact that this slide was preceded by that of a nude male. With the forward procedure of course this was not the case. There was no indication of a reduction in the unconditioned penile volume response throughout the two conditioning procedures. The mean response of the total group to the first presentation of the male slide was 2.80 and to the final 12 presentations of the heterosexual relationships, 3.03. Conditioning of the increase in penile volume to pictures of male nudes shown by homosexuals has been reported to occur to pictures of preceding green triangles. when both sets of stimuli are presented in movie film form (McConaghy, 1967). Failure of conditioning to occur with the forward conditioning procedure in this study could be due to the fact that the stimuli were presented as still slides. It was found in a subsequent experiment that heterosexual subjects show much greater unconditioned penile responses to moving pictures as compared to still slides of nude women. Equally they show much better conditioning to a geometric figure that precedes the moving pictures as compared to one preceding the still slides (McConaghy. 1974a). It is likely that this would be equally true of homosexual males, in relation to still and moving pictures of nude men. However, if the author’s conclusion referred to earlier is correct, and many homosexual males show an unconditioned penile volume decrease to pictures of nude women. to attempt to reverse this by setting up a conditioned penile volume increase may be difficult, as appetitive conditioned responses are weaker than the unconditioned responses on which they are based (Pavlov, 1927). Measurement of se.uual orientatiorl

in relatiorl

to treatment

In two previous studies (McConaghy et al.. 1970a. 1972) there was a significant relationship between change of the U-score to the film assessment at follow-up and reported reduction in homosexual feeling. In a further study (McConaghy and Barr, 1973) there was a trend in this direction but it was not statistically significant. In the present study there was no such trend, either for patients receiving aversive or positive conditioning. Less patients attended for follow-up film assessment in the previous studies-32 and 33 of 40 and 33 of 46 respectively as against 28 of 3 1 in the present study. However, any resultant variation in the composition of the groups would be insufficient to account for the difference in the presence or absence of this finding. It would seem most likely that the significant relationship in the first two studies was a chance false-positive error. The frequency with which such ‘Type I’ errors occur in research and the necessity for replication to eliminate them has been repeatedly stressed by the author (McConaghy and Lovibond, 1967; McConaghy, 1970~ 1974b). This relationship between change in U-score and in homosexual feelings with aversive treatment was considered evidence of the validity of the change in U-score as a measure of response to such treatment (McConaghy, Procter and Barr, 1972). Clearly this argument can no longer be maintained now it has been found that the change in U-score is the same whether the patient receives an ineffective treatment or an apparently effective one.

N. MCCONAGHY

316

The significance of the change in U-score cannot be determined at present. The possibility that it is due to repeated exposure to the film was considered to be excluded in the first two studies (McConaghy et al.. 1970a. 1972). In these. half the patients were randomly allocated to ‘immediate treatment’. and half to ‘delayed treatment’. With immediate treatment the patients were initially assessed with the film, received treatment, and were reassessed with the film 3 weeks later. With delayed treatment the patients were assessed with the film twice at a 3-week interval before receiving treatment. In this way the changes in the responses to the film with treatment intervening in the immediate treatment group could be compared with the changes due to watching the film twice without treatment. in the delayed treatment group. In both studies a significantly greater change in U-score in the heterosexual direction occurred with the second assessment in the treated as compared to the control group. Whether this was also a chance finding or whether factors associated with having a treatment procedure, effective or otherwise, influenced the response on the second occasion cannot be determined without further evidence. If the change in response is affected by a treatment procedure. it cannot be attributed to the effect of viewing a number of pictures of nude men and women. i.e.. to some form of satiation. In the first study (McConaghy, 1969) the change was the same with a treatment in which the patients were shown such material as with one in which the sexual arousing material was written phrases. The U-score derived from a subject’s penile volume response to the initial viewing of the film used in these studies is a valid measure of his sexual orientation (McConaghy, 1967; Barr and McConaghy, 1971). The fact that in the present study the change in U-score on the subject’s second viewing of the film following treatment was the same for aversive treatment as for the ineffective positive conditioning procedure, means either that the Uscore derived from this second viewing is not a valid measure of sexual orientation or aversive therapy does not change sexual orientation. U-scores before and 3 weeks after treatment are presented in Table 2 for 18 patients treated with aversive therapy for sexual deviations other than homosexuality. Eight were exhibitionists, 4 predominantly heterosexual paedophiliacs, 2 transvestites and 2 fetishists, one had bondage fantasies and one pathological jealousy. They were treated with apomorphine aversion or aversion-relief similar to that used in the treatment of homosexuals in the author’s earlier studies. It will be seen that though the U-scores before treatment discriminate these patients from the homosexual patients in the present study better than do the scores following treatment, the latter are still highly significantly related to the patients’ known sexual orientation. Hence if the change in sexual feelings and behaviour produced by aversive therapy included a change in sexual orientation this change should be reflected in the U-scores on this second assessment. The change in U-scores from the first to the second assessment would be expected to differ significantly in patients receiving aversive therapy as compared with those who received the ineffective positive conditioning. The fact that it did not suggests strongly that aversive therapy as used in this study did not alter sexual orientation.

