Download Overview of Treatment Modalities

Overview of
Treatment Modalities
Jessica M. Cronce, PhD
University of Oregon
How do gambling problems develop?
Social
Psycho
Bio
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BIO:
Genetic predisposition
Neurochemistry
Effect of medications
Immune response
HPA axis (stress)
Flight-fight response
Other physiological
responses
Biology: Neurotransmitters
Disordered Gambling:
 Noraepinephrine =  heart rate / excitement
 Serotonin =  impulsive behavior
 Dopamine =  reward seeking behavior
(some dopamine agonists have been shown to induce
pathological gambling behavior)
How do gambling problems develop?
Social
Psycho
Bio
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PSYCHO:
Perceptions
Thoughts/cognitions
• Attitudes & beliefs
Emotions
Learning
Memory
Behavior
• Coping
Psychology: Cognitions
?
?
No matter how much we KNOW that each
event is independent, we tend to hold a deep
belief that chance is self-correcting in the
short run (the Gambler’s Fallacy).
Psychology: Learning
Withdrawal is a reinforcer
How do gambling problems develop?
Social
Psycho
Bio
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SOCIAL:
Social support
Family dynamics
Peer relationships
Culture
Socio-economic status
Access to gambling
Exposure to events
Levels of “Social”: Ecological Model
Microsystem: Direct environment
e.g., Family, School, Church
Mesosystem: Interaction of microsystems
e.g., Parents<=>School
Exosystem: Indirect Environment
e.g., Spouse’s employment
Macrosystem: Culture
e.g., Economy, social norms
Chronosystem: Change over time
e.g., Aging, culture change
How do gambling problems develop?
Social
Environment
Psycho
Bio
Genes
Gene x Environment
interactions (G x E)
Gene-Environment
Correlations (rGE)
Gene-environment interactions (GxE):
Environment causes gene expression
• The “C gene” in Himalayan rabbits regulates development of
pigments in the fur and skin, and is maximally active from 59°F to
77°F and inactive above 95°F.
Reared at
68°F
Reared at
96°F
http://www.nature.com/scitable/topicpage/environmental-influences-on-gene-expression-536
“Genes load the gun;
the environment pulls the trigger.”
https://www.aeaweb.org/research/has-tribal-gaming-been-a-boon-for-american-indians
How do we alleviate gambling problems?
BIOLOGY
PSYCHOLOGY
SOCIOLOGY
Medication
Motivational
Interviewing (MI)
Family
education/therapy
Change biology through
psychology (CBT,
mindfulness meditation)
Cognitive Therapy
Cognitive-Behavioral
Therapy (CBT)
Dialectical Behavior
Therapy (DBT)
12-step programs
Change cultural norms
Limit access to gambling
venues (exclusion)
Laws
Medication
Norepinephrine:
• Bupropion* (Wellbutrin)
Serotonin:
• SRIs & SSRIs*
• Mood Stablizers*
(Lithium carbonate)
Dopamine antagonist:
• Naltrexone (ReVia)**
*FDA approved for MDD
**FDA approved for SUDs, which
are highly comorbid with
disordered gambling
1Foster
Some emerging evidence for
potential regulating effect of
**glutamatergic medications
(e.g., acamprosate, Nacetylcysteine).1
Olive, Cleva, Kalivas & Malcolm (2012)
Motivational Interviewing (MI)

Rooted in:
• Carl Rogers; Humanism
• Transtheoretical model of change

Client-centered form of guiding
• vs. following or directing

Helps people get “unstuck”, resolving their
own ambivalence regarding change

David Hodgins: MI + self-help workbook1 =
fewer gambling days, less lost money, and
lower SOGS scores up to 2 years later2
1BECOMING
A WINNER: Defeating Problem Gambling;
Adaptation: http://www.oregonpgs.org/workbooks/gear-workbook.pdf
2Hodgins, Currie, el-Guebaly, & Peden (2004)
Cognitive Therapy (CT)

Rooted in:
 Cognitivism:
behavior
Thoughts shape

Establishing clear understanding of
randomness (i.e., the outcomes of gambling
events are independent, thus past events do
not signal future outcomes)

Increasing awareness of other erroneous
beliefs about gambling (e.g., illusions of
control, belief in luck/systems) and how they
relate to the individual’s gambling behavior

