treating problem gamblers: basic notions and avenues to reduce drop-outs
TRANSCRIPT
Treating Problem Gamblers:Basic Notions and Avenues to
Reduce Drop-outs
Current Trends in Treatment of Pathological Gambling
Terveyden ja hyvinvoinnin laitos, Helsinki, Finland
March 15th and 16th, 20016
Robert Ladouceur, Ph.D.
Professor EmeritusUniversité Laval, Québec, Canada
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OutlineSection 1: 09.45 - 11.15
1.Why do people gamble? The basis of cognitive modification and the root or the common denominator of all erroneous perceptions.2.Degree of conviction in their “erroneous” perceptions3.Dissonance; The key factor in challenging conviction and motivation
Section 2: 12.00 - 16.30 4. How to reduce drop-outs in the treatment of pathological gamblers?5. Abstinence vs Controlled gambling as a treatment outcome6. Case discussion from the participants and role playing
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Gambling1. Individual must realize that he/she
is putting money or a valuable object at risk,
2. Once bet, this money or valuable object is irreversible
3. The outcome of the game is determined by
chance
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What is Chance or Randomness ?Chance An unpredictable event or accidental
happening
Randomness A method in which all possible events have
equal probability of selection
From an operational standpoint Impossibility of controlling or predicting the
outcome of an event
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Two different concepts, crucial to our understanding of gambling behavior
Chance ---------------------------------- Skills
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What is the difference between a game of chance and a game of skill?
Different criteria may be used to distinguish a game of skills from a game of chance. In a game of skill…
• The more you play, the better is your performance
• The more feedback you receive, the better is your performance
• Practice increases your self-confidence
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What is a game of chance?
Different criteria may again be used, but in a game of chance…
Regardless of the time you spend practicing and studying the game, your performance
will never improve !!!!
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Main difference between the lottery and life ?
« The big difference between Lotto and life is that in Lotto everyone has the same chance »Gerald Williams
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What is the difference between a game of chance and a game of skill?
The main problem is that the gambler has a perception of skills where there is no skills at all involved.
“What makes Lotto so charming and attractive for many players is the belief in having a personal influence-or so on thinks- on Lady Luck or Fortuna.” (Around the world in 80 games)
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What is the difference between a game of chance and a game of skill?
In order to implement cognitive (…and behavioral) treatment, we need to clarify the level of chance and skill in each game with
each patient.
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Why do people gamble ?
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The paradox of GamblingWhy do people gamble ?
The necessary condition (may not be sufficient for all gamblers) is the possibility of
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Its the Money…
Problem gambling is about moneyMore specifically... loosing money
No gamblers will seek treatment if they were always winning….
I am not saying that this is the only factor or problem, but it is the core cognitive problem to be addressed…
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The paradox of Gambling
• Percentage of return on money gambled varies from place to place and from game to game
• In all games, the return on money is always negative for the gambler
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The main (or one of the main) reason is...
While gambling,
most of us (if not all) misperceive or deny that the outcome of the
game is based on the notion of Chance and Randomness
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One crucial answer is...
We analyzed what people were saying to
themselves while gambling.
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20
40
60
80
100
Erroneous AdequatePercepti
ons
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Our first practical exercise
In small groups, I would like you to list the most frequent erroneous perceptions you
hear from your patients (4 or 5).
We will then write them on the board
And I will ask you to find the common denominator at the root of these
erroneous perceptions
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Theoretical Perspective
SituationTriggers
GamblingCognitiveVariables
Arousal
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•If erroneous perceptions are pivotal in understanding and helping problem gamblers, we should not forget their
Degree of conviction in their erroneous perceptions is even more
important.
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Degree of conviction in our erroneous perceptions
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What is the difference between a problem and a non problem gambler in terms of
erroneous perceptions ?
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Method
Participants• Adults meeting the DSM-IV diagnostic
criteria for pathological gambling participated in this study Age: 40.6 years
• Adults not meeting the DSM-IV diagnostic criteria for pathological gambling
• Age; 38.1 years
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Procedure
1. Training in thinking aloud
2. Sequence of the game was preprogrammed and identical for all Ss
3. Rate of return was 92 %
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Method
1. All perceptions were tape-recorded
2. An independent judge rated the verbalizations according to 3 categories
- Adequate: “It is all programmed” - Erroneous: “The machine is due” - Neutral: “I have a date tonight”
3. 20 % of the verbalizations were independently rated by a second judge.
