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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

ns

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