Table

2. U scores

before

and after

aversive treatment patients

of homosexual

and non-homosexual

” a.zczree c-23

23.5-50

50-16.5

77-100

Total

Conditioning

treatments

of homosexuality

317

QTecr qf'aversivr tlrrrap?

Compared with positive conditioning, aversive therapy was followed by a statistically significant reduction in reported homosexual feelings at 3 weeks and in homosexual behaviour in the period from 6 months to 1 yr. In view of the evidence discussed above that this therapy did not produce a change in sexual orientation. were these changes in homosexual feeling a specific effect, or could they be due to suggestion‘? That is to say, could aversive therapy. presumably because of the associated electric shocks. have a significantly greater suggestibility effect than positive conditioning’! If this is so. it means that this enhanced suggestibility was still operating 1 yr after treatment, which seems unlikely. The only other study comparing aversive therapy with a presumably ineffective control conditioning procedure not employing electric shocks also reported a marked diminution in homosexual feelings and behaviour following the aversive as compared to the control procedure, the difference in reduction in homosexual behaviour over the following year being statistically significant (Birk et al.. 1971). These workers also reported that over half the patients who received the aversive conditioning. reported a striking change in their sexual feelings and behaviour in that there was a marked diminution in their homosexual urges and feelings which enabled them to abstain from homosexual behaviour without effort. This parallels the author’s experience (McConaghy. 197Oa) that following this treatment patients reported a marked reduction in preoccupation with homosexual thoughts and an ability to control desires to make homosexual contacts which they previously experienced as uncontrollable. In view of the regular association of homosexual stimuli with aversive sensations in this treatment, if it acted by suggestion one would expect patients to report following it not merely a reduction in homosexual feeling but some negative reaction to homosexual stimuli. Certainly most lay people who have heard of the treatment consider it will produce this type of response, a view widely promulgated by Anthony Burgess (1972). In the author’s experience it is rare for patients to report such negative reactions following treatment, nor are such responses commonly recorded in the literature. In view of the lack of aversion following this therapy, the term ‘aversion’ therapy is misleading and ‘aversive’ therapy would seem preferable, as the use of aversive stimuli is invariable. The possibility that aversive therapy produces its effects through enhanced suggestibility would seem unlikely but cannot be excluded until definite evidence is available that it does act specifically. A similar consideration of course applied to any form of therapy shown to be more effective than a control procedure. unless one can be confident that both therapy and control procedure have equal effects on the patients’ suggestibility.

It has been argued (McConaghy, 1969; McConaghy and Barr, 1973) that aversive therapy does not act by means of aversive conditioning. In the present study during the forward aversive procedure, a conditioned G.S.R. was set up to the male slides similar to the unconditioned G.S.R. to the electric shock which followed their presentation. The squareroot conductance change both to the mean of the 2nd to 12th and the 21st to 32nd presentation of the male slides was significantly greater (Wilcoxon test of paired replicates) than that to the 1st presentation {i.e.. prior to reinforcement). The mean G.S.R. to the 45th to 56th pre~ntation was also greater than that to the first presentation, but not to a significant extent. The G.S.R.s to the male nudes in the second film assessment (i.e., following treatment) were not significantly reduced in the patients who received forward and backward aversive treatment but were in those who received positive conditioning (p < 0.05, Wilcoxon test). This could suggest that a conditioned G.S.R. was present in the former group, but not in the latter, whose G.S.R. therefore was reduced by habituation. This finding would need replication before it could be accepted. Hallam. Rachman and Falkowski (1972) found no evidence of conditioned G.S.R.s to fantasy stimuli in patients following aversive therapy as compared to a control group. However, their results are not strictly comparable as they used a different measure of G.S.R.