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Results
1. % Erroneous perceptions• PG: 80.6• NPG: 68.7 % p < .07 (n.s.)
2. Gambling related perceptions• PG > NPG p < .04
3. Conviction• PG > NPG p < .0001
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ResultsDegree of conviction
01234567
NPG PG
Non Pathological
Pathological
1 2 3 4 5
Conviction measure
2,00
4,00
6,00
8,00
Estim
ated
mar
gina
l mea
ns
Group vs Conviction
5,00
3,00
7,00
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Degree of conviction in their erroneous perceptions is what needs to be challenged and modified
How?By creating
DISSONANCE not CONFRONTATION
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Difference between Confrontation and Difference between Confrontation and DissonanceDissonance
CONFRONTATION: By using logical arguments, trying to demonstrate that the line of though of the patient is wrong (external process or the ping pong effect)DISSONANCE: By widening personal perception about a consequence in the patient, contradictory outcomes are created by the same behavior (internal process). In essence, who has to work harder, the therapist or the patient?
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Formal definition of Dissonance
Dissonance
Inconsistency between the beliefs one holds or between one's actions and one's beliefs —
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Dropouts
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Dropouts
What is a drop out?
Do gamblers drop out of Treatment ?
What is dissonance ?
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About 30 % à 50 % of the gamblers will drop out of treatment.
Is drop out a normal phenomenon ???
Yes, and lets try to explain and prevent dropouts.
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How do we explain drop out ?
Few studies have examined this issue.Only one has directly investigated why
people drop out of Tx (Grant et al, 2005)
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How do we explain drop outs ?Variables that distinguish treatment completers vs
dropouts1. Impulsivity (Leblond et al., 2003)2. Co morbidity with alcohol and drug problems but not
with motivation and participation in GA (Milton et al., 2002)
3. High level of anxiety (Escheburua et al., 2001)4. Enjoyment in gambling et belief in personal luck (Hart
et al., 2006)
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How do we explain drop outs?
Grant, Kim & Kuskowski (2004)
50 gamblers seeking treatment (drug and psycho Tx)All met DSM-IV criteria for pathological gamblingContacted drop outs for an inteview
Age M: 47.7 ans
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How do we explain drop outs?Grant, Kim & Kuskowski (2004)
Non significant predictors of drop outs: 1. Sex2. Age at the beginning of Tx3. Age when the gambling problem started4. Marital status5. Severity of the problem6. Amount of time gambling7. Co mordibity
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How do we explain drop outs?Grant, Kim & Kuskowski (2004)
Predictor of Tx adherence : Support from a collateral
They contacted 21 of 24 drop outs: Predictors of drop out A) Lack of the thrill gambling B) Winning expectations and recoup the money lost (Chasing)
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How do we explain drop outs?
How to use these information to reduce drop outs ?
Thrill of gamblingMotivational interviewWinning expectations and chasing lossesCognitive correction. Warn the patient about this infoIs drop out a normal phenomenon ???Yes and we need to inform our patients
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The first motivation to change needs to be challenged and reinforced for the good reasons
How?
By creating dissonance
The next 3 slides will show how
Stop gambling means...
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Phases of excessive gambling
WinsWins
LossesLosses
DespairDespair
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1. RECOGNIZE and ACCEPT than money lost is lost forever
2. Declare yourself beaten by Gambling3. Accept that you have lost an important
activity4. STOP thinking that gambling is the solution
to your problems Needs to be emphasized5. Plan a financial reorganization6. Work hard in developing new coping
strategies
Stop gambling means...
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A pivotal question…
Do we sometimes accept for granted that the help requested by our problem gambler is the result of a profound and well balanced decision?
How do we know and how can we verify this in order to HELP our patient?
