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?
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
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.
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
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)
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
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
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
• 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
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)?
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?
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
Dowling at al. (2007) women in CBT Oei & Raylu (2010) both genders in CBT- MI combo • Treatment manual Slightadvantages for 1:1 Implications?
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
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)
Alcohol field – appropriate goal for less severe dependence, more socially stable clients; people choose appropriately over time Some studies offer this (e.g. Hodgins)
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
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.
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%)
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?