Correcting/changing erroneous beliefs with
thought records

Robert Ladouceur: CT = decreased gambling
frequency, urges, and PG symptom severity up
to 12 months later1
1Ladouceur,
Sylvain, Boutin, Lachance, Doucet, Leblond, & Jacques (2001)
Cognitive-Behavioral Therapy (CBT)

Rooted in:

Behaviorism: Behaviors are shaped
by internal (thoughts) and external
contingencies

Changing thoughts, emotional
reactions, or behaviors can “break
the chain” leading to problems

Focuses on changing unhelpful thoughts and behaviors, or
adding helpful thoughts and behaviors

Nancy Petry: CBT = reduced gambling severity up to 12
months later1
1Petry,
Ammerman, Doersch, Gay, Kadden, Molina, & Steinberg (2006)
CBT
A
B
C
A: Make a mistake at work.

ntecedents
B: Think: “I can’t do anything right!”

ehaviors/beliefs
B: Feel: Sad, Worthless

B: (Think: “I need to feel like a winner.”
onsequences
“I need to do something fun.”)
Challenge cognitions

Teach adaptive coping
B: Go out to the casino and gamble.
skills

Teach protective
behaviors
C: Lose my money needed for bills.
Dialectical Behavior Therapy (DBT)

Rooted in:
 Behaviorism
 Acceptance

and mindfulness
Focuses on accepting emotions without
letting emotions dictate behavior, and
simultaneously changing other
contingencies that reinforce problematic
behavior.
DBT

DBT has been tested in a small pilot study for
treatment-resistant gamblers with apparent
clinically-significant effects, but these were
not statistically significant.1

However, DBT is effective at treating
Borderline Personality Disorder (BPD), which
may be present in roughly 1 in 8 (13.1%)
treatment seeking gamblers.2 As impulsive
gambling can be a diagnostic feature of BPD,
referring these individuals to DBT treatment
may eliminate gambling behaviors.
1Christensen
et al. (2013); 2Dowling et al. (2015)
Mindfulness Meditation

Key component of DBT.

Has been added to CBT1 and CT2 with some success, but
more research is needed; combining mindfulness with
CT/CBT more reliably shown effects on depression
(MBCT).

Has been shown to be effective for substance use
disorders (mindfulness-based relapse prevention; MBRP).

May similarly reduce relapse to gambling by decreasing
dissociation, avoidance coping, and reactive response to
urges.

Mindfulness meditation has been shown to alter brain
structure and activation in regions related to attention,
memory, affect, emotion regulation, and selfawareness,3 as well as positively impact immune
functioning.4
1Toneatto,
3Tang,
Pillai, & Courtice (2014); 2de Lisle, Dowling, & Sabura Allen (2011);
Holzel, & Posner (2015); 4Davidson et al. (2003)
Self-Help Programs

Gamblers Anonymous (GA) is the most widely available
gambling treatment approach. Limited research due to
anonymous nature of the program.

Used as both primary treatment (self-help) and
aftercare (referral to GA following formal treatment).

>50% of people attend less than 6 sessions1, and the
median number of sessions attended is zero2

GA, like any treatment, doesn’t work for everyone.
Consider whether GA as aftercare will work for your
client, or if something else is needed.

May be less effective for young adults and adolescents to attend
general adult GA meetings.

SMART Recovery meetings may be an alternative.

Develop Moderation Management for gambling?
1Petry
(2003); 2Petry & Weiss (2009)
Limit gambling access

Stimulus control:
• Self-exclusion
• Procedures and enforcement differ from state to state, venue to
venue, gambling modality to gambling modality
• Breaches are common
• Everi STeP: block access to cash at casino ATMs and booth
services
• GamBlock: blocks access to online gambling
• Advocate for local or state laws to limit gambling access

Enlist help of family members (couples/family therapy)
Case Study Exercise

Please break up into groups of 2-3 people.

Read the case study I’ve provided.

Work together to answer the questions on
the back of the page.

We’ll come back together to discuss the
case before the end of the session.
“Natural recovery” & moderation

About 33% of individuals with PG
quit or reduce gambling on their
own without treatment or GA.

Resolved gamblers most
frequently report they stopped
gambling via “stimulus control”
and “new activities.”

Maintain changes through “new
activities,” “remembering
negative consequences,” and
“social support.”