Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Treating Problem Gamblers: Basic Notions and Avenues to Reduce Drop-outs


Published on

Current Trends in Treatment of Pathological Gambling -yleisöluento sekä työpaja terapeuteille 15.3.2016, Terveyden ja hyvinvoinnin laitos, Helsinki

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Treating Problem Gamblers: Basic Notions and Avenues to Reduce Drop-outs

  1. 1. Treating Problem Gamblers: Basic Notions and Avenues to Reduce Drop-outs Current Trends in Treatment of Pathological Gambling Terveyden ja hyvinvoinnin laitos, Helsinki, Finland March 15th and 16th, 20016 Robert Ladouceur, Ph.D. Professor Emeritus Université Laval, Québec, Canada
  2. 2. 2 Outline Section 1: 09.45 - 11.15 1. Why do people gamble? The basis of cognitive modification and the root or the common denominator of all erroneous perceptions. 2. Degree of conviction in their “erroneous” perceptions 3. Dissonance; The key factor in challenging conviction and motivation Section 2: 12.00 - 16.30 4. How to reduce drop-outs in the treatment of pathological gamblers? 5. Abstinence vs Controlled gambling as a treatment outcome 6. Case discussion from the participants and role playing
  3. 3. 3 Gambling 1. Individual must realize that he/she is putting money or a valuable object at risk, 2. Once bet, this money or valuable object is irreversible 3. The outcome of the game is determined by chance
  4. 4. 4 What is Chance or Randomness ? Chance An unpredictable event or accidental happening Randomness A method in which all possible events have equal probability of selection From an operational standpoint Impossibility of controlling or predicting the outcome of an event
  5. 5. Two different concepts, crucial to our understanding of gambling behavior Chance ß----------------------------------à Skills 5
  6. 6. 6 What is the difference between a game of chance and a game of skill? Ø Different criteria may be used to distinguish a game of skills from a game of chance. In a game of skill… • The more you play, the better is your performance • The more feedback you receive, the better is your performance • Practice increases your self-confidence
  7. 7. 7 What is a game of chance? Different criteria may again be used, but in a game of chance… Regardless of the time you spend practicing and studying the game, your performance will never improve !!!!
  8. 8. Main difference between the lottery and life ? « The big difference between Lotto and life is that in Lotto everyone has the same chance » Gerald Williams 8
  9. 9. 9 What is the difference between a game of chance and a game of skill? The main problem is that the gambler has a perception of skills where there is no skills at all involved. “What makes Lotto so charming and attractive for many players is the belief in having a personal influence-or so on thinks- on Lady Luck or Fortuna.” (Around the world in 80 games)
  10. 10. 10 What is the difference between a game of chance and a game of skill? In order to implement cognitive (…and behavioral) treatment, we need to clarify the level of chance and skill in each game with each patient.
  11. 11. Why do people gamble ? 11
  12. 12. 12 The paradox of Gambling Why do people gamble ? The necessary condition (may not be sufficient for all gamblers) is the possibility of
  13. 13. 13 Its the Money… Problem gambling is about money More specifically... loosing money No gamblers will seek treatment if they were always winning…. I am not saying that this is the only factor or problem, but it is the core cognitive problem to be addressed…
  14. 14. 14 The paradox of Gambling • Percentage of return on money gambled varies from place to place and from game to game • In all games, the return on money is always negative for the gambler
  15. 15. 15 The main (or one of the main) reason is... While gambling, most of us (if not all) misperceive or deny that the outcome of the game is based on the notion of Chance and Randomness
  16. 16. 16 One crucial answer is... We analyzed what people were saying to themselves while gambling. 0 20 40 60 80 100 Erroneous Adequate Perceptions
  17. 17. Our first practical exercise In small groups, I would like you to list the most frequent erroneous perceptions you hear from your patients (4 or 5). We will then write them on the board And I will ask you to find the common denominator at the root of these erroneous perceptions 17
  18. 18. 18 Theoretical Perspective Situation Triggers GamblingCognitive Variables Arousal
  19. 19. 19 •If erroneous perceptions are pivotal in understanding and helping problem gamblers, we should not forget their Degree of conviction in their erroneous perceptions is even more important.
  20. 20. 20 Degree of conviction in our erroneous perceptions
  21. 21. 21 What is the difference between a problem and a non problem gambler in terms of erroneous perceptions ?
