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Thomas Nilsson - Treatment Online, Does it work?

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Treatment online? Does it work for problem
gamblers?

Thomas Nilsson, C. Psychologist
Email: thomas@silabs.se

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Talk about
Online self help programs for problem
gamblers – past present and future

How does it work?
Does it work?

If o...

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What I like
Accessible
Easy to use
It is something in between
prevention, self help and treatment
It reduces barriers to t...

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Thomas Nilsson - Treatment Online, Does it work?

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Thomas Nilsson's presentation on "Treatment Online. Does it Work for Problem Gamblers?" Part of a joint-presentation with Dr. Richard Wood. Presented at the New Horizons in Responsible Gambling conference. January 28-30, 2013 in Vancouver, BC.

Thomas Nilsson's presentation on "Treatment Online. Does it Work for Problem Gamblers?" Part of a joint-presentation with Dr. Richard Wood. Presented at the New Horizons in Responsible Gambling conference. January 28-30, 2013 in Vancouver, BC.

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Thomas Nilsson - Treatment Online, Does it work?

  1. 1. Treatment online? Does it work for problem gamblers? Thomas Nilsson, C. Psychologist Email: thomas@silabs.se
  2. 2. Talk about Online self help programs for problem gamblers – past present and future How does it work? Does it work? If online self help programs/treatment programs is the future, what will they look like?
  3. 3. What I like Accessible Easy to use It is something in between prevention, self help and treatment It reduces barriers to treatment We meet a new group of PG You can try and try You can follow your own progress Coast are low
  4. 4. It already started back in 2000 We where working on developing the national help line for problem gamblers in Sweden. We wrote a self help book for problem gamblers 2000 to 2002. Then we meet professor Per Carlbring (www.carlbring.se) who is an world leader in treatment online and made the book into a online self help program with CBT therapeutic support. We got financial support from The Swedish National Public Health Institute. Then we started 2004!
  5. 5. Our work is inspired by: •  Theories on dependencies – gambling, alcohol, drugs… •  Bandura, Jacobs, Hodgins, Ladoucuer, Heaster & Miller… •  CBT in general and for depression and anxiety in particular •  Work and theories around motivational interviewing (MI) •  Clinical experience •  What works! The self help online program is inspired from: •  Becoming A Winner: Defeating problem Gambling a gambling self-help manual. Hodgins and Makarchuk Gambling research project, University of Calgary and Addiction Centre- Calgary Regional Health Authority •  The self help manual is evaluated by professor, Per Carlbring, Clinical psychology, University of Umeå, Sweden, his Background colleagues and students
  6. 6. For the patient: •  Read and do exercises described in the module •  Provide answers to essay questions via e-mail •  Post a comment on a bulletin board •  Talk to a CBT therapist on the phone for approximately 25 to 30 minutes/week For the therapist: •  Therapists judge if a patient is ready to go to the next module, and gives feedback A typical week in the program
  7. 7. Modules 1- 4 lead to a decision: Stop all together or cut down? Modules 5 - 8 are the actual treatment: Information – e.g. luck, random Cognitive restructuring Risk situations – stopping impulses Sort out the economic situation Filling the void with meaningful activities Pace: One module per week In total eight (8) treatment modules
  8. 8. •  NODS •  MADRS-S •  HADS-anxiety/-depression •  QOLI •  Help seeking behaviour •  Social situation, education, work etc •  Us of alcohol and drugs •  Readiness to change questionnaire The screening is made via the •  Self reported gambling (like frequency, magnitude, computer online intensity, etc) •  Jacobs five questions (dissociation) •  And more (in total 99 questions) Screening and decision – yes or no
  9. 9. Gambling background Consequences - economic, relations, health… Function -positive/negative reinforcement in short/long term Present state - Why treatment now? - Actual gambling behaviour? - Expectations and goals? Gambling free periods - coping strategies First telephone session with therapist
  10. 10. Module 1 Module 2 Texts about: Last three gambling situations: • How an addiction develops • Triggers, thoughts, feelings before and after gambling • Characteristics for addictions Questions about: • Wins and losses last 30 days of • Values and life goals gambling • Costs per month and year • Positive and negative consequences from gambling • Why gambling
  11. 11. Module 3 Module 4 Ask a family member or a dear About: friend: •  Acceptance and mindfulness - how has my gambling affected as a tool me? •  The importance of - how has my gambling affected acceptance for the losses you? •  Dreams of big wins • Advantages and disadvantages with either continuing or stop The contract with yourself – stop / gambling control? • Make a decision whether you want Tell families and friends about your to change gambling behaviour or not gambling problem
  12. 12. Module 5 Module 6 • Alternative activities • Make a plan to avoid relapse • Common negative thoughts • Ask family and friends for help • Miss consumptions about chance • Strategies for handling urges and luck • Exercise can be an alternative • Erroneous beliefs about gambling
