University of Sydney
Alberta Gaming Research Institute
Behavioural therapies: Process & outcomes
Professor Alex Blaszczynski
School of Psychology
University of Sydney Gambling Research Unit
1
Presentation Overview
Describe adolescent & adult pathways to
problem & pathological gambling
Need for selective application of interventions
according to presumed aetiological processes
Historical developments in treatment
What are the new empirically-validated
innovations?
Outcomes
Theoretical processes of change
Cognitive versus behavioural study: similar
processes & outcomes?
2
What is Needed in the Treatment Field?
Researchers need to listen to clinicians
(Loreen Rugle)
Rich source of clinical information for
differentiating sub-types of problem &
pathological gamblers
Translation into testable hypotheses
Methodologically rigorous research designs
25 years to assess treatments is unacceptable
Clinicians need to translate empirical data
into improved clinical practices
3
Outcomes?
Set of ‘best-practice’ guidelines derived from
empirical studies (Randomised controlled long-term outcome
designs).
Jackson, Thomas & Blaszczynski (2003) review for Victorian Gambling
Research Panel concluded nil best practice guidelines currently
available
Treatments based on theoretical models
Process of change consistent with theory:
Cognitive interventions causally related to changes in
target cognitive beliefs & dose-dependent relationship
to behavioural outcomes
Similar for arousal reduction interventions
4
Adolescent/youth gambling
Jeff Derevensky: prevalence & clinical issues in
youth
Nature of adolescence (risk-taking/maturation)
Motivation linked to enjoyment, excitement, money
Poor self-esteem & stress: gambling as coping strategy
Interventions include enhanced problem solving &
coping skills, affective states & peripheral problems
? Link between coping skills & excitement
? Information versus attitude shift –
image/promotion, parental acceptance. Information
ineffective in modifying alcohol use, safe sex, tobacco use
unless accompanied by changes in attitude (RBT, smoking
policy)
5
Children & Adolescents
Legal age
Social gamblers
6
Children & Adolescents
Harmful gambling
Gambling
problems
Legal age
Social gamblers
7
Children & Adolescents
Harmful gambling
Age 16/20
Legal age
Significant
Increase from
Age 18-19
or 21
Problem gamblers
Social gamblers
8
Children & Adolescents
Harmful gambling
At-risk
pathological
gamblers
At school
&
School dropouts
Legal age
Pathological gamblers
Entry into
treatment
after age 18yrs
9
Children & Adolescents
Harmful gambling
Comorbid
disturbed
adolescents
More likely to
seek treatment
Legal age
Pathological gamblers
Comorbidity with
Gambling problem
10
Children & Adolescents
Harmful gambling
Gambling
problems
Pathological
gamblers
Legal age
Social gamblers
Problem &
Pathological
gamblers
Comorbid
Gambling problem
11
Problem Gamblers
Ecological
Ecologicalfactors
factors
Availability
Availability
Accessibility
Accessibility
Acceptability
Acceptability
Exposure
Classical & Operant Conditioning
Subjective excitement
Physiological arousal
Erroneous Cognitions
Irrational Beliefs
Illusions of control
Biased evaluations
12
Problem Gamblers
Ecological
Ecologicalfactors
factors
Availability
Availability
Accessibility
Accessibility
Acceptability
Acceptability
Exposure
Classical & Operant Conditioning
Erroneous Cognitions
Habitual patterns of gambling.
‘Chasing losses’ - HARM
13
Three pathways model
(Blaszczynski & Nower 2002)
1.
Behaviourally conditioned
Reinforcement & cognitive distortions ! bad decisions
Brief interventions, cognitive therapy
2.
Emotionally vulnerable
Relieve/modulate pre morbid aversive affective states +
become behaviourally conditioned
Cognitive-behavioural interventions: gambling &
concurrent problems
3.
Biologically based impulsive
Impulsivity, multiple maladaptive behaviours + become
behaviourally conditioned (differential reward)
Intensive CBT & medication
14
Conceptual models
Psychodynamic explanations (Bergler)
Behavioural (McConaghy & Blaszczynski; Echeburua)
Cognitive (Walker)
Cognitive-behavioural (Ladouceur)
Addictions (predominant paradigm)
Biological (Potenza, Comings, Hollander: genetic & neurotransmitters)
Public Health (Korn & Shaffer)
Treatment outcomes:
7% to 85% (G.A. ~ multimodal)
Best-practice guidelines for any:?
15
Historical developments
Epoch I
Psychodynamic: 22% success
Epoch II
Behavioural: 20% - 80% success
Aversion/covert sensitization therapy
Cue exposure/stimulus control
Satiation, paradoxical intention
Epoch III
Cognitive & cognitive-behavioural: ~ 85% success
Epoch IV ?
