Treatment online? Does it work for problem gamblers?

Thomas Nilsson, C. Psychologist Email: thomas@silabs.se

Talk about Online self help programs for problem gamblers – past present and future

How does it work? Does it work?

If online self help programs/treatment programs is the future, what will they look like?

What I like Accessible Easy to use It is something in between prevention, self help and treatment It reduces barriers to treatment We meet a new group of PG You can try and try You can follow your own progress Coast are low

It already started back in 2000 We where working on developing the national help line for problem gamblers in Sweden.

We wrote a self help book for problem gamblers 2000 to 2002.

Then we meet professor Per Carlbring (www.carlbring.se) who is an world leader in treatment online and made the book into a online self help program with CBT therapeutic support.

We got financial support from The Swedish National Public Health Institute.

Then we started 2004!

Background

Our work is inspired by: •  Theories on dependencies – gambling, alcohol, drugs… •  Bandura, Jacobs, Hodgins, Ladoucuer, Heaster & Miller… •  CBT in general and for depression and anxiety in particular •  Work and theories around motivational interviewing (MI) •  Clinical experience •  What works!

The self help online program is inspired from: •  Becoming A Winner: Defeating problem Gambling a gambling self-help manual. Hodgins and Makarchuk Gambling research project, University of Calgary and Addiction Centre-Calgary Regional Health Authority •  The self help manual is evaluated by professor, Per Carlbring,

Clinical psychology, University of Umeå, Sweden, his colleagues and students

A typical week in the program

For the patient:

•  Read and do exercises described in the module

•  Provide answers to essay questions via e-mail

•  Post a comment on a bulletin board

•  Talk to a CBT therapist on the phone for approximately 25 to 30

minutes/week

For the therapist:

•  Therapists judge if a patient is ready to go to the next module,

and gives feedback

In total eight (8) treatment modules

Modules 1- 4 lead to a decision: Stop all together or cut down?

Modules 5 - 8 are the actual treatment: Information – e.g. luck, random Cognitive restructuring Risk situations – stopping impulses Sort out the economic situation Filling the void with meaningful activities

Pace: One module per week

Screening and decision – yes or no

•  NODS •  MADRS-S •  HADS-anxiety/-depression •  QOLI •  Help seeking behaviour •  Social situation, education, work etc •  Us of alcohol and drugs •  Readiness to change questionnaire •  Self reported gambling (like frequency, magnitude,

intensity, etc) •  Jacobs five questions (dissociation) •  And more (in total 99 questions)

The screening is made via the computer online

First telephone session with therapist

Gambling background Consequences

- economic, relations, health… Function

-positive/negative reinforcement in short/long term

Present state - Why treatment now? - Actual gambling behaviour? - Expectations and goals?

Gambling free periods - coping strategies

Module 1 Texts about:

• How an addiction develops

• Characteristics for addictions

Questions about:

• Values and life goals

• Positive and negative consequences from gambling

• Why gambling

Module 2 Last three gambling situations: • Triggers, thoughts, feelings before and after gambling

• Wins and losses last 30 days of gambling • Costs per month and year

Module 3 Ask a family member or a dear friend: - how has my gambling affected me? - how has my gambling affected you? • Advantages and disadvantages with either continuing or stop gambling • Make a decision whether you want to change gambling behaviour or not

Module 4 About:

•  Acceptance and mindfulness as a tool

•  The importance of acceptance for the losses

•  Dreams of big wins The contract with yourself – stop /control?

Tell families and friends about your gambling problem

Module 5 • Alternative activities • Common negative thoughts • Miss consumptions about chance and luck • Erroneous beliefs about gambling

Module 6 • Make a plan to avoid relapse • Ask family and friends for help • Strategies for handling urges • Exercise can be an alternative

Module 7 • Listing your debts • Making a plan for paying back • Strategies to control your economic

Module 8 • Reward yourself for job well done • Laps and relapse • A plan for change • Look back on goals and contract • More support?

Key words - telephone support

•  Listen, respect and follow each individual

•  Show empathy, normalize •  Reinforce, give hope, encourage •  Encourage self reinforcement •  Increase self confidence/self efficacy •  Encourage acceptance •  Reduce rumination- increase change

of behaviour •  Share knowledge

Follow up – post, 6 months, 18 and 36 months

•  NODS •  HADS •  Quality of Life Inventory •  Self reported gambling •  Questions on how they experienced the

treatment, contact with the therapist, etc

What at do they think about the program?

