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7/11/2012
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And now for “real treatment”…
• Development of an 8-week managed care model
– 1 session per week
– 50 min in length
– 8 weeks
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Traditional Cognitive Behavioral Therapy
• Focus on identifying “triggers” or antecedents
• Developing strategies for engaging in alternative behaviors that lead to similar reinforcers
• Learning how to control urges (by thinking of alternative behaviors)
• Avoidance of gambling establishing operations
Pathological Gamblers w/ co-occurring Brain Injury
• Brain injury often results in development of impulse control disorders
• Our data have shown that in a survey of over 200 persons with brain injury the rate of problem gambling was 20%
• Unsure if gambling problems were in life prior to brain injury or as a result of the injury
• Captive population allowing for cleaner experimental control
Guercio, Johnson, & Dixon (in press, JABA)
• Participants: 3 participants with acquired brain injury
• Method: • Baseline: Trips taken to casino and lab-casino and
given 20 dollars to gamble • Intervention: 8 weeks of 1 hour therapy sessions.
Allowed lab-casino gambling immediately after therapy session.
• DV: money spent on gambling, self-reports of gambling severity
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Behavioral Treatment Works
• Does it work well enough?
• Have we really “fixed” the problem?
• Is CBT the “best” we can do? – When compared to alternative behavioral models
it often falls short
• Avoidance of gambling related stimuli is harder to do as gambling opportunities continue to expand
• Is there an alternative to “avoiding” life?
Acceptance and Commitment Therapy
• Alternative to traditional CBT – Acceptance not
suppression of thoughts (forced exposure to private events and aversive stimuli)
– Contacting life in the moment (responding relationally to temporal relations of here-now; not before-after)
– Creating distance between your discrimination of “self” (and overt/covert verbal behavior that describes yourself)
Move Over Fred
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Psychological
Flexibility
The ACT Question
Freely chose a direction you
want to head in
Not the stories you tell about yourself, but you
Willing to show up to whatever you are experiencing without defenses
See things for what they are, and not what they say they are
In this moment are you
And gently return to that
direction when you find yourself
off track
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Number of ACT Empirical Publications
Cummulative Outcome Publications
0
10
20
30
40
50
60
70
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
Nu
mb
er o
f P
ub
lica
tio
ns
ACT
Number of ACT
RCTs
Cummulative RCTs
0
5
10
15
20
25
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
Nu
mb
er o
f P
ub
lica
tio
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ACT
ACT Outcomes
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcome. Behaviour Research and Therapy, 44, 1-25.
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Present Study
• Participants – 7 pathological gamblers seeking treatment – 3 wait-list control gambler seeking treatment – Paid total of 200 dollars for participating in study
• Setting – Gambling therapy clinic – Carbondale Memorial Hospital
• Procedure – Pre-screening – Baseline evaluation (behavioral/neurological) – 8 hours of 1:1 ACT therapy – Treatment evaluation (behavioral/neurological)
Setting and Experimental Task
Self-referral to
treatment Program
Intake with therapist in clinic within
aprox 7 day of call Completion of
battery of psychometric
tests and actual gambling exposure
Initial Scanning in fMRI at Hospital
8 hours of 1:1 therapy delivered in
clinic
Final Scanning in fMRI at Hospital
Subject Age Gender Attempts
to Quit SOGS
GFA
Pre Post
4836 24 M 2 6 T
4841 52 F 1 7 S/A* T
4338 56 F 1 7 T
1 18 M 2 9 A S/A
2 20 M 2 9 A S
3 20 M 1 4 A A
9 19 M 2 6 A T
Control 1 23 M 1 6 T T
Control 14 19 M 1 5 S A/S
Control 12 18 M 2 9 T T
T
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0
5
10
15
20
25
30
0 2 4 6 8 10 12 14
GFA
co
mp
on
ent
sco
re
SOGS
GFA_ATTENTION
GFA_ESCAPE
GFA_TANGIBLE
GFA_SENSORY
Linear (GFA_ATTENTION)
Linear (GFA_ESCAPE)
Linear (GFA_TANGIBLE)
Linear (GFA_SENSORY)
Component analysis; frequency count
Component Wk 1
Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 Total % exposure
ACCEPTANCE 1 1 3 4 2 1 22.64%
DEFUSION 2 1 3 11.32%
SELF AS CONTEXT
1 1 4 11.32
VALUES 3 1 1 2 1 2 18.87
COMMITTED ACTION
1 2 2 1 4 9.43
PRESENT MOMENT
1 1 1 2 1 11.32
OTHER 1 1 1 1 1 1 1 1 15.09
Valued Living Questionnaire – Rate on Scale 1-10
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fMRI Scanner Task
• 5 blocks of exposure to 2.5 sec of slot machine reels spinning & 2.5 sec of slot machine outcome
– 20 near-miss outcomes
– 20 total loss outcomes
– 20 win outcomes
• Participants asked to rate on scale of 1-5 how pleasurable each outcome was.
