2010 Conference - Toward a Ttreatment Standard for Pathological Gambling (Hodgins)

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2010 Conference - Toward a Ttreatment Standard for Pathological Gambling (Hodgins)

  1. 1. David HodginsUniversity of Calgary NCRG, 2010
  2. 2. Descriptive Accounts Uncontrolled TrialsRandomized Controlled Trials (RCTs) - efficacy Effectiveness Trials/Mechanisms/Systems
  3. 3.  Does this work in the real world? •  Real clients, group vs. individual, therapists competence? How does it work? Can we make it more efficient or more effective? What place does it have in the overall range of treatment options?
  4. 4.  Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment
  5. 5.  Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment
  6. 6.  Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment
  7. 7.  Pallesen et al. (2005) •  22 uncontrolled and controlled studies, 1434 clients •  Large effect of treatment post-treatment and at follow-up (17 months), compared with no treatment
  8. 8.  Gooding & Tarrier (2009) •  25 CBT trials - very diverse •  Mode: Individuals, group, self-directed •  Therapy: CBT, Imaginal desensitization, CBT-MI combos •  Type of gambling: •  Length: 4 to 112 sessions (Median = 14.5) •  Large effects at 3, 6, 12, and 24 months •  Better quality studies, smaller effects •  File drawer effect – 585 studies required.
  9. 9.  Morasco et al., 2007- within treatment descriptions of what clients are doing Petry et al. (2007) – coping skills Hodgins et al., (2009)- Change talk in MI
  10. 10.  Nancy Petry’s 8 session CBT (Petry, 2005) Each session has a worksheet Overall goal is to improve coping skills Petry et al. (2007) – coping skills improvement does lead to better outcomes (i. e., effective ingredient)
  11. 11. Session 4 Session 8Social 26% 67%SupportGA/therapy 4% 43%supportCognitive 21% 31%skillsDistraction 45% 26%Avoid 40% 20%triggers
  12. 12. Specific day of the 33%weekMood- stressed, bored, 30%lonelyUnstructured time 27%Access to money 22%Gambling cue 19%A specific time of the 17%day
  13. 13. Action % of peopleNew activities/Change in focus 68%Stimulus Control/Avoidance 48%Treatment/GA support 37%Cognitive skills 34%Budgeting 31%Willpower/Decision-making/self-control 23%Social support 10%Others – confession, no money, non- <5%gambling external factors, self-reward,spiritual, addressing other addictions Hodgins et al., 2009
  14. 14.  Premise: what an individual says about change during MI is related to subsequent change Verbalizing an intention to change (CHANGE TALK) leads to public and personal obligation to modify one’s behavior
  15. 15. •  Coded therapy transcripts for ChangeTalk•  Does amount of Change Talk correlatewith change in gambling behavior? •  3 months r = -.39* •  6 months r = -.36* •  12 months r = -.35* * p < .05 Hodgins , Ching & MacEwan,, 2009
  16. 16.  Does MI reduce drop-out? Effectiveness of individual versus group formats? Potential role for desensitization? Does giving clients a choice of goals make a difference (Abstinence versus controlled gambling)?
  17. 17.  Large issue for CBT, GA, etc. Wulfert et al. (2006) pilot study Standard treatment dropout 34%, post- treatment SOGS = 10.4 CBT-MI dropout 0%, post-treatment SOGS 1.2 Subsequent CBT-MI combos – perhaps slight decrease in drop-out?
  18. 18.   MI (4 sessions)  Group CBT (8 sessions)  Waitlist  MI, GCBT > waitlist  Attendance •  Mi: M = 2.9 of 4 sessions (72%) •  GCBT: 5.6 of 8 sessions (70%) •  Mi: 43% attended all 4 •  GCBT: 29% attended all 8  More to learn – we need to do better with drop-out
  19. 19.  Dowling at al. (2007) women in CBT Oei & Raylu (2010) both genders in CBT- MI combo •  Treatment manual Slightadvantages for 1:1 Implications?
  20. 20.  Not all CBT is the same •  Relative focus on cognition versus behaviour •  Behaviour – coping skills from alcohol literature (Petry) •  Desensitization from anxiety literature (Dowling, Blaszyzcnski, Battersby) Systematic and graded exposure to cues to gamble – imaginal, in vivo, or both McConaghy et al., 1983 – Imaginal > in vivo, aversion
  21. 21.  GA referral MI plus Imaginal desensitization •  6 sessions plus audiotape Post-treatment abstinence- GA- 17%, MI/ ID- 63% Is this an effective ingredient? Battersby in vivo model – well described in Oakes at al., (2010)
  22. 22.  Alcohol field – appropriate goal for less severe dependence, more socially stable clients; people choose appropriately over time Some studies offer this (e.g. Hodgins)
  23. 23.  Dowling at al., (2009) 12 session CBT Abstinent goal Cut down goal Post treatment – 84% 83% no diagnosis Six month – no 89% 83% diagnosis Depression 8.9 7.1 (BDI) Gambling 0.3 0.5 frequency
  24. 24.  Toneatto & Dragonetti (2008) CBT (8 sessions) •  Abstinence goal – 35% Twelve-step facilitation (8 sessions) •  Abstinence goal – 96% No difference in treatments Clients choosing abstinence had more severe problems, attended more treatment, and were more likely to meet their personal goals at 12 mos.
  25. 25.  Ladouceur at al. (2009) CBT (12 sessions) aimed at control No diagnosis – post treatment -63%, six months- 56%, 12 months -51% 66% shifted goal to abstinence, more likely to meet their goal Offering choice did not seem to reduce dropout. (31%)
  26. 26.   People do move towards the appropriate goal – does offering goal choice increase treatment seeking?  Moving in the right direction in terms of offering better treatments, that people stick with. •  Both RCTs and effective studies are useful  Treatmentsystem issues largely unaddressed - < 10% treatment uptake – how do we get people to participate in self- directed recovery or attend treatment?

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