best practices in the treatment of disordered …best practices in the treatment of disordered...
TRANSCRIPT
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Best Practices in the Treatment of Disordered Gambling
Lori Rugle, Ph.D., ICGCII, BACC Program Director, Maryland Center of Excellence on Problem Gambling
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OverviewOverview – individuals to systemsThe Usual SuspectsCommonalities Evidence based therapists or
therapies?Technology transfer: research to
practiceOut of silosROSC
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Priorities
Keep the client aliveKeep the client in treatment
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Treatments that have been applied
Psychodynamic12-StepBehavioral and Cognitive BehavioralMotivational and Brief InterventionsHarm ReductionPharmacotherapyMarital/familyFinancial Counseling Mindfulness Based
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Psychodynamic Approaches(Bergler, 1958; Rosenthal & Rugle, 1994)
Understand Meaning of GamblingHistorical ConnectionPsychological Defenses, Self-
Deception and DenialTransference and Counter-
transference Reactions
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Meaning of Gambling
ExcitementRebelliousness and AngerFreedom from DependencySocial AcceptanceEscape from AffectHope
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Twelve Step Approaches Social Support and Fellowship
– Understanding and Acceptance– Decrease Shame and Isolation
Structured Recovery Program Amends and Restitution Spirituality as Recovery Tool Self-Change and Self-Forgiveness VA Study – 74% of pts. Attending GA
abstinent vs. 42% of those not attending GA (Taber et al 1987)
12 Step = CBT (Toneatto & Dragonetti, 2008)
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Cognitive Model – Individuals who gamble problematically have erroneous beliefs about gambling based on false assumptions and biased information processing
Irrational Thoughts– Illusions of Control
Ladouceur et al., 1998; Petry, 2000– Irrational and Distorted Thinking
Breen et al., 1999; Ladouceur & Walker, 2000– Superstitious Beliefs
Tonetto et al., 1997; – Interpretive Biases
Attribution, Gambler’s Fallacy, Near Misses
Cognitive Behavioral Therapy
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Irrational Ideas about Gambling Held by Some Gamblers.
1. Gambling is an easy way to earn money 2. I can win it back 3. I’m smart; I have a system to beat the odds 4. Gambling will be the solution to my problems 5. Gambling makes me feel better 15. Money is my problem 6. I will pay it back 7. Stealing to gamble isn’t really stealing 8. The more money I have to gamble with the more I can
win 9. Even if I only have a few bucks, I’m better off taking a
shot at winning[Adapted from “In the Shadow of Chance,” and Internet book by Julian I. Taber, 1998.]
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Cognitive Interventions
– Correct Erroneous Beliefs
– Cognitive Restructuring to correct cognitive distortions and biases
Cognitive Behavioral Therapy
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Behavioral Model
–Behavioral Model based on view of gambling as a learned maladaptive behavior.
– Interventions use classical and operant conditioning techniques to reduce the excitement, arousal and cravings linked with gambling
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Behavioral Model
Specific Intervention Strategies–Exposure-extinction strategies– Imaginal desensitization –Problem Solving and Coping Skills–Relapse Prevention
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Imaginal Exposure Individual Script: Describe a situation where you
typically would engage in gambling. Describe exactly what you imagine happening
step-by-step and your urge to gamble. Describe as many details about the experience as
possible, including all your senses, what you imagined/or did see, hear, smell etc.
If relevant, would you be using alcoholic, drugs, smoking etc.
What physical symptoms are you aware of (e.g., rapid heart rate, sweating)
What negative consequences do you anticipate from gambling.
Imagine coping with the urge to gamble and resisting gambling.
Consider the positive consequences of not gambling.
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Symptoms: Record all symptoms that accompany this feared situation.
Difficulty breathingNausea/abdominal distress
Muscle tension Other
Racing/pounding heart
Chest pain/discomfort
Dry throat
Choking sensation Hot/cold flashes Restless/pacing
Numbness/tingling Sweating
Shakiness/trembling
Faint/dizziness
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Imaginal Exposure Rating FormDate (Exercise)
Pre-tape Urge Peak Level of Urge
Post-tape Urge
Practice 1 (am)
Practice 2 (am)
Practice 1 (pm)
Practice 2 (pm)
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Imaginal Desensitization + MI(Jon Grant)
Session 1: MISession 2: FinancesSession 3: Behavioral InterventionsSession 4: Imaginal ExposureSession 5: Cognitive TxSession 6: Relapse PreventionSession 7: Family Session (Optional)
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Relapse Prevention
Identify triggers (Trigger timeline)Functional AnalysisBrain storming alternative responses
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Impulse to Action Circle
Perceptions
Thoughts
FeelingsWantsand
Needs Optionsand
Choices
Valuesand
Decision
Action
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Motivational Interventions
Interventions based on enhancing client’s presenting level of motivation
Help individuals explore and resolve ambivalence
Client centered approachStudies have shown (Hodgins et al,
2002; Petry et al., 2008) significant gambling reduction with brief motivational interventions
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Four General Principles
Express EmpathyDevelop DiscrepancyRoll with ResistanceSupport Self-Efficacy
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Life Goals
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MI Techniques
Open-ended questionsAffirming strengths and choicesReflective listeningEliciting change talk
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Mindfulness Based Relapse Prevention
Change relationship to gambling thoughts
Coping with cravingsSelf-awarenessAffect toleranceDecrease impulsivitySelf-compassion(Bowen, Chawla & Marlatt, 2010;Toneatto et al., 2007)
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Common Factors
Structure from chaos Increase self-awareness and insightDefine risk factors and vulnerabilities
(triggers)Provide alternative responses
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Dual Motivation for Seeking PG Counseling ( Carnie, 2007)
Internal Experience of
Shame
