2010 conference - toward a ttreatment standard for pathological gambling (hodgins)
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David Hodgins University of Calgary
NCRG, 2010
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Effectiveness Trials/Mechanisms/Systems
Randomized Controlled Trials (RCTs) - efficacy
Uncontrolled Trials
Descriptive Accounts
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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?
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Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment
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Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment
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Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment
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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
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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.
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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
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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)
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Session 4 Session 8 Social Support
26% 67%
GA/therapy support
4% 43%
Cognitive skills
21% 31%
Distraction 45% 26%
Avoid triggers
40% 20%
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Specific day of the week
33%
Mood- stressed, bored, lonely
30%
Unstructured time 27% Access to money 22% Gambling cue 19% A specific time of the day
17%
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Action % of people
New 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-gambling external factors, self-reward, spiritual, addressing other addictions
<5%
Hodgins et al., 2009
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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
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* p < .05 Hodgins , Ching & MacEwan,, 2009
• Coded therapy transcripts for Change Talk • Does amount of Change Talk correlate with change in gambling behavior?
• 3 months r = -.39* • 6 months r = -.36* • 12 months r = -.35*
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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)?
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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?
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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
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Dowling at al. (2007) women in CBT Oei & Raylu (2010) both genders in CBT-
MI combo • Treatment manual
Slight advantages for 1:1 Implications?
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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
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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)
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Alcohol field – appropriate goal for less severe dependence, more socially stable clients; people choose appropriately over time
Some studies offer this (e.g. Hodgins)
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Dowling at al., (2009) 12 session CBT Abstinent goal Cut down goal
Post treatment – no diagnosis
84% 83%
Six month – no diagnosis
89% 83%
Depression (BDI)
8.9 7.1
Gambling frequency
0.3 0.5
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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.
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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%)
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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
Treatment system issues largely unaddressed - < 10% treatment uptake – how do we get people to participate in self-directed recovery or attend treatment?