Dr Barry Tolchard, University of Essex, U.K. Wednesday 15 September - - PowerPoint PPT Presentation

8th European Conference on Gambling Studies and Policy Issues

Cognitive-Behaviour Therapy for problem gamblers: characteristics of treatment completer’s and non-completer’s

Dr Barry Tolchard,

University of Essex, U.K.

Wednesday – 15 September 2010

Gambling before CBT

• Freud

– gamblers were trying to punish themselves for their unresolved oedipal urges and that this meant they were deliberately trying to lose

• Bergler

– “…the gambler is not a weak person who wants to gain money [easily]…but a neurotic with an unconscious wish to lose”

Cognitive-Behavioural Theories (CBT) of gambling

• A number CBT models have been described

– e.g., Petry, 2005; Sylvain, et al., 1997; Toneatto, 2002 – no single unified approach has been tested and the efficacy of CT continues to be debated

• Sharpe and Tarrier (1993)—CBT model

– incorporating relaxation, exposure and cognitive restructuring – while cited frequently – reservations must exist lack of empiricism – generalisation to all gambling problems is limited

Blaszczynski and Nower (2002)

• Pathways

1. behaviourally conditioned problem gamblers

– a purely conditional response resulting in common gambling behaviours such as chasing losses

2. emotionally vulnerable problem gamblers

– relationship between pathway 1 and various vulnerability markers, and

3. anti-social, impulsivist problem gamblers

– elements of pathways 1 & 2 but including specific personality issues of impulsivity and anti-social behaviour.

• Bio-psycho-social model

1. ecological determinants

– related to availability and access to gambling opportunities

2. the role of classical and operant conditioning

– where subjective excitement, dissociation and increased heart rate create an urge to gamble leading to habitual gambling behaviour and,

3. cognitive schemas

– resulting in irrational beliefs that gambling is an effective source of income

CBT and gambling: early behavioural techniques

• Aversion techniques (AT)

– e.g., Barker & Miller, 1968; Cross, 1966; Koller, 1972; Seager, 1970 – the evidence for such approaches can only be described as circumstantial at best

• Imaginal Desensitisation (ID)

– McConaghy, and colleagues(1983—91)

• Shown to be superior to AT and two forms of exposure
• serious flaws in the research, most notably in the incorrect use of

exposure, which was prescriptive rather than response dependent

• success rate of ID due to the exposure element alone and that the

relaxation component is unnecessary

CBT and gambling: exposure therapy

• Exposure therapy has been shown to be effective in a small

number of studies

– e.g., Echeburúa, et al., 1996; Hodgins, et al., 2004; Tolchard & Battersby, 2000/2010; Symes & Nicki, 1997 – Echeburúa et al., 1996—RCT

• exposure was shown to be superior to a wait list control, individual

cognitive restructuring and a combined cognitive restructuring and exposure group

– Tolchard & Battersby (2000 & 2010)—naturalistic study

• reported 70% success with exposure
• not controlled and the efficacy of exposure was not tested against any
• ther approaches
• common protocol was followed for all participants
• similar results were found in other reports

– E.g., Kushner, et al., 2007; Oaks, et al., 2008; Tolchard, et al., 2006

Cognitive-Behaviour Therapy (CBT) and gambling: cognitive techniques

• Ladouceur et al. (1996—present)

– common misunderstandings about crucial elements of games of chance which lead to

• a) an overestimation of the chance of winning,
• b) belief that skills influence outcome and
• c) erroneous beliefs of independent events and randomness

– therapeutic approach

• education regarding chance and randomness
• challenge clients’ erroneous beliefs in treatment sessions
• encouraging stimulus control and avoidance of gambling cues (anti-

exposure)

• total number of improved clients rarely reaches 50%
• anti-exposure element may be one reason for these results
• introduction of exposure as behavioural experiments may prove to be

more effective

Cognitive-Behaviour Therapy (CBT) and gambling: cognitive techniques

• Petry (2005—present)

– reinforcement of non-gambling activities – form of activity diary to monitor their gambling and non- gambling days – encouraged to select from a range of reward options which increase with longer periods of abstinence – avoidance is encouraged and increasing pleasurable non- gambling activities are introduced – relaxation is taught to reduce gambling urges – cognitive restructuring takes place

• relies on a very loose understanding of CBT

– anti-exposure is encouraged in the form of urge avoidance

Cognitive-Behaviour Therapy (CBT) and gambling: cognitive techniques

• Variants of CBT

– Wulfert et al. (2003)

• 1) MI, 2) CBT and, 3) relapse prevention

– Griffiths (1993)

• Audio-Playback

– speak their thoughts aloud during play which are then recorded – listen back to the recordings give opportunity to consider process of thinking while gambling