• Talk to the therapist • The content was spot on • Anonymous • Internet is everywhere anytime • Those with social phobia • There are no treatment where they live • The forum • Working on there own (most clients spend between 2-5 hours/week) Client information

Problem games • VLT

• Internet poker

• Poker

• Trotting

• Casino Internet

Participants • Mean age: 33.2

• Male: 81 % • Female: 19 % • Started playing regularly at 23.7 yrs • Problematic gambling since 5.70 yrs • Debts: M=1354 CAD

From the screening

Screening n=464

Excluded n = 148

Pre treatment data n=316

Never showed up n = 32

Started treatment n=284

M 1: n = 275 M 2: n = 214 M 3: n = 186 M 4: n = 174 M 5: n = 158 M 6: n = 150 M 7: n = 147 M 8: n = 148 No M: n = 9

Post treatment data: n=219

6 month follow up data: n=197

18 month follow up data: n=181

36 month follow up data: n=196

Follow up - population

Measure Mest SDest dest

NODS Pre Post 6 18 36

8.16 2.09 2.16 2.25 2.04

2.48 2.78 2.95 3.07 2.98

2.31 2.21 2.13 2.24

HADS-A Pre Post 6 18 36

11.0 7.25 6.56 6.29 6.35

4.38 4.85 5.11 5.33 5.24

0.81 0.93 0.97 0.96

HADS –D Pre Post 6 18 36

9.12 5.53 4.87 4.89 5.05

3.39 4.36 4.60 4.79 4.74

0.86 0.99 0.97 0.94

QOLI Pre Post 6 18 36

0.30 1.14 1.37 1.50 1.24

1.72 1.94 2.04 2.12 2.07

0.46 0.57 0.62 0.50

Results – some screening instruments

Success? Out of the 196 clients 77 (40 %) was regarded as successful. They meet following criteria on the 36 month follow up:

• 0 points on NODS • no gambling the last month

References Carlbring, P., Smit, F. (2008). Randomized Trail of Internet-Delivered Self-Help With Telephone Support for pathological Gamblers. Journal of Consulting and Clinical Psychology Degerman, N. (2010). Internetbaserad självhjälpsbehandling i kombination med telefonstöd vid spelmani - En effectiveness-studie på kort och lång sikt samt prediktion av behandlingsutfall, avhopp från behandling och återfall. Linköpings Universitet. Institutionen för beteendevetenskap och lärande. Psykologprogrammet. Statens Folkhälsoinstitut. (2010). Internetbaserat självhjälpsprogram för spelberoende. Slutrapport. Carlbring, P., Degerman, N., Jonsson, J., & Andersson, G. (2012). Internet-Based Treatment of Pathological Gambling with a Three-Year Follow-Up. Cognitive Behaviour Therapy. Link:http://dx.doi.org/10.1080/16506073.2012.689323 Gainsbury, SM & Blaszczynski, A (2011) 'A systematic review of Internet-based therapy for the treatment of addictions', Clinical Psychology Review, vol. 31, no. 3, pp. 490-498. Clinical Psychology. Available at: www.elsevier.com/locate/issn/02727358Publisher's version of article available at http://dx.doi.org/10.1016/j.cpr.2010.11.007

Gambling – the future is already here

Accessible Digital Innovative Interactive Global

Responsible gambling is evolving Player education Links to treatment/forums Voluntary/obligatory Setting limits Self test Self exclusion Block your self Behavioural tracking systems Research

Obligatory player card? Proactive approach to PG?

In the future? Online (treatment) programs –

therapist no therapist

Forums – large online communities. No secrets! Player card connected to both online and “live” gambling Gaming will be included in gambling – more sophisticated and “internet smart” group More focus on the player and player experience - smarter information, more proactive support teams, more interactive and multi channelled information with the players

Support online - what's next? Our (SI) next step is to test (during 2013) an self help program online using the knowledge, experience and research we done so far. This is how we think:

• Exclude live therapist and include therapist role in the program • Develop screening and create individual “playlists” • Motivation loop • Relapse button • Evaluation • Cooperate with large forums • Player education (version 2.0)

Brand new! This is version 1.0 of our totally interactive self help program for problem gamblers. Launched January 2013 and research is in progress.

Wow! Looks simple?

Looks simple 2

Looks like this

What next? •  Online gambling is growing, so must online support •  Integration with gaming companies, direct links

from games to support •  Integration of different online services •  Technology can not be un-invented and the

Internet is impossible to fully control. But technology can and does offer some solutions

THANKS!

For every complex problem there is an easy answer, and it is wrong. H.L Mencken