Key issue…
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Advantages & disadvantagesAdvantages & disadvantages
Positive Positive consequenceconsequence
s s of gamblingof gambling
Negative Negative consequences consequences
of gamblingof gambling
Positive Positive consequences consequences
of NOT gamblingof NOT gambling
Negative Negative consequenceconsequence
ss of NOT of NOT
gamblinggambling
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Could offering controlled gambling as the main goal of
therapy is a viable goal to help PG ?
• Supported by a grant from the OPGRC (Rob Simpson, ceo)
• Many thanks to Stella Lachance and Patricia-Maude Fournier
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Relevant and important questions related to the Tx of PG
• How many individuals are pathological gamblers?
• How many PG will seek treatment for their gambling problem?
• Why some “obvious” PG do not seek help?
• Which treatment should be offered to PG?
• What should be the ultimate goal of the Tx?
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Prevalence of pathological gambling
How many individuals will become pathological gamblers?
Recent studies conducted over the last years show that less than 1% of the general adult population
are classified or screened as pathological gambling.
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How many PG will seek treatment for their gambling problem?
Less than 10 % PG will seek formal Treatment,
Distributed over a 3 yr period
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Why some “obvious” PG do not seek help?
Keep the fun and entertainment of gambling
Recoup their lossesConvinced that they can control their
gambling habits but not have yet succeeded. So they keep trying…. And keep gambling…
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Which treatment should be offered to PG?
Without hesitation, I will say….
Evidence based treatment
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What should be the ultimate goal of the Tx?
Complete abstinenceAbstinence on the problematic games
and control over the othersControl over both problematic games
and others
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But without any doubt, offering controlled gambling instead of abstinence to help pathological
gamblers to overcome their problem is
a controversal issue
A controversal issue…
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Controlled Gambling
Rationale for control rather than abstinence as the main Treatment Goal for Pathological Gamblers
Few pathological gamblers seek treatment; High dropout rates;Abstinence may not be the unique solution for all
pathological gamblers;
So, offering a goal of controlled gambling may bring ambivalent PG into treatment.
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Goal of the study
To evaluate the viability (Myth or reality) of control in the treatment of pathological gamblers using a cognitive-behavior therapy.
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Controlled Gambling
Inclusion criteria
(a) Gambler’s objective: control not abstinence;(b) Primary diagnosis of pathological gambling; (c) No evidence of immediate suicidal intent; (d) No evidence of present and past psychosis; (e) Not already involved in another therapy for gambling
problem.
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Defining Controlled Gambling
Clinician and participants established a personalized treatment goal that is acceptable for PG in terms of (a) amount of money bet per session; (b) amount of money bet per week; (c) number of gambling sessions per week; (d) time (min/hours) spent on gambling per week
The goals are accepted by both the PG and the Therapist
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Controlled Gambling
Cognitive and behavioral Tx (13 weeks) (Tx Manual)
Motivation-confirmation of the personalized goal, Analysis of a gambling session, Identifying at-risk situations and implementing behavioral
interventions, Erroneous beliefs awareness training, Cognitive correction of erroneous beliefs, In vivo exposure under the therapist’s supervision, Relapse prevention.
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Controlled Gambling-Measures
Successful Outcome
Controlled gambling Abstinence
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Controlled Abstinence
36 (60 %) 24 (40 %)
38 (68 %) 18 (32 %)
Post-test
6-monthfollow-up
12-monthfollow-up
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Implications
All participants said that they would have not seek Tx if abstinence was the goal
Working with a professional to help them control their gambling was a great experience
PG shift to Abstinence on the basis of experience• Only 1/3 (N=21) kept control as a K outcome during the
whole treatment, • so 2/3 “TRAVELLED” to abstinence
Shift to Abstinence was based on informed consent and on a deliberate decision, never on Therapist’s advices or suggestions.
WHY THEY SHIFTED TO ABSTINENCE?
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Conclusions
• Drop out is a normal phenomenon• We do not have a definitive answer on how to eliminate it
Some questions need to be asked
• Do we pay enough attention to the need of the patient?• Are we flexible enough to adapt to the goals of the patient?• Do we influence the goal of the therapy?
Drop-outs and treatment of pathological gamblers
Thank you very much
[email protected] Prof. Robert Ladouceur, Université Laval