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