N. MCCOKAGHI

318

There was no trend for a conditioned negative penile volume response to be set up to the presentations of the male slide during forward aversive therapy similar to the response produced by the following shock. The majority of patients continued to show penile volume increases to the male slides throughout the treatment, and there was no significant tendency for these responses to diminish. This was a somewhat unexpected finding, as patients who received both positive conditioning and aversive therapy showed a significant reduction in penile volume response to the male nudes in the second film assessment compared with their response in the first. The reduction was significantly greater in the patients who received forward aversive therapy than in those who received the other forms of treatment (p = 0.01, Mann-Whitney U-test). This seems almost certainly a false-positive finding, as in a previous study (McConaghy and Barr, 1973) there was no trend for patients who received aversive therapy in forward conditioning paradigms to show greater reduction in this response with the second film assessment. compared to the group who received backward conditioning. If any of these findings prove capable of replication and so demonstrate that conditioned responses are set up following some forms of aversive therapy. this does not invalidate the major argument (McConaghy and Barr. 1973) against the theory that aversive therapy acts by conditioning. In our present state of knowledge this explanation is ruled out by the demonstration that aversive therapies administered in a backward conditioning paradigm are not markedly less effective than forward conditioning forms. It was suggested (McConaghy, 1969) that a more satisfactory mode of action of aversive therapy could be found in the description of animal behaviour following the setting-up of an experimental neurosis. Pavlov (1927) reported that when an attempt was made in a dog to establish a difficult differentiation between a circle and an ellipse with ratio of semi-axes 9: 8, the animal lost its ability to make much simpler differentiations. This means that previously established learned connections associated with the differentiation no longer determined the animal’s behaviour. Pavlov attributed this change to a conflict in the nervous system between the excitatory process associated with the reinforced circle and the inhibitory process associated with the unreinforced ellipse. The alternation of excitatory male slides and inhibitory electric shocks in aversive therapy would produce a similar conflict, and hence a similar experimental neurosis. After aversive therapy for homosexuality patients report less preoccupation with homosexual thoughts and a weakening of compulsions to become involved in homosexual activity which in the past they found were activated by passing locations, such as lavatories or parks, where they had regularly carried out such activity. This would result if these stimuli lost their secondary reinforcing property previously built up by association with homosexual gratification. Such associations would become inoperative following an experimental neurosis of the type described by Pavlov. If all stimuli built up over years of homosexual experience lost their secondary reinforcing properties in this way, patients could well experience this as a weakening of homosexual feelings and interest, even if their sexual orientation remained unchanged. Psychiatric

symptomsfbllowing

hehaviour thcrap~~

In the year following aversion therapy, it has been reported (McConaghy and Barr, 1973) that a small number of patients showed depressive reactions. These patients had shown similar symptoms prior to treatment and it was considered they were not ‘symptom substitutions’. In the present study 4 patients were admitted to psychiatric units for periods of up to 6 weeks in the year following behaviour therapy. All had previously received psychiatric treatment. Thfee of the 4 had positive conditioning and were admitted following drug over-dose, for depression, and for a schizophrenic reaction, respectively. The fourth received aversive therapy and was admitted following a drug over-dose. Ten patients were receiving psychotropic medication prior to behaviour therapy and all had greatly reduced or ceased this medication at 1 yr follow-up. One patient was drinking heavily prior to aversive therapy and ceased this but required Valium 10 mg daily for a period at 1 yr following the therapy. The fact that psychiatric symptoms were more marked following the ineffective positive conditioning procedure supports the conclusion that aversion therapy is not followed by

