8th European Conference on Gambling Studies and Policy Issues Cognitive-Behaviour Therapy for problem gamblers: characteristics of treatment completer’s and non- completer’s Dr Barry Tolchard, University of Essex, U.K. Wednesday – 15 September 2010
Gambling before CBT • Freud – gamblers were trying to punish themselves for their unresolved oedipal urges and that this meant they were deliberately trying to lose • Bergler – “…the gambler is not a weak person who wants to gain money [easily]…but a neurotic with an unconscious wish to lose”
Cognitive-Behavioural Theories (CBT) of gambling • A number CBT models have been described – e.g., Petry, 2005; Sylvain, et al., 1997; Toneatto, 2002 – no single unified approach has been tested and the efficacy of CT continues to be debated • Sharpe and Tarrier (1993) — CBT model – incorporating relaxation, exposure and cognitive restructuring – while cited frequently – reservations must exist lack of empiricism – generalisation to all gambling problems is limited
Blaszczynski and Nower (2002) • Pathways 1. behaviourally conditioned problem gamblers – a purely conditional response resulting in common gambling behaviours such as chasing losses 2. emotionally vulnerable problem gamblers – relationship between pathway 1 and various vulnerability markers, and 3. anti-social, impulsivist problem gamblers – elements of pathways 1 & 2 but including specific personality issues of impulsivity and anti-social behaviour. • Bio-psycho-social model 1. ecological determinants – related to availability and access to gambling opportunities 2. the role of classical and operant conditioning – where subjective excitement, dissociation and increased heart rate create an urge to gamble leading to habitual gambling behaviour and, 3. cognitive schemas – resulting in irrational beliefs that gambling is an effective source of income
CBT and gambling: early behavioural techniques • Aversion techniques (AT) – e.g., Barker & Miller, 1968; Cross, 1966; Koller, 1972; Seager, 1970 – the evidence for such approaches can only be described as circumstantial at best • Imaginal Desensitisation (ID) – McConaghy, and colleagues(1983 — 91) • Shown to be superior to AT and two forms of exposure • serious flaws in the research, most notably in the incorrect use of exposure, which was prescriptive rather than response dependent • success rate of ID due to the exposure element alone and that the relaxation component is unnecessary
CBT and gambling: exposure therapy • Exposure therapy has been shown to be effective in a small number of studies – e.g., Echeburúa, et al., 1996; Hodgins, et al., 2004; Tolchard & Battersby, 2000/2010; Symes & Nicki, 1997 – Echeburúa et al., 1996 — RCT • exposure was shown to be superior to a wait list control, individual cognitive restructuring and a combined cognitive restructuring and exposure group – Tolchard & Battersby (2000 & 2010) — naturalistic study • reported 70% success with exposure • not controlled and the efficacy of exposure was not tested against any other approaches • common protocol was followed for all participants • similar results were found in other reports – E.g., Kushner, et al., 2007; Oaks, et al., 2008; Tolchard, et al., 2006
Cognitive-Behaviour Therapy (CBT) and gambling: cognitive techniques • Ladouceur et al. (1996 — present) – common misunderstandings about crucial elements of games of chance which lead to • a) an overestimation of the chance of winning, • b) belief that skills influence outcome and • c) erroneous beliefs of independent events and randomness – therapeutic approach • education regarding chance and randomness • challenge clients’ erroneous beliefs in treatment sessions • encouraging stimulus control and avoidance of gambling cues (anti- exposure) • total number of improved clients rarely reaches 50% • anti-exposure element may be one reason for these results • introduction of exposure as behavioural experiments may prove to be more effective
Cognitive-Behaviour Therapy (CBT) and gambling: cognitive techniques • Petry (2005 — present) – reinforcement of non-gambling activities – form of activity diary to monitor their gambling and non- gambling days – encouraged to select from a range of reward options which increase with longer periods of abstinence – avoidance is encouraged and increasing pleasurable non- gambling activities are introduced – relaxation is taught to reduce gambling urges – cognitive restructuring takes place • relies on a very loose understanding of CBT – anti-exposure is encouraged in the form of urge avoidance
