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Society for the Study of Addiction 2008

Natural Recovery from Gambling Problems. David C. Hodgins University of Calgary www.addiction.ucalgary.ca. Society for the Study of Addiction 2008. Convergent Validity. With different research methods in the gambling area With alcohol and other drug natural recovery.

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Society for the Study of Addiction 2008

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  1. Natural Recovery from Gambling Problems David C. Hodgins University of Calgary www.addiction.ucalgary.ca Society for the Study of Addiction 2008

  2. Convergent Validity • With different research methods in the gambling area • With alcohol and other drug natural recovery

  3. Alberta = 3 million people • 16 casinos • 7,000 slots, 350 tables • 47 race tracks • 6,000 VLTs • 2100 Ticket lottery sites

  4. Continuum of Gambling Treatment-seeking No gambling Recreational Problem Pathological

  5. DSM IV Impulse-control Disorders Not Elsewhere Classified • Intermittent explosive disorder • Kleptomania • Pyromania • Pathological gambling • Trichotillomania • Impulse-control disorder NOS

  6. British Gambling Prevalence Survey - 2007 • N=9003 • Pathological Gambling past year prevalence: • 0.60 % overall • 0.90 % of past year gamblers (68% of population) • 284,000 people

  7. Where Does Disordered Gambling Fit? Lifetime Past year Pathological gambling 1.6 1.1 Antisocial personality 2.6 1.2 Obsessive compulsive disorder 2.6 1.7 Pathological/problem gambling 5.4 3.9 Drug abuse/dependence 6.2 2.5 Major depressive episode 6.4 3.7 Generalized anxiety 8.5 3.8 Alcohol abuse/dependence 13.8 6.3 [Modified from Shaffer et al, 1997]

  8. Natural Recovery Research • Population samples • Convenience samples • Combined methods – Do the results from convenience samples replicate in population samples? • Knowledge translation intervention projects

  9. Estimated Recovery Rates From Prevalence Surveys Prevalence Rate Percent Lifetime Past Year Recovery Pathological Gambling 1.7 1.0 41% Problem Gambling 4.0 2.5 39% Both 5.7 3.5 38% Hodgins, Wynne, Makarchuk, 1999

  10. Slutske (2006) – US Surveys • National Epidemiologic Survey on Alcohol & Related Conditions (N=43,093) • Lifetime PG – 0.4%, n=185 • No past year symptoms – 38%, n=70 • Treatment-seekers – 11% , n=8 • Natural recovery – 89% , n=62 American Journal of Psychiatry, 163, 297-302

  11. Slutske (2006) • Gambling Impact & Behavior Study (N=2,417) • Lifetime PG – 0.9%, n=21 • No past year symptoms – 43%, n=9 • Treatment-seekers – 11% , n=1 • Natural recovery – 89% , n=8 • Hispanic & Native American Veterans (N=1624) – 30% recovery rate • Westermeyer et al., 2006 American Journal of Psychiatry, 163, 297-302

  12. Conclusions from Community Samples • Natural recovery is common • Estimates difficult to make because PG is a low base rate disorder • Do not discriminate intentional versus unintentional change (maturing out) Convenience samples- focus on specifics of the change process of intentional change

  13. Problem Gambling Recovery Study • Hodgins & el-Guebaly, 2000 *Minimal Treatment <5 Sessions or meetings

  14. Sample Characteristics [N=106, R Vs NR = NS] Female [%] 50 Age - mean [S.D.] 42 [10.0] Married/Common-Law [%] 47 Single - never married [%] 23 High school education or greater [%] 72 Employment: full-time [%] 56 unemployed [%] 25 Gambling Problem Primarily Video Lottery Terminal [VLT] 47% Primarily Mixed Games 37% Primarily Casino 8% Primarily Horses 4% Primarily Bingo 2% South Oaks Gambling Screen [SOGS] - mean: 12[3.28] Pathological Gambling [DSM-IV 5+ criteria] 94%

  15. Predicting Who Seeks Treatment Demographics [age, gender] Comorbidities [alcohol, other drugs, depression] Type of gambling Severity of problem [SOGS, # of DSM-IV criteria] # of DSM-IV Criteria None Minimal Moderate+ TREATMENT *Most frequent reason for no treatment: “Wanted to handle problem on own” 79%

  16. Gamblers Resolution(Mean 3.5 years, Median 14 months) Reason Percentage of people stating reason (2 rater content analysis) Negative emotion (stress, panic) 44% Financial concern 42% Family influence 26% Incompatible with desired self-image or goals 23% Lack of financial resources 21% Rock bottom 19% Confrontation 19% Support 14% Spiritual 12% Cognitive appraisal (pros and cons evaluation) 12% Legal 9% Out of awareness 9% Rationalization 9% Environmental change 9% Fear of future negative consequences 2%

