1. David Hodgins
University of Calgary
NCRG, 2010

2. Descriptive Accounts
Uncontrolled Trials
Randomized Controlled Trials (RCTs) - efficacy
Effectiveness Trials/Mechanisms/Systems

3.  Does this work in the real world?
• Real clients, group vs. individual,
therapists competence?
 How does it work? Can we make it
more efficient or more effective?
 What place does it have in the
overall range of treatment options?

4.  Family models
 Psychodynamic models
 Gamblers Anonymous
 Cognitive
 Behavioural
 Cognitive-behavioural models
 Motivational Interviewing
 Multimodal Treatment

5.  Family models
 Psychodynamic models
 Gamblers Anonymous
 Cognitive
 Behavioural
 Cognitive-behavioural models
 Motivational Interviewing
 Multimodal Treatment

6.  Family models
 Psychodynamic models
 Gamblers Anonymous
 Cognitive
 Behavioural
 Cognitive-behavioural models
 Motivational Interviewing
 Multimodal Treatment

7.  Pallesen et al. (2005)
• 22 uncontrolled and controlled studies,
1434 clients
• Large effect of treatment post-treatment
and at follow-up (17 months), compared
with no treatment

8.  Gooding & Tarrier (2009)
• 25 CBT trials - very diverse
• Mode: Individuals, group, self-directed
• Therapy: CBT, Imaginal desensitization, CBT-MI
combos
• Type of gambling:
• Length: 4 to 112 sessions (Median = 14.5)
• Large effects at 3, 6, 12, and 24 months
• Better quality studies, smaller effects
• File drawer effect – 585 studies required.

9.  Morasco et al., 2007- within treatment
descriptions of what clients are doing
 Petry et al. (2007) – coping skills
 Hodgins et al., (2009)- Change talk in MI

10.  Nancy Petry’s 8 session CBT (Petry, 2005)
 Each session has a worksheet
 Overall goal is to improve coping skills
 Petry et al. (2007) – coping skills
improvement does lead to better
outcomes (i. e., effective ingredient)

11. Session 4 Session 8
Social 26% 67%
Support
GA/therapy 4% 43%
support
Cognitive 21% 31%
skills
Distraction 45% 26%
Avoid 40% 20%
triggers

12. Specific day of the 33%
week
Mood- stressed, bored, 30%
lonely
Unstructured time 27%
Access to money 22%
Gambling cue 19%
A specific time of the 17%
day

13. Action % of people
New activities/Change in focus 68%
Stimulus Control/Avoidance 48%
Treatment/GA support 37%
Cognitive skills 34%
Budgeting 31%
Willpower/Decision-making/self-control 23%
Social support 10%
Others – confession, no money, non- <5%
gambling external factors, self-reward,
spiritual, addressing other addictions Hodgins et al., 2009

14.  Premise: what
an individual says about
change during MI is related to
subsequent change
 Verbalizing
an intention to change
(CHANGE TALK) leads to public and
personal obligation to modify one’s
behavior

15. • Coded therapy transcripts for Change
Talk
• Does amount of Change Talk correlate
with change
in gambling behavior?
• 3 months r = -.39*
• 6 months r = -.36*
• 12 months r = -.35*
* p < .05 Hodgins , Ching & MacEwan,, 2009

16.  Does MI reduce drop-out?
 Effectiveness of individual versus group
formats?
 Potential role for desensitization?
 Does giving clients a choice of goals
make a difference (Abstinence versus
controlled gambling)?

17.  Large issue for CBT, GA, etc.
 Wulfert et al. (2006) pilot study
 Standard treatment dropout 34%, post-
treatment SOGS = 10.4
 CBT-MI dropout 0%, post-treatment
SOGS 1.2
 Subsequent CBT-MI combos – perhaps
slight decrease in drop-out?

18.  MI (4 sessions)
 Group CBT (8 sessions)
 Waitlist
 MI, GCBT > waitlist
 Attendance
• Mi: M = 2.9 of 4 sessions (72%)
• GCBT: 5.6 of 8 sessions (70%)
• Mi: 43% attended all 4
• GCBT: 29% attended all 8
 More
to learn – we need to do better with
drop-out

19.  Dowling at al. (2007) women in CBT
 Oei & Raylu (2010) both genders in CBT-
MI combo
• Treatment manual
 Slightadvantages for 1:1
 Implications?

20.  Not all CBT is the same
• Relative focus on cognition versus behaviour
• Behaviour – coping skills from alcohol literature
(Petry)
• Desensitization from anxiety literature (Dowling,
Blaszyzcnski, Battersby)
 Systematic and graded exposure to cues
to gamble – imaginal, in vivo, or both
 McConaghy et al., 1983 – Imaginal > in
vivo, aversion

21.  GA referral
 MI plus Imaginal desensitization
• 6 sessions plus audiotape
 Post-treatment abstinence- GA- 17%, MI/
ID- 63%
 Is this an effective ingredient?
 Battersby in vivo model – well described
in Oakes at al., (2010)

22.  Alcohol field – appropriate goal for less
severe dependence, more socially stable
clients; people choose appropriately
over time
 Some studies offer this (e.g. Hodgins)

23.  Dowling at al., (2009) 12 session CBT
Abstinent goal Cut down goal
Post treatment – 84% 83%
no diagnosis
Six month – no 89% 83%
diagnosis
Depression 8.9 7.1
(BDI)
Gambling 0.3 0.5
frequency

24.  Toneatto & Dragonetti (2008)
 CBT (8 sessions)
• Abstinence goal – 35%
 Twelve-step facilitation (8 sessions)
• Abstinence goal – 96%
 No difference in treatments
 Clients choosing abstinence had more
severe problems, attended more
treatment, and were more likely to meet
their personal goals at 12 mos.

25.  Ladouceur at al. (2009)
 CBT (12 sessions) aimed at control
 No diagnosis – post treatment -63%, six
months- 56%, 12 months -51%
 66% shifted goal to abstinence, more
likely to meet their goal
 Offering choice did not seem to reduce
dropout. (31%)

26.  People do move towards the appropriate
goal – does offering goal choice increase
treatment seeking?
 Moving in the right direction in terms of
offering better treatments, that people stick
with.
• Both RCTs and effective studies are useful
 Treatmentsystem issues largely
unaddressed - < 10% treatment uptake –
how do we get people to participate in self-
directed recovery or attend treatment?