Belief that it isHard to disclose To others in own
network
Motivation forUnderstanding and
support
Motivated to Seek counseling
GamblingProblem
RecognizedMotivation to do
something tochange behaviors Seeing counseling
As a solution toProblem gambling
Motivation to Seek counseling
Motivation to accessSomeone to talk to
Motivated to not Do it on my own
And to have someoneMonitor me
Motivation for therapeutic relationship
Motivation to stop gambling
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What Effects Treatment Outcome
15%Type of Therapy
15%Placebo
30%Relationship
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Treatment Outcome
1 3
2 4
In Out
Med
Placebo
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Redefining Best Practices
Ensuring the application of specific guidelines and approved or “empirically validated” psychotherapeutic methods does not lead to improved treatment outcome. Differences in treatment methods, diagnoses, and even length of treatment account for less than 5% of the variance in outcomes (Bowen, Dries & Nace in the Heart and Soul of Change: What Works in Therapy)
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Treatment Outcome
Meta-analysis establishing association between alliance and outcome (Horvath et al.,2011; Tryon & Winograd, 2011) even in structured CBT (Waddington, 2002) and pharmacological treatment (McKay et al 2006)
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Redefining Best Practices Development of evidence-based therapists is at
least as much as, if not more, [important] than the dissemination of specific therapies
“No amount of theory, coursework, continuing education, or on-the-job experience will lead to the development of ‘experienced judgement’ required for superior performance… For that it appears that practitioners must be engaged in the process ..[of] continuously reaching for objectives just beyond their current ability.” (Miller, Hubble & Duncan)ki;lo
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Treatment Outcome and Client Attribution of Therapist
CharacteristicsHigh On: Low On:Empathy BlamingWarmth IgnoringUnderstanding RejectingAcceptancePositive RegardCollaborationSuccessful repair of relationship rupturesGenuiness
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Therapist Mindfulness Skills
Acceptance Nonjudgmental Attentive – being present Observant (self and others) Reflective Listening Awareness (self and others) Relaxed alertness Understanding Compassionate communication
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Treatment Matching
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Where to Intervene in Addiction Cycle?
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Matching to Level of Motivation
Precontemplation Contemplation
ActionMaintenance
Planning
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Matching to Level of Motivation
Precontemplative &Contemplative
Planning & Action
Maintenance
Motivational Interviewing
Cognitive Behavioral
Mindfulness Based
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Technology Transfer: Research to Clinical
Reality
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DSM-5 GAMBLING DISORDER AMONG CLIENTS IN MAT
(Himelhoch et al, 2015)
0
20
40
60
80
100
120
Non-DisorderedGambler (<4)
Disordered Gambler (≥4)
Mild Gambler(4-5)
Moderate Gambler(6-7)
Severe Gambler(8-9)
46.2% met DSM-5 criteria for Gambling Disorder
75.2% identified as Moderate or Severe Gambling Disorder
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DSM-5 GAMBLING DISORDER AMONG CLIENTS IN MAT
(Himelhoch et al, 2015)
CONCLUSIONS–Brief screening measures (Lie/Bet,
NODS-CLiP, NODS-PERC, BBGS) preform well in the substance abuse treatment setting
However– In actual clinical settings these screens
result in 1 – 4% positive screens (Maryland, Iowa, Oklahoma)
Funded by DHMH/BHA
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Other Issues
High rates of drop out in both research studies and clinical practice–Research drop out rates 14% to 50%
(Thomas et al, 2015)–Treatment drop out in one study 44.8%
Exclusion Criteria–Co-occurring disorders–Problem gambling severity–Medication
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Barriers to Help Seeking(Pulford et al, 2008; Evans & Delfabbro, 2005; McMillen et al (2004); Taveres, 2002)
Person-Centered Factors Predominant– Want to resolve problem on own and pride– Shame and embarrassment– Reluctance to admit problem– Too overwhelmed to get help
Service Centered Factors– Bad help seeking experience– Being treated like “addict” or mentally-ill
person– Couldn’t get service at time or place wanted
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Future Directions
Addressing financial problems and asset protection planning
Family involvementTreatment outcome differences
based on gender, age, culture, gambling preference
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Future Directions:Clinical Best Practices
Study best providers–Highest screening rates–Highest engagement rates–Best clinical outcomes–Highest client satisfaction
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Challenges: Coming Out of Silos
Substance Use Disorders
Mental Health Disorders
Gambling Disorders
Primary Care
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Why Bother
Lifetime Co-morbidity Although nearly half (49%) of those with
lifetime pathological gambling received treatment for mental health or substance abuse problems, none reported treatment for gambling problems
Kessler et al., 2008 (National Comoribidty Survey Replication)
45Funded by DHMH/BHA
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GamblingProblems
GamblingSpecific
Assessment
GamblingScreen
GamblingScreenScreen
Positive
Screen
Positive
PG EnhancedTreatment
PG EnhancedTreatment
MentalHealthCenter
SubstanceAbuseTreatmentCenter
46
Gambling IntegratedAssessment
Pos or Neg Pos or NegGambling Integrated
Assessment
GamblingSpecific
Treatment
Pos or NegPos or Neg Pos or Neg Pos or Neg
No Wrong Door
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Disordered Gambling Integration (DiGIn)
http://www.mdproblemgambling.com/treatment-providers
Addressing gambling and gambling problems for individuals presenting with a primary concern of a substance use, mental health or medical disorders is not just about making a diagnosis or finding cases of gambling disorder.
Rather this approach involves assuring that the impact of gambling on recovery, health and well-being is an ongoing topic of conversation in treatment, recovery and prevention settings.
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Beginner’s Mind Knowledge is not enough, unless it leads you to
understanding, and, in turn, to wisdom.
- Sarnoff, "Youth in a Changing World," 1954