16
Multi-modal addiction treatments
Range of therapeutic components
contained in multi-modal treatments for
addiction: ethical obligations to provide
informed choice & evidence-based interventions
New applications in field of gambling:
(Tavares, Zilberman & el-Guebaly (2003))
Cognitive restructuring
Imaginal desensitisation
In-vivo exposure
17
Behavioural: Underlying assumptions
Excitement: Reinforcing physical & subjective
arousal associated with winning
Classical & operant conditioning (positive &
negative reinforcers)(FI & variable ratio resistant to
extinction – contribution of erroneous cognitions)
Treatment designed to diminish arousal:
Counter-conditioning
Reciprocal inhibition
Habituation
Problem solving & coping skills – eliminate
negative reinforcement
18
Arousal in gambling
Evidence of increased autonomic arousal in gambling
Anderson & Brown (1984), Leary & Dickerson (1985),
Blaszczynski et al, (1986), Sharpe (2000)
Failure to replicate effect of regularity of play on
arousal
Coulombe et al, (1992), Coventry & Constable (1999),
Sharpe et al, (1995)
Arousal higher in-vivo versus laboratory settings
Differential arousal with some forms (horse/casino
versus electronic gaming devices)
?Arousal & irrational beliefs (Coventry & Norman,
1998)
19
Counter-conditioning
Interventions
Electrical aversion therapy
20
Aversive Therapy
Conditioned
stimulus
+
Unconditioned
stimulus
Unconditioned
response
Excitement/Arousal
Conditioned response
21
Conditioned
stimulus
+
Unconditioned
stimulus
Unconditioned
response
22
Outcomes: Counter-conditioning
Interventions
Electrical aversion therapy
Covert sensitisation
Stimulus control + in-vivo exposure + rubber
band aversion
Studies do not address issue of negative
reinforcement
Outcomes: 20% to 60%
23
Reciprocal Inhibition: Imaginal desensitisation
Theoretical model
Behaviour Completion Mechanism Model
Model developed by Neil McConaghy (1980)
in treatment of repetitive sexual paraphilic
behaviors
Randomised control studies demonstrated
effectiveness with several other impulsive
driven behaviours
24
Repetitive behaviours characterised by impaired
control
Sexual paraphilic behaviours
Pyromania
Kleptomania
No evidence of efficacy with substance use
disorders
25
Imaginal Desensitization
Simple technique designed to reduce drive to
gamble
Empowers client with an effective skill to use invivo
Relaxation procedure incorporating mental
imagery. Similar to systematic desensitization
Involves client:
Visualizing exposure to gambling stimuli
Brief muscle relaxation procedure
Visualizing leaving scene without gambling
26
Relaxation
Gambling
imagery
Relaxation
Gambling
imagery
+
+
relaxation
relaxation
Leaving gambling
environment
+
relaxation
Relaxation
Decision not
to gamble
+
relaxation
27
Outcomes: Counter-conditioning
Randomized controlled outcome (McConaghy, et al
1983; McConaghy et al 1991; Blaszczynski et al 1991)
Behaviour completion mechanism model
Imaginal desensitisation (70% success)
Aversion therapy
Relaxation
Brief & prolonged in-vivo exposure
53% success
Problems encountered with exposure:
Habituation subject to external events: others winning
Poor maintenance of habituation effects across sessions
28
Process of Change
Proposed competing excitatory &
inhibitory cortical arousal producing
experimental neurosis
Reduction in arousal & drive to complete
behavioural habit response
STAI scores predict outcome at 12 months
No measure of physiological arousal
Inability to determine relationship between
behavioural indices of gambling & reduced arousal
No measure of cognitive changes
? Self efficacy
29
Outcomes
Imaginal desensitisation at 5 year follow-up
79% abstinent or controlled compared to 53%
for alternative therapies (aversion, brief &
prolonged)
Advantages of imaginal desensitisation
Simple cost-effective intervention
Audio-cassette version home-based version
30
Criticisms of ID Studies: Toneatto & Ladouceur (2003)
Absent pre-treatment measures of urges &
behaviour: ? What are the key measures?
Influence of crisis on anxiety/arousal states?
Reliability of clinical assessment of behavioural
changes: ? access to cash, external monitoring by
others, clinical reports of nil urge/nil money,
money/’hot’
Nil blind ratings of outcome
Nil placebo/waitlist control
Integrity of treatment delivery
31
Exposure-response Prevention
Echeburua, Baez & Fernandez-Montalvo
(1996)
Randomised controlled outcome study
Individual stimulus control, exposure-response
prevention
Group restructuring
Combination of above two active interventions
Wait-list control
32
Outcomes
Success rates at six month follow-up
Wait-list
Combined
Cognitive
Response-prevention
= 25%
= 37%
= 62%
= 75%
Criticisms:
Similar to ID studies
? Validity of individual versus group
comparison
Was habituation achieved & how measured?
33
Common mode of action?
Do behavioural and cognitive interventions
exert their influence through a common
active therapeutic component?
and/or
Is the therapeutic effect consistent with the
proposed theoretical mode of action?
Tested in a pilot study conducted by
Blaszczynski, Maccallum & Joukhador (in
preparation)
34
Study design
Randomised controlled outcome study
Imaginal desensitisation
Cognitive therapy
One month follow-up
Limited to self-report changes in cognition
& urges
No measure of subjective or physical
arousal included: A regretful & stupid
oversight!