Conditioning

treatments

of homosexuality

319

substitute symptoms. This lack of evidence of any general disturbance of behaviour following aversion therapy indicates that if the hypothesis advanced is correct and this therapy acts by setting up an experimental neurosis. this is limited to homosexual behaviour. Evidence of this possibility exists in Pavlov’s description (1927) of ‘abnormal foci’, where the disturbance consequent on production of an experimental neurosis remained strictly localized. Value of behaviour therapy in homosexuality If aversive therapy reduces the secondary reinforcement properties of stimuli associated with homosexual behaviour this both limits and defines the type of patient most likely to be helped. Clearly this therapy will not be of use if the patient is almost exclusively homosexual and seeks treatment to become more heterosexual. It will be of value to such patients if they consider they are excessively preoccupied by homosexual fantasies or compelled to become involved in behaviour they find guilt provoking, distasteful, dangerous, or excessively time-consuming. Some patients for example complain that they cannot concentrate on their work due to such preoccupations or spend hours daily unsuccessfully seeking homosexual experiences. Equally, it will be of value to bisexual patients who have similar problems or who consider their marriage threatened by such behaviour. Frequently these patients report that their heterosexual relations are enhanced following aversive therapy, presumably secondarily to the reduction in homosexual feelings. Clearly, further research is required to determine whether any forms of behaviour therapy can increase heterosexual feelings directly. REFERENCES BARLOW D. H. (1973) Increasing heterosexual responsiveness in the treatment of sexual deviation: A review of the clinical and experimental evidence. E&u. Therapy 4, 65s671. BARR R. F. and MCCONAGHY N. (1971) Penile volume responses to aooetitive and aversive stimuli in relation to sexual orientation and conhitioning performance. B;. J. Psychi:;. 119, 377-383. BARR R. F. and MCCONAGHY N.71972) A general factor of conditionability: A study of galvanic skin responses and penile responses. Brhav. Res. & Therapp 10,2 15277. BIRR L.. HC’DDLESTONW., MILLER E. and COHLER B. (1971) Avoidance conditioning for homosexuality. Arch. gen. Psychiat. 25,314323. BURGESSA. (1972) A Clockwork Orange. Penguin Books. Hammondsworth. FELDMAN M. P. and MACCULLOCH N. J. (1965) The application of anticipatory avoidance learning to the treatment of homosexuality. Theory, technique and preliminary results. Behav. Res. & Therapy 2, 16>183. FRANKS C. M. (1958) Alcohol, alcoholism and conditioning: A review of the literature and some theoretical considerations. J. mem. Sci. 104, 14-33. FREUND K. (1960) Some problems in the treatment of homosexuality. In Behaviour Therapy and the Neuroses (Ed. H. J. EYSENCK). Pergamon Press, Oxford. FREUND K. (1963) A laboratory method for diagnosing predominance of homo- or hetero-erotic interest in the male. &hat,. Res. & Therapy 1, 85-93. FREUND K.. LANGEVIN R., CIBIRI S. and ZAJAC Y. (1973) Heterosexual aversion in homosexual males. Br. J. Psq’chiat. 122, 163-169. HALLAM R.. RACHMAN S. and FALKOWSKI W. (1972) Subjective. attitudinal and physiological effects of electrical aversion therapy. Behau. Res. & Therapy IO, I-13. MCCONAGHY N. (1967) Penile volume change to moving pictures of male and female nudes in heterosexual and homosexual males. Behar. Rex & Therapy 5, 43-4X. MCCONAGHY N. (1969) Subjective and penile plethysmograph responses following aversion-relief and apomorphine therapy for homosexual impulses. Br. J. Psychiut. 115, 723-730. MCCONAGHY N. (1970a) Subjective and penile plethysmograph responses to aversion therapy for homosexuality: a follow-up study. Br. J. Psychiat. 117. 555-560. MCCOXAGHY N. (1970b) Penile response conditioning and its relationship to aversion therapy in homosexuals. Behar. Therapy 1, 213-221. MCCONAGHY N. (197Oc) Results of systematic desensitization with phobias re-examined. Br. J. Psychiat. 117, 89-92. MCCONAGHY N. (1974a) Penile volume responses to movmg and still pictures of male and female nudes. Arch. Sex. Brhac. 3. 565-570. MCCONAGHY N. (1974b) Evaluation of behaviour therapy. Behac. Science Tape Library, New York. MCCONAGHY N. and BARR R. F. (1973) Classical. avoidance and backward conditioning treatments of homosexuality. Br. J. Psychiat. 122, 151-162. MCCONAGIIY N. and LOVIBOND S. H. (1967) Methodological formalism in psychiatric research. J. nerv. r?lerlt. Dis. 144, 117-123. MCCONAGHY N.. PROCER D. and BARR R. F. (1972) Subjective and penile plethysmography responses to aversion therapy for homosexuality: a partial replication. Arch. Sex Behav. 2. 6>78. PAVLOV I. P. (1927) Condirimed R&rc~s (Tr. and Ed. C. V. ANREP). Oxford University Press. Oxford. THORPE J. G.. SCHMIDT E., BROWN P. T. and CASTELL D. (1964) Aversion-relief therapy: a new method for general application. Behac. Rrs. & Therapy 2, 71-82.