CBT and gambling: efficacy

• Systematic reviews

– Pallesen et al., 2005; Toneatto & Ladouceur, 2003

• Both support CBT
• confirm that methods based on exposure have the

highest effect sizes for efficacy at follow-up

CBT and gambling: efficacy

Trial Sylvain, Ladouceur, & Boisvert, (1997) Ladouceur, Sylvain, Letarte, Giroux, & Jaques (1998) Tolchard & Battersby, (2000) Ladouceur et al. (2003) Petry (2005) Completion (%) 64 59 81 87 61 Success (%) 36 42 72 77 49

Treatment failures

• explanations for treatment failure include;
• 1. clients being motivationally unprepared for

therapy

• 2. therapists being inadequately trained in the

therapeutic approach or not adhering to the treatment protocol

• 3. ineffective treatments being used and
• 4. costs and availability of receiving treatment

Types of failure

• three main groups
• 1. do not attend the initial screening or assessment

appointment (DNA)

• 2. drop-out after assessment (DO-A) and,
• 3. drop-out during treatment (DO-T)
• a fourth group may also be considered
• 4. drop out in follow-up (DO-FU)

Treatment failures in gambling treatment

• Melville, Casey, & Kavanagh, 2007

– summarise the results of 12 published works

• drop-out ranges from 14 to 50%
• median drop-out of 26%
• increasing to 31% when calculated as a weighted

average

– 10 used CBT and two were based on self-help and Gamblers Anonymous – CBT median drop-out rate of 32% vs. 22%

Definitions of failure

• Ladouceur, et al., 2003

– treatment completer to be least three sessions

• Robson, Edwards, Smith, & Colman, 2002

– Considered this a DO-T

Characteristics of failures

• Mixed evidence has been found

– demographic

• Age
• Employment status

– Gambling specific

• Age of onset
• Time spent gambling

– Co-morbidity – Personal factors

• ‘loss of the thrill’
• continue to believe they can still win

Flinders approach

• State-wide gambling service providing;

– Out-patient, in-patient and group programmes

• Five components to the out-patient

treatment:

• 1. Assessment and stimulus control (sessions 1–2)
• 2. exposure (imaginal and in-vivo) (sessions 3–10)
• 3. cognitive re-appraisal (sessions 6–10)
• 4. relapse prevention (sessions 9–10)
• 5. Follow-up (at 1-, 3-, 6- months and 1 year)

Measures

• Demographic and gambling
• 1. BreakEven Questionnaire (BEN-Q)
• 2. Victorian Gambling Screen
• 3. South Oaks Gambling Screen
• Psychopathology
• 1. Beck Depression Inventory
• 2. Beck Anxiety Inventory and,
• Disability
• 1. Work & Social Function Scale

Treatment status

• 205 gamblers presenting to an out-patient

service

– DO-A 21% – DO-T 9% – C’s 70%

demographics

Main Form of Gambling (n=205)

• Gaming Machines

88.5%

• TAB/Racing Codes

7.7%

• Casino Games

3.8%

– Female gamblers were over-represented in the Gaming machine group (95%) and male gamblers in the horse racing group (23%)

demographics

• Gender (M 42% vs. F 58%)

– DO-A (M 39% vs. F 61%) – DO-T (M 61% vs. F 39%) – C (M 41% vs. F 59%)

• Expected ratio in DO-A/C
• Men more likely to discontinue treatment

demographics

• Current age showed no differences
• DO-As never married; DO-T/C were married or

divorced

• DO-T higher levels of employment

Level of gambling

• No difference on SOGS scores
• More variation on VGS
• Helped make decision to drop SOGS
• Replace with VGS / PGSI

Gambling severity

• ? DO-Ts similar to OCD
• Gambling as a ritual—neutralising the urge
• Exposure removes ritualistic elements—increases urge
• Altering treatment so the eventual increase in urge is dealt with differently

Gambling behaviour

• Financial frequency

may be more about a strength of belief

• Cs have a greater

variation in gambling frequency

• DOs longer history
• f gambling

Psychopathology

Relationship between anxiety and depression

• increase in depression

scores impacted on the level of anxiety

• reflected the resolve of

the gamblers to remain in treatment

• strongest in the DO-A

group (r = .75) vs. DO-T (r = .53) & Cs (r = .53)

Disability

Summary of findings

Summary of findings

Conclusion

1. Behaviourally conditioned problem gamblers

– Seen largely in Cs – Responded well to exposure

2. Emotionally vulnerable problem gamblers

– DO-As – High psychopathology – ?in-patient delivery

3. Anti-social, impulsivist problem gamblers

– ?DO-Ts – No specific personality measures were used – ? Number of traumatic early life experiences – Disability score indicate relationship issues