  13. 13. Module 7 Module 8 • Listing your debts • Reward yourself for job well done • Making a plan for paying • Laps and relapse back • A plan for change • Strategies to control your economic • Look back on goals and contract • More support?
  14. 14. •  Listen, respect and follow each individual •  Show empathy, normalize •  Reinforce, give hope, encourage •  Encourage self reinforcement •  Increase self confidence/self efficacy •  Encourage acceptance •  Reduce rumination- increase change of behaviour •  Share knowledge Key words - telephone support
  15. 15. •  NODS •  HADS •  Quality of Life Inventory •  Self reported gambling •  Questions on how they experienced the treatment, contact with the therapist, etc Follow up – post, 6 months, 18 and 36 months
  16. 16. What at do they think about the program? • Talk to the therapist • The content was spot on • Anonymous • Internet is everywhere anytime • Those with social phobia • There are no treatment where they live • The forum • Working on there own (most clients spend between 2-5 hours/week) Client information
  17. 17. Problem games Participants • VLT • Mean age: 33.2 • Internet poker • Male: 81 % • Female: 19 % • Poker • Started playing regularly at 23.7 yrs • Trotting • Problematic gambling since 5.70 yrs • Casino Internet • Debts: M=1354 CAD From the screening
  18. 18. Screening n=464 Excluded n = 148 Pre treatment data n=316 Never showed up n = 32 Started treatment n=284 M 1: n = 275 Post treatment data: n=219 M 2: n = 214 M 3: n = 186 6 month follow up data: n=197 M 4: n = 174 M 5: n = 158 18 month follow up data: n=181 M 6: n = 150 M 7: n = 147 36 month follow up data: n=196 M 8: n = 148 No M: n = 9 Follow up - population
  19. 19. Measure Mest SDest dest NODS Pre 8.16 2.48 Post 2.09 2.78 2.31 6 2.16 2.95 2.21 18 2.25 3.07 2.13 36 2.04 2.98 2.24 HADS-A Pre 11.0 4.38 Post 7.25 4.85 0.81 6 6.56 5.11 0.93 18 6.29 5.33 0.97 36 6.35 5.24 0.96 HADS –D Pre 9.12 3.39 Post 5.53 4.36 0.86 6 4.87 4.60 0.99 18 4.89 4.79 0.97 36 5.05 4.74 0.94 QOLI Pre 0.30 1.72 Post 1.14 1.94 0.46 6 1.37 2.04 0.57 18 1.50 2.12 0.62 36 1.24 2.07 0.50 Results – some screening instruments
  20. 20. Success? Out of the 196 clients 77 (40 %) was regarded as successful. They meet following criteria on the 36 month follow up: • 0 points on NODS • no gambling the last month
  21. 21. References Carlbring, P., Smit, F. (2008). Randomized Trail of Internet-Delivered Self-Help With Telephone Support for pathological Gamblers. Journal of Consulting and Clinical Psychology Degerman, N. (2010). Internetbaserad självhjälpsbehandling i kombination med telefonstöd vid spelmani - En effectiveness-studie på kort och lång sikt samt prediktion av behandlingsutfall, avhopp från behandling och återfall. Linköpings Universitet. Institutionen för beteendevetenskap och lärande. Psykologprogrammet. Statens Folkhälsoinstitut. (2010). Internetbaserat självhjälpsprogram för spelberoende. Slutrapport. Carlbring, P., Degerman, N., Jonsson, J., & Andersson, G. (2012). Internet-Based Treatment of Pathological Gambling with a Three-Year Follow- Up. Cognitive Behaviour Therapy. Link:http:// dx.doi.org/10.1080/16506073.2012.689323 Gainsbury, SM & Blaszczynski, A (2011) 'A systematic review of Internet-based therapy for the treatment of addictions', Clinical Psychology Review, vol. 31, no. 3, pp. 490-498. Clinical Psychology. Available at: www.elsevier.com/ locate/issn/02727358Publisher's version of article available at http://dx.doi.org/10.1016/ j.cpr.2010.11.007
  22. 22. Gambling – the future is already here Accessible Digital Innovative Interactive Global
  23. 23. Responsible gambling is evolving Player education Links to treatment/forums Voluntary/obligatory Setting limits Self test Self exclusion Block your self Behavioural tracking systems Research Obligatory player card? Proactive approach to PG?
  24. 24. In the future? Online (treatment) programs – therapist no therapist Forums – large online communities. No secrets! Player card connected to both online and “live” gambling Gaming will be included in gambling – more sophisticated and “internet smart” group More focus on the player and player experience - smarter information, more proactive support teams, more interactive and multi channelled information with the players
  25. 25. Support online - what's next? Our (SI) next step is to test (during 2013) an self help program online using the knowledge, experience and research we done so far. This is how we think: • Exclude live therapist and include therapist role in the program • Develop screening and create individual “playlists” • Motivation loop • Relapse button • Evaluation • Cooperate with large forums • Player education (version 2.0)
  26. 26. Brand new! This is version 1.0 of our totally interactive self help program for problem gamblers. Launched January 2013 and research is in progress.
  27. 27. Wow! Looks simple?
  28. 28. Looks simple 2
  29. 29. Looks like this
  30. 30. What next? •  Online gambling is growing, so must online support •  Integration with gaming companies, direct links from games to support •  Integration of different online services •  Technology can not be un-invented and the Internet is impossible to fully control. But technology can and does offer some solutions
  31. 31. For every complex problem there is an easy answer, and it is wrong. H.L Mencken THANKS!

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