  22. 22. 22 Method Participants • Adults meeting the DSM-IV diagnostic criteria for pathological gambling participated in this study Age: 40.6 years • Adults not meeting the DSM-IV diagnostic criteria for pathological gambling • Age; 38.1 years
  23. 23. 23 Procedure 1. Training in thinking aloud 2. Sequence of the game was preprogrammed and identical for all Ss 3. Rate of return was 92 %
  24. 24. 24 Method 1. All perceptions were tape-recorded 2. An independent judge rated the verbalizations according to 3 categories - Adequate: “It is all programmed” - Erroneous: “The machine is due” - Neutral: “I have a date tonight” 3. 20 % of the verbalizations were independently rated by a second judge.
  25. 25. 25 Results 1. % Erroneous perceptions • PG: 80.6 • NPG: 68.7 % p < .07 (n.s.) 2. Gambling related perceptions • PG > NPG p < .04 3. Conviction • PG > NPG p < .0001
  26. 26. 26 Results Degree of conviction 0 1 2 3 4 5 6 7 NPG PG
  27. 27. Non Pathological Pathological 1 2 3 4 5 Conviction measure 2,00 4,00 6,00 8,00 Estimatedmarginalmeans ] ] ] Group vs Conviction 5,00 3,00 7,00
  28. 28. 28 Degree of conviction in their erroneous perceptions is what needs to be challenged and modified How? By creating DISSONANCE not CONFRONTATION
  29. 29. 29 Difference between Confrontation and Dissonance CONFRONTATION: By using logical arguments, trying to demonstrate that the line of though of the patient is wrong (external process or the ping pong effect) DISSONANCE: By widening personal perception about a consequence in the patient, contradictory outcomes are created by the same behavior (internal process). In essence, who has to work harder, the therapist or the patient?
  30. 30. 30 Formal definition of Dissonance Dissonance Inconsistency between the beliefs one holds or between one's actions and one's beliefs —
  31. 31. 31 Dropouts
  32. 32. 32 Dropouts What is a drop out? Do gamblers drop out of Treatment ? What is dissonance ?
  33. 33. 33 About 30 % à 50 % of the gamblers will drop out of treatment. Is drop out a normal phenomenon ??? Yes, and lets try to explain and prevent dropouts.
  34. 34. 34 How do we explain drop out ? Few studies have examined this issue. Only one has directly investigated why people drop out of Tx (Grant et al, 2005)
  35. 35. 35 How do we explain drop outs ? Variables that distinguish treatment completers vs dropouts 1. Impulsivity (Leblond et al., 2003) 2. Co morbidity with alcohol and drug problems but not with motivation and participation in GA (Milton et al., 2002) 3. High level of anxiety (Escheburua et al., 2001) 4. Enjoyment in gambling et belief in personal luck (Hart et al., 2006)
  36. 36. 36 How do we explain drop outs? Grant, Kim & Kuskowski (2004) 50 gamblers seeking treatment (drug and psycho Tx) All met DSM-IV criteria for pathological gambling Contacted drop outs for an inteview Age M: 47.7 ans
  37. 37. 37 How do we explain drop outs? Grant, Kim & Kuskowski (2004) Non significant predictors of drop outs: 1. Sex 2. Age at the beginning of Tx 3. Age when the gambling problem started 4. Marital status 5. Severity of the problem 6. Amount of time gambling 7. Co mordibity
  38. 38. 38 How do we explain drop outs? Grant, Kim & Kuskowski (2004) Predictor of Tx adherence : Support from a collateral They contacted 21 of 24 drop outs: Predictors of drop out A) Lack of the thrill gambling B) Winning expectations and recoup the money lost (Chasing)
  39. 39. 39 How do we explain drop outs? How to use these information to reduce drop outs ? Thrill of gambling Motivational interview Winning expectations and chasing losses Cognitive correction. Warn the patient about this info Is drop out a normal phenomenon ??? Yes and we need to inform our patients
  40. 40. The first motivation to change needs to be challenged and reinforced for the good reasons How? By creating dissonance The next 3 slides will show how Stop gambling means...
  41. 41. 41 Phases of excessive gambling Tätä kuvaa ei voi näyttää tällä hetkellä.Tätä kuvaa ei voi näyttää tällä hetkellä. Wins Losses Despair
  42. 42. 1. RECOGNIZE and ACCEPT than money lost is lost forever 2. Declare yourself beaten by Gambling 3. Accept that you have lost an important activity 4. STOP thinking that gambling is the solution to your problems Needs to be emphasized 5. Plan a financial reorganization 6. Work hard in developing new coping strategies Stop gambling means...
