The Big Questions in Treatment for Pathological Gambling David Hodgins University of Calgary AGRI, 2011
Effectiveness Trials/Mechanisms/Systems • 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?
Descriptive Accounts Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment Various medications
Uncontrolled Trials Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment Various medications
Randomized Controlled Trials Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment Various medications
Psychosocial Metaanalysis • 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
Medication RCTs Hodgins, Stea & Grant, The Lancet, in press
CBT Metaanalysis • 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.
How does therapy work? Two examples…. Coping Skills Treatment Trial Self-directed Treatment (Motivational Interviewing & workbook)
Morasco et al., 2007 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)
What worked in Self-directed Treatment? Hodgins et al., 2009
How does Brief self-directed treatment work? • Motivational Interviewing Premise: what an individual says about change during MI is related to subsequent change • Theory: verbalizing an intention to change (CHANGE TALK) leads to public and personal obligation to modify one’s behavior • Does amount of Change Talk correlate with change in gambling behavior? • 12 months r = -.35* * p < .05 Hodgins , Ching & MacEwan,, 2009
Other important questions about effective mechanisms of CBT-MI? Does MI reduce drop-out? Effectiveness of individual versus group formats? Does giving clients a choice of goals make a difference (Abstinence versus controlled gambling)?
How can we reduce drop-out? 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?
Carlbring et al., 2010 • 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
Group vs. Individual? • Dowling at al. (2007) women in CBT • Oei & Raylu (2010) both genders in CBT-MI combo • Treatment manual • Slight advantages for 1:1 • Implications?
Goal Choice (quit or cut down?) Alcohol field – appropriate goal for less severe dependence, more socially stable clients; people choose appropriately over time “recovered” individuals in community surveys are typically doing some gambling (Slutske et al., 2010) Some treatment studies offer this (e.g. Hodgins)
Systematic studies of goal choice • Dowling at al., (2009) 12 session CBT
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.
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%)
Conclusions • 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?
Some clues about promoting treatment • General population knows about gambling problems • Perceived addictiveness • Perceived prevalence
Perceived Problem Prevalence in Alberta (N = 6000) Wild, Hodgins, Patten, Coleman, el-Guebaly, Schopflocher, 2010
Perceived Addictiveness Wild, Hodgins, Patten, Coleman, el-Guebaly, Schopflocher, 2010
Some clues about promoting treatment • Reasons for seeking treatment studies • Consistent findings • Trying it on your own is the first step (98%) • Worries about future consequences is a major motivator (Suurvali et al., 2010) • Messages: • Early signs of problems • Basic change strategies • Nipping it in the bud
Some clues about promoting treatment • Evidence that campaigns increase treatment-seeking • Productivity Commission Report, 2010 review • Web-site and helpline spikes
Conclusions • 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 but research suggests some strategies to get people to participate in self-directed recovery or attend treatment