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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
Patients Treated: Before Casinos
400
200
Year
'02
'00
98
96
94
92
90
88
86
0
84
100
82
Number
300
Number of Gamblers Seeking
Treatment in CT
Patients Treated: Foxwoods Opens
400
Foxwoods
Casino
Opens
200
Year
2
0
97
96
94
92
90
88
86
0
84
100
82
Number
300
Number of Gamblers Seeking
Treatment in CT
Patients Treated: Today
Mohegan
Foxwoods Sun Casino
Opens
Casino
Opens
400
200
Year
'02
'00
98
96
94
92
90
88
86
0
84
100
82
Number
300
Gambling Treatment
Treatment Options for PG
1. 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
n
Manual
Therapy
63
84
84
Male
50.0%
57.6%
58.8%
Caucasian
81.3%
84.7%
84.7%
44.5
44.2
46.0
Married
39.1%
36.5%
42.4%
Income
$42,500
$43,000
$46,000
31.7%
29.8%
21.2%
Age
Prev. Subs
Abuse TX
Gambling Treatment - Adherence
Treatment compliance
GA Attendance
Manual
75
100
75
%
50
25
50
25
0
N
on
e
So
m
e
>7
5%
y
Th
er
ap
M
an
re
ua
l
f
0
A
G
% Subjects
100
Therapy
Gambling Treatment - Results
Days Gambled
Median $ Gambled
GA ref
2500
15
Days
Manual
10
Therapy
5
2000
1500
$
1000
500
0
0
Pre Wk 4 Wk 8
TX
Pre Wk Wk
TX 4 8
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 Treatment
Psycho-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
Wed
04/04
Don’t want
to go.
Go to church Church
Bulletin
Sun.
04/08
Over sleep!
Have coffee
with sister
Sat.
04/07
She’s busy.
Go to GA
Mtg.
Signed
Slip
Receipt
Done
?
CM For Gambling Treatment
31 clients assigned to CBT+CM
Thus far, 493 activities contracted with 66%
completed.
 135 activities were completing CBT homework
(27.4%)
 43 activities were going to GA meeting (8.3%)
M ean Session
Preliminary Results - I
Therapy attendance
8
6
4
2
0
CBT
CBT-CM
Preliminary Results - II
% C o m p le te d
Homework exercises
80
60
40
20
0
CBT
CBT-CM
Preliminary Results - III
GA Attendance
M ean M eetings
5
4
3
2
1
0
CBT
CBT-CM
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.
Summary
1. 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