  43. 43. A pivotal question… Do we sometimes accept for granted that the help requested by our problem gambler is the result of a profound and well balanced decision? How do we know and how can we verify this in order to HELP our patient? Key issue…
  44. 44. 44 Advantages & disadvantages Positive consequences of gambling Negative consequences of gambling Positive consequences of NOT gambling Negative consequences of NOT gambling
  45. 45. 45 Could offering controlled gambling as the main goal of therapy is a viable goal to help PG ? • Supported by a grant from the OPGRC (Rob Simpson, ceo) • Many thanks to Stella Lachance and Patricia- Maude Fournier
  46. 46. 46 Relevant and important questions related to the Tx of PG • How many individuals are pathological gamblers? • How many PG will seek treatment for their gambling problem? • Why some “obvious” PG do not seek help? • Which treatment should be offered to PG? • What should be the ultimate goal of the Tx?
  47. 47. 47 Prevalence of pathological gambling How many individuals will become pathological gamblers? Recent studies conducted over the last years show that less than 1% of the general adult population are classified or screened as pathological gambling.
  48. 48. 48 How many PG will seek treatment for their gambling problem? Less than 10 % PG will seek formal Treatment, Distributed over a 3 yr period
  49. 49. 49 Why some “obvious” PG do not seek help? Keep the fun and entertainment of gambling Recoup their losses Convinced that they can control their gambling habits but not have yet succeeded. So they keep trying…. And keep gambling…
  50. 50. 50 Which treatment should be offered to PG? Without hesitation, I will say…. Evidence based treatment
  51. 51. 51 What should be the ultimate goal of the Tx? Complete abstinence Abstinence on the problematic games and control over the others Control over both problematic games and others
  52. 52. 52 But without any doubt, offering controlled gambling instead of abstinence to help pathological gamblers to overcome their problem is a controversal issue A controversal issue…
  53. 53. 53 Controlled Gambling Rationale for control rather than abstinence as the main Treatment Goal for Pathological Gamblers Few pathological gamblers seek treatment; High dropout rates; Abstinence may not be the unique solution for all pathological gamblers; So, offering a goal of controlled gambling may bring ambivalent PG into treatment.
  54. 54. 54 Goal of the study To evaluate the viability (Myth or reality) of control in the treatment of pathological gamblers using a cognitive- behavior therapy.
  55. 55. 55 Controlled Gambling Inclusion criteria (a) Gambler’s objective: control not abstinence; (b) Primary diagnosis of pathological gambling; (c) No evidence of immediate suicidal intent; (d) No evidence of present and past psychosis; (e) Not already involved in another therapy for gambling problem.
  56. 56. 56 Defining Controlled Gambling Clinician and participants established a personalized treatment goal that is acceptable for PG in terms of (a) amount of money bet per session; (b) amount of money bet per week; (c) number of gambling sessions per week; (d) time (min/hours) spent on gambling per week The goals are accepted by both the PG and the Therapist
  57. 57. 57 Controlled Gambling Cognitive and behavioral Tx (13 weeks) (Tx Manual) § Motivation-confirmation of the personalized goal, § Analysis of a gambling session, § Identifying at-risk situations and implementing behavioral interventions, § Erroneous beliefs awareness training, § Cognitive correction of erroneous beliefs, § In vivo exposure under the therapist’s supervision, § Relapse prevention.
  58. 58. 58 Controlled Gambling-Measures Successful Outcome Controlled gambling Abstinence
  59. 59. 59 Initial Sample N = 89 Tx Completers N = 61 (69 %) Drop out N = 28 (31 %)
  60. 60. 60 Pre-test N=61 100 % Controlled 37 (61 %) 24 (39 %) Controlled Abstinence 36 (60 %) 24 (40 %) 38 (68 %) 18 (32 %) Post-test 6-month follow-up 12-month follow-up
  61. 61. 61 Implications All participants said that they would have not seek Tx if abstinence was the goal Working with a professional to help them control their gambling was a great experience PG shift to Abstinence on the basis of experience • Only 1/3 (N=21) kept control as a K outcome during the whole treatment, • so 2/3 “TRAVELLED” to abstinence Shift to Abstinence was based on informed consent and on a deliberate decision, never on Therapist’s advices or suggestions. WHY THEY SHIFTED TO ABSTINENCE?
  62. 62. 62 Conclusions • Drop out is a normal phenomenon • We do not have a definitive answer on how to eliminate it Some questions need to be asked • Do we pay enough attention to the need of the patient? • Are we flexible enough to adapt to the goals of the patient? • Do we influence the goal of the therapy?
  63. 63. Drop-outs and treatment of pathological gamblers Thank you very much Prof. Robert Ladouceur, Université Laval