contingency management in problem gambling treatment jeremiah weinstock, ph.d. university of...

Contingency Management in Problem Gambling

Treatment

Jeremiah Weinstock, Ph.D.

University of Connecticut Health Center

Farmington, CT USA

Overview

1. Pathological Gambling & Its Treatment

2. Background on Contingency Management (CM)

3. Applying CM to Gambling Treatment

Pathological Gambling

Quick Review:

Pathological Gambling (PG) is characterized by maladaptive gambling behavior.

1% - 2% of general adult population meets DSM-IV diagnostic criteria for PG.

Vulnerable populations include: SUD, Forensic, Adolescents.

Availability of gambling is increasing dramatically.

Number of Gamblers Seeking Treatment in CT

0

100

200

300

400

Num

ber

82 84 86 88 90 92 94 96 98 '00

'02

Year

Patients Treated: Before Casinos

Number of Gamblers Seeking Treatment in CT

0

100

200

300

400

Num

ber

82 84 86 88 90 92 94 96 97 0 2

Year

Patients Treated: Foxwoods Opens

FoxwoodsCasino Opens

Number of Gamblers Seeking Treatment in CT

0

100

200

300

400

Num

ber

82 84 86 88 90 92 94 96 98 '00

'02

Year

Patients Treated: Today

FoxwoodsCasino Opens

MoheganSun Casino Opens

Gambling Treatment

Treatment Options for PG1. Gamblers Anonymous (12-Step)2. Outpatient Counseling

• Cognitive Behavioral Therapy (CBT)• Marital Therapy

3. Brief Interventions• Motivational Enhancement Therapy

4. Pharmacotherapy (medication)5. Inpatient Treatment

No single treatment is appropriate for everyone.*

Gambling Treatment

Obstacles to Effective Treatment:Less than 8% of PG ever seek or get treatment (Slutske,

2006).

Many PGs drop-out of treatment prior to completion 33% - 50% (Leblonde et al. 2003; Ladouceur et al., 2001).

Adherence with treatment program. Petry et al. (2006) – 40% completed less than 75% of intended

treatment. Best predictor of gambling abstinence was treatment

adherence: number of CBT sessions/chapters completed.

Gambling Treatment

1st Treatment Study at UConn Health Center: 231 Pathological Gamblers randomly

assigned to:

1. Referral to Gamblers Anonymous

2. GA Referral + CBT self-help manual

3. GA Referral + CBT counseling.

Petry et al., 2006

Gambling Treatment - Demos GA Ref Manual Therapy n 63 84 84

Male 50.0% 57.6% 58.8%

Caucasian 81.3% 84.7% 84.7%

Age 44.5 44.2 46.0

Married 39.1% 36.5% 42.4%

Income $42,500 $43,000 $46,000

Prev. Subs Abuse TX

31.7% 29.8% 21.2%

Gambling Treatment - Adherence

GA Attendance

0

25

50

75

100

% S

ubje

cts

Treatment compliance

0

25

50

75

100

None

Some

>75%

%

Manual

Therapy

Gambling Treatment - Results

Days Gambled

0

5

10

15

PreTX

Wk 4 Wk 8

Day

s

GA ref

Manual

Therapy

Median $ Gambled

0

500

1000

1500

2000

2500

PreTX

Wk4

Wk8

$

Gambling Treatment

WHAT CAN BE DONE?

Contingency Management

Contingency Management: Based upon principles of operant conditioning.

Three behavioral tenets of CM:1. Frequent monitoring of target behavior.2. Providing tangible reinforcement for completion of

target behaviors.3. Remove reinforcement when target behavior does not

occur.

Typically, CM is added onto another SUD treatment.

Contingency Management

Contingency Management Reinforcement:1. Vouchers - $$$$

Silverman et al. (1996) = $1,155 Higgins et al. (2000) = $997.50

2. Prize Bowl – Lower cost alternative. Not appropriate for PGs as it involves an element

of chance somewhat similar to gambling.