35
Imaginal Desensitisation
Standardised audio-tapes
1. Brief muscle relaxation
2. Visualize exposure to gambling cues
a.
b.
Relax while visualizing cues
Imagine walking away without gambling
Focus on physical relaxation
No cognitive component included
36
Comparative study n=68
Individual imaginal desensitisation - ID (n =21)
Group cognitive therapy - CT (n = 26)
Group imaginal desensitisation and cognitive
therapy - ID + CT (n = 21)
All met DSM-IV criteria for Pathological
Gambling & SOGS > 10
37
Imaginal Desensitisation (Individual)
Audiocassette demonstrated and
instructions given for home use
Three times per day for five days
Review at two weeks
38
Cognitive Therapy Group
• Six weekly 1.5 hr sessions
• Focus on modifying unhelpful beliefs:
Gambling as income
Illusions of control
Probability
Concepts of randomness & independence
Biased evaluations
Scale (GBQ) designed to assess changes in cognitions
targeted in treatment
• Manual based for treatment integrity
39
Imaginal Desensitisation & CT
Combined group CT with ID instructions
for use at home
40
Assessments
Baseline pre-treatment: semi-structured
interview eliciting gambling demographics
One month outcome
41
Treatment completion
ID
CT
6
16
8
6
4
6
46
12
20
14
68%
57%
77% 66% (ns)
N
Male
30
Female 16
Total
ID-CT
42
Age
Male
34.6 (SD = 9.2) p<.001
Female
47.8 (SD = 8.5)
43
Sample characteristics
Male
Female
Slots
Race
Other
78.8%
100%
16.7%
-
4.5%
-
SOGS
Problem gambling
Mean
12.00
4.6 yrs
44
Outcome measures
Gambling behaviour
Self-reported problems
Clinical rating
45
Outcome criteria
Abstinent: nil gambling
Controlled: <$20 per session & no more
than intended
Uncontrolled: repeated failure to resist
urge, spending more than intended, chasing
1-2 lapses: minor slip defined as gambling
more than intended but not to extent of
creating harm
46
Gambling behaviour (1 month)
Total
ID
CT ID-CT
Abstinent
35%
37%
42%
Controlled
14%
}49%18%
30%
10%
16%
1-2 episodes 28%
18%
35%
27%
Uncontrolled 23%
27%
25%
16%
No differences in behaviour across conditions
(? Sufficient power to detect differences)
47
Self reported problems (1 month)
Total
7.3%
12.2%
Total
ID
31.7%
40%
CT
35%
IDCT
18%
Reported some on-going gambling
Troubled by persistent urges & preoccupation
12.2% Persistent gambling & urges
48
Clinical ratings (1 month)
Total
ID
21%
18% 25% 17%
Improvement
Moderate 33%
27% 35% 33%
No change
Significant 47%
}80%
CT ID-CT
55% 40% 50%
49
Cognitive Changes
65 item Gambling Beliefs Questionnaire (Joukhador,
Blaszczynski & Maccallum (2004). Superstitious Beliefs in Gambling
among Problem and Non-problem Gamblers: preliminary data.
Journal of Gambling Studies)
12 categories (e.g., illusions of control, superstitions,
entrapment, memory biases, source of income) with items rated on 5point Likert scale as to degree they believed each statement.
Group by time repeated measures indicated significant
decline in scores from pre- to post- treatment for all
groups.
? Practice effects
No significant between group differences in terms of
degree of change in cognitions from pre- to posttreatment
50
Gambling beliefs
CT
IDCT
ID
45
40
35
30
25
20
15
10
5
0
Pre-treatment
1 month followup
.
51
Conclusions
Gambling reduced following treatment
Treatment effects comparable (1 month)
Long term follow up needed
• Mode of action to be determined
52
Treatment options
Short term management to stop gambling
Break association between cues & arousal (ID)
Restricting access to cash & venues
Cognitive therapy
Target vulnerability factors
Impulsivity & intolerance of boredom
Problem solving & alternative activities
Stress management
Co-morbidity
53
Future Directions
Tease out specific from non-specific effects
of treatment
Identify active ingredient in treatment
Interaction between arousal & cognitions
Determine if the mechanism or mode of
action is consistent with conceptual
framework
Shift to empirically validated interventions
with capacity for innovative clinical
judgment
54
Recommendations
Randomized controlled outcome studies
Proper blind rating procedures & outcome measures
Compare experimental group/s to placebo/waitlist
Impact of single versus combined treatments
Dependent variables assess therapeutic mode of
action (cognitive schemas vs physiological arousal)
Intention to treat (report attrition rate)
Long term follow-up data
55
Recommendations
Brief interventions
Imaginal desensitisation to reduce arousal
Cognitive – behavioural therapy
(erroneous perceptions & problem
solving/coping skills)
Management of comorbid conditions
Medication for affective & impulsive
disordered subgroups
56