– 1 not at all pleasurable
– 5 very pleasurable
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4836
16%
18%
7%
20%
14%
14%
11% ACCEPTANCE
DEFUSION
SELF AS CONTEXT
VALUES
COMMITTED ACTION
PRESENT MOMENT FOCUS
OTHER
Treatment Content Assessment
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4841
19.35%
14.52%
6.45%
14.52% 8.06%
25.81%
11.29%
ACCEPTANCE
DEFUSION
SELF AS CONTEXT
VALUES
COMMITTED ACTION
PRESENT MOMENT FOCUS
OTHER
Treatment Content Assessment
4338
18%
15%
5%
15% 9%
24%
14%
ACCEPTANCE
DEFUSION
SELF AS CONTEXT
VALUES
COMMITTED ACTION
PRESENT MOMENT FOCUS
OTHER
Treatment Content Assessment
Sub ID AAQ PRE
AAQ POST
MAAS PRE
MAAS POST
VLQ PRE
VLQ POST GSAS PRE
GSAS POST
4836 40 40 54 50 37.5 39.3 3 7
4841 41 45 58 56 36.9 61.9 13 13
4338 38 36 51 55 36.9 41.4 20 22
1 28 36 58 62 34.7 23.6 11 6
2 22 37 49 51 33.5 43.7 15 10
3 55 50 76 65 65.2 52.2 6 13
9 69 51 75 63 82.1 97 21 0
Control 1 64 62 70 68 49.7 49.5 10 13
CONTROL 2 19 17 48 61 71.6 65.5 15 20
CONTROL 3 62 50 71 57 55.3 69.8 29 27
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0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Ave
rage
Rat
ing
Average NM Rating pre/post 8 hr ACT
Pre
Post
4836 4841 4338 1 2 3 9 C1 C2 C3
Treatment: Wins - Losses Pre
631 642
Post
644 652
643 653
Treatment: Near-Misses - Losses Pre
631 642
Post
644 652
643
P<0.05
653
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Treatment: Losses - Wins Pre
631 642
Post
644 652
643 653
Control Pre (648) Post (654)
Wins - Losses
Near-Misses - Losses
Losses - Wins
Treatment: Wins - Losses Pre
631 642
Post
644 652
643 653
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Treatment: Near-Misses - Losses Pre
631 642
Post
644 652
643
P<0.05
653
Wins – Losses Pre-Treatment (Both Groups Combined)
Wins – Losses Post-Treatment (Treatment Group)
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Wins – Losses Post-Treatment (Control Group)
Near Misses – Losses Pre-Treatment (Both Groups Combined)
Near Misses – Losses Post-Treatment (Treatment Group)
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In Summary
• Therapy was effective at changing:
– Self-ratings of what a valued life was to each person
– Reducing the near-miss effect in terms of degree of “pleasure” in therapy context & in fMRI scanner
– Brain activation patterns
• Gambling stimuli are not “seen” by the client as the “same” following therapy
– Multiple novel functions have entered into the relationship between the stimuli and what they “mean” to the person
I just spent my kid’s lunch money
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Final Thoughts
• Gambling is not the problem – it is the outcome of the problem.
• Treat the language mess that got the client in the mess they are in.
• Move beyond contingencies and we will move beyond the limited changes we have made in treatment for the pathological gambler.
Bridging the Gap between Research and Practice
Mark R. Dixon & Alyssa Wilson
Southern Illinois University
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