Contingency Management

Contingency Management SUD Tx Outcomes:Participants stay in treatment longer

75% vs. 40% completed 24 weeks (Higgins et al., 1994). 84% vs. 22% completed 8 weeks (Petry et al., 2000).

Longer durations of continuous abstinence (LDA) during treatment 55% vs. 15% obtained 2-months of continuous abstinence. 2.7 and 4.5 times more likely to achieve 8 weeks and 12 weeks

LDA, respectively (Petry et al., 2005).

Regardless of type of treatment, LDA during treatment is associated with long term success

Contingency Management

CM reduces drug use:Opioids (Bickel et al., 1999; Preston et al., 1998)Cocaine (Higgins et al., 1994; Silverman et al., 1996)Benzodiazepines (Stitzer et al., 1992)Marijuana (Budney et al., 1991, 2000)Nicotine (Shoptaw et al., 2002; Roll et al., 1996) Alcohol (Petry, 2000)Polydrug (Downey et al., 2000; Petry et al., 2005b)

Contingency Management

CM increases treatment adherence:Medication compliance (Carroll et al., 2001)

Complete activities consistent with treatment improves treatment outcome (Bickel et al., 1997; Iguchi et al., 1997)

Lewis & Petry (2005) found those completing family oriented activities: Remained in treatment longer. Longer durations of abstinence. Reported greater reductions in family conflict.

CM for Gambling Treatment

How do we apply CM to gambling treatment? Cannot reinforce gambling abstinence, no objective

measure. Reinforce compliance with homework. Reinforce GA attendance. Reinforce behavioral activation.

ONGOING STUDY @ UCHC: Eight sessions of individual therapy. Longer term (2 year) follow-ups included.

CM for Gambling TreatmentPsycho-Education:

Provides educational materials about gambling.Encourages attendance at GA.

CBT:Functional analysis of gambling behavior, coping skills training.Encourages attendance at GA.

CBT + CM:Same content as CBT, and GA encouragement.Earn up to $187 in vouchers for completing activity contracts.

Sample Activity Contract

Activity Proof To Be Done

Potential Problems

Done?

Go to GA Mtg.

Signed Slip

Wed 04/04

Don’t want to go.

Go to church Church Bulletin

Sun.

04/08

Over sleep!

Have coffee with sister

Receipt Sat.

04/07

She’s busy.

CM For Gambling Treatment

31 clients assigned to CBT+CMThus far, 493 activities contracted with 66%

completed. 135 activities were completing CBT homework

(27.4%) 43 activities were going to GA meeting (8.3%)

Preliminary Results - ITherapy attendance

0

2

4

6

8

CBT CBT-CM

M e a

n S

e s

s i

o n

Preliminary Results - II

Homework exercises

0

20

40

60

80

CBT CBT-CM

%

C

o

m

p

l e

t e

d

Preliminary Results - IIIGA Attendance

0

1

2

3

4

5

CBT CBT-CM

M

e a

n

M e e

t i

n g

s

CM for Gambling Treatments

How can I apply this to my clinic?

Reinforcement does not have to be vouchers: Clinic privileges – parking spots, take-home bottles. Donations from the community.

Summary1. PG is associated with a host of adverse consequences.2. Numerous treatment options are available, however

few PGs seek treatment.3. Current treatments can be effective, but there is room

for improvement.4. Contingency management is one way to improve

treatment attendance and adherence.5. With the recurrent nature of PG, it’s helpful for

clients to have a positive experience with treatment – CM can be a positive addition to tx.

Acknowledgements

Thank You: Nancy M. Petry, Yola Ammerman, Anne Doersch,

Heather Gay, Elise Kabela-Cormier, David M. Ledgerwood, Suzanne McColl, Ben Morasco, Betsy Parker, & Nicole Reilly.

This study is supported by Nat’l Institute of Mental Health