  17. Actions Per Content Analysis Action Percentage reporting action Stimulus control (avoidance control) 49% New activities (leisure, family) 47% Treatment 28% Cognitive (self-talk, thought stopping) 26% Social support 23% Spiritual 12% Will power/decision making 9% Miscellaneous 7% Nothing 7% Limited access to money 5%* Self-reward 5% Confession 5%

  18. Maintenance factors from open-ended interview questions Factor % of people New activities 44 Remembering negative aspects/anticipating future negative consequences 33 Social support 30 Treatment 28 Focusing on improvements in life 19 Cognitive strategies for urges 16 Stimulus control/avoidance 16 Spiritual 12 Insight into gambling behaviors 9 Lack of finances 9 Focusing on family responsibilities 7 Limiting access to money 5 Self-reward 2

  19. Is Recovery Precipitated by Negative Life Events? RESOLVED 2 years 1 Year NON-RESOLVED 3 years Recovery

  20. Mean Negative Life Events

  21. Mean Positive Life Events

  22. Problem Gambling Recovery Study: Conclusions • “Naturally recovered” gamblers recruited - less than half had treatment/self-help involvement. • Emotional and financial concerns precipitate change. • Predominant change strategies were behavioural (stimulus control, new activities) and cognitive-motivational (recall of past consequences, anticipating future ones, will power).

  23. Conclusions (Continued) • Reduction in negative and increase in positive life events help maintain change. • Severity of problem predicted treatment-seeking. • People who don’t seek treatment want to “do it on their own” (79%).

  24. Replication – Toneatto at al., 2008 • Abstinent 6 mos. or SOGS = 0 • 26 untreated, 11 treated • Untreated less severe, fewer negative consequences • Similar recovery techniques – stimulus control, incompatible activities… • Advice? • Nothing (50%), awareness raising (30%), probabilties of winning (15%)

  25. Toneatto et al. (2008) study 2 • 34 untreated recovered PGs, 48 untreated current PGs • No demographic or gambling history differences. • Active PGs – more Axis 1 and Axis 2 DSM psychiatric disorders

  26. Conclusions from Convenience Samples • Consistent with the hypothesis that natural recovery is the preferred pathway for less serious, less complicated gambling problems • Recovery strategies are practical, problem-focused, cognitive-behavioural • Recovery precipitated by financial and emotional concerns versus large negative life events

  27. Combined Method: Cunningham, Hodgins & Toneatto, in progress Less severe problems than non-recovered Typical Natural Recovery Sample – 37%

  28. Natural Recovery Assessment

  29. Can you please tell me what lead you to quit or cut down on your gambling?” • Negative consequences 25% • Drifting out 42% • Reflective/maturation 42% more severe problems

  30. In order to help us design more effective ways to help people with their gambling, we are interested in anything that you can tell us about what helped you to quit or cut down on your gambling. Can you tell me about any strategies you used to help you cut down on your gambling?

  31. Strategies Identified • Common sense/figured out what was important and stuck to it/came to realization – 32% • Set a limit/stick to it/don’t bring credit or debit cards – 23% • Avoided gambling situations – 19% • Took up other hobbies/activities/kept busy- 8%

  32. Intervention Studies: Problem Gambling Self-recovery Program Hodgins, Currie & el-Guebaly, 2001, 2004

  33. Hodgins Brief Treatment • Media Recruitment • Random assignment to 4 conditions (N=314) • waiting list control (6 weeks). • self-help workbook through the mail. • self-help workbook through the mail plus a motivational telephone interview. • self-help workbook,motivational telephone interview plus 5 booster calls. • Telephone follow-up 1, 3, 6,12 months. • Collateral verification

  34. Brief Treatment Demographics (n=314) Gender (female) 52% Problem Type VLT’s 76% Slots 51% Casinos 13% Bingo 6% Horse racing 4% Lotteries 5% Card games 1% Internet 1% Games of skill 1% South Oaks Gambling Screen M =11 Previous Treatment 42%

  35. Reasons for not seeking treatment (N=314)

  36. Replication Study – Days Gambled/Month

  37. What worked? (Mode = 1, Mean = 1.6)

  38. Tentative Predictors of Outcome • Yes • Males • No previous treatment • High self-efficacy • High motivation • Not depressed/bipolar • Family support • No mental health treatment • No • SOGS/NODS/ CPGI scores • Substance abuse history

  39. Ideal Candidate for Brief Treatment • Male pathological gambler who has no previous gambling or mental health treatment, is not depressed, has good family support and is highly motivated and believes that he/she can succeed with brief treatment

  40. Future Directions • Practical applications – effectiveness studies (Oregon, Alberta, New Zealand) • Comparative designs • Search for matching factors • Dismantling studies • Strategies, MI, Normative feedback

  41. Convergent Validity • With different research methods in the gambling area • With alcohol and other drug natural recovery

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