Cognitive-Behaviour Therapy (CBT) and gambling: cognitive techniques • Variants of CBT – Wulfert et al. (2003) • 1) MI, 2) CBT and, 3) relapse prevention – Griffiths (1993) • Audio-Playback – speak their thoughts aloud during play which are then recorded – listen back to the recordings give opportunity to consider process of thinking while gambling
CBT and gambling: efficacy • Systematic reviews – Pallesen et al., 2005; Toneatto & Ladouceur, 2003 • Both support CBT • confirm that methods based on exposure have the highest effect sizes for efficacy at follow-up
CBT and gambling: efficacy Trial Sylvain, Ladouceur, Tolchard & Ladouceur Petry (2005) Ladouceur, Sylvain, Battersby, et al. (2003) & Boisvert, Letarte, (2000) (1997) Giroux, & Jaques (1998) Completion (%) 64 59 81 87 61 Success (%) 36 42 72 77 49
Treatment failures • explanations for treatment failure include; 1. clients being motivationally unprepared for therapy 2. therapists being inadequately trained in the therapeutic approach or not adhering to the treatment protocol 3. ineffective treatments being used and 4. costs and availability of receiving treatment
Types of failure • three main groups 1. do not attend the initial screening or assessment appointment (DNA) 2. drop-out after assessment (DO-A) and, 3. drop-out during treatment (DO-T) • a fourth group may also be considered 4. drop out in follow-up (DO-FU)
Treatment failures in gambling treatment • Melville, Casey, & Kavanagh, 2007 – summarise the results of 12 published works • drop-out ranges from 14 to 50% • median drop-out of 26% • increasing to 31% when calculated as a weighted average – 10 used CBT and two were based on self-help and Gamblers Anonymous – CBT median drop-out rate of 32% vs. 22%
Definitions of failure • Ladouceur, et al., 2003 – treatment completer to be least three sessions • Robson, Edwards, Smith, & Colman, 2002 – Considered this a DO-T
Characteristics of failures • Mixed evidence has been found – demographic • Age • Employment status – Gambling specific • Age of onset • Time spent gambling – Co-morbidity – Personal factors • ‘loss of the thrill’ • continue to believe they can still win
Flinders approach • State-wide gambling service providing; – Out-patient, in-patient and group programmes • Five components to the out-patient treatment: 1. Assessment and stimulus control (sessions 1 – 2) 2. exposure (imaginal and in-vivo) (sessions 3 – 10) 3. cognitive re-appraisal (sessions 6 – 10) 4. relapse prevention (sessions 9 – 10) 5. Follow-up (at 1-, 3-, 6- months and 1 year)
Measures • Demographic and gambling 1. BreakEven Questionnaire (BEN-Q) 2. Victorian Gambling Screen 3. South Oaks Gambling Screen • Psychopathology 1. Beck Depression Inventory 2. Beck Anxiety Inventory and, • Disability 1. Work & Social Function Scale
Treatment status • 205 gamblers presenting to an out-patient service – DO-A 21% – DO-T 9% – C’s 70%
demographics
Main Form of Gambling (n=205) • Gaming Machines 88.5% • TAB/Racing Codes 7.7% • Casino Games 3.8% – Female gamblers were over-represented in the Gaming machine group (95%) and male gamblers in the horse racing group (23%)
demographics • Gender (M 42% vs. F 58%) – DO-A (M 39% vs. F 61%) – DO-T (M 61% vs. F 39%) – C (M 41% vs. F 59%) • Expected ratio in DO-A/C • Men more likely to discontinue treatment
demographics • Current age showed no differences • DO-As never married; DO-T/C were married or divorced • DO-T higher levels of employment
Level of gambling • No difference on SOGS scores • More variation on VGS • Helped make decision to drop SOGS • Replace with VGS / PGSI
Gambling severity • ? DO-Ts similar to OCD • Gambling as a ritual — neutralising the urge • Exposure removes ritualistic elements — increases urge • Altering treatment so the eventual increase in urge is dealt with differently
Gambling behaviour • Financial frequency may be more about a strength of belief • Cs have a greater variation in gambling frequency • DOs longer history of gambling
Psychopathology
Relationship between anxiety and depression • increase in depression scores impacted on the level of anxiety • reflected the resolve of the gamblers to remain in treatment • strongest in the DO-A group ( r = .75) vs. DO-T ( r = .53) & Cs ( r = .53)
Disability
Summary of findings
Summary of findings
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