David Hodgins University of Calgary

NCRG, 2010

Effectiveness Trials/Mechanisms/Systems

Randomized Controlled Trials (RCTs) - efficacy

Uncontrolled Trials

Descriptive Accounts

 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?

 Family models  Psychodynamic models  Gamblers Anonymous  Cognitive  Behavioural  Cognitive-behavioural models  Motivational Interviewing  Multimodal Treatment

 Family models  Psychodynamic models  Gamblers Anonymous  Cognitive  Behavioural  Cognitive-behavioural models  Motivational Interviewing  Multimodal Treatment

 Family models  Psychodynamic models  Gamblers Anonymous  Cognitive  Behavioural  Cognitive-behavioural models  Motivational Interviewing  Multimodal Treatment

 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

 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.

 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

 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)

Session 4 Session 8 Social Support

26% 67%

GA/therapy support

4% 43%

Cognitive skills

21% 31%

Distraction 45% 26%

Avoid triggers

40% 20%

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%

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

 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

* 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*

 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)?

 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?

 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

 Dowling at al. (2007) women in CBT  Oei & Raylu (2010) both genders in CBT-

MI combo •  Treatment manual

 Slight advantages for 1:1  Implications?

 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

 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)

 Alcohol field – appropriate goal for less severe dependence, more socially stable clients; people choose appropriately over time

 Some studies offer this (e.g. Hodgins)

 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

 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%)

 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?