Contingency Management in Problem Gambling Treatment Jeremiah Weinstock, Ph.D. University of Connecticut Health Center Farmington, CT USA
Overview • Pathological Gambling & Its Treatment • Background on Contingency Management (CM) • 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.
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Gambling Treatment • Treatment Options for PG • Gamblers Anonymous (12-Step) • Outpatient Counseling • Cognitive Behavioral Therapy (CBT) • Marital Therapy • Brief Interventions • Motivational Enhancement Therapy • Pharmacotherapy (medication) • 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: • Referral to Gamblers Anonymous • GA Referral + CBT self-help manual • GA Referral + CBT counseling. Petry et al., 2006
Gambling Treatment • WHAT CAN BE DONE?
Contingency Management • Contingency Management: • Based upon principles of operant conditioning. • Three behavioral tenets of CM: • Frequent monitoring of target behavior. • Providing tangible reinforcement for completion of target behaviors. • Remove reinforcement when target behavior does not occur. • Typically, CM is added onto another SUD treatment.
Contingency Management • Contingency Management Reinforcement: • Vouchers - $$$$ • Silverman et al. (1996) = $1,155 • Higgins et al. (2000) = $997.50 • 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.
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%)
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 • PG is associated with a host of adverse consequences. • Numerous treatment options are available, however few PGs seek treatment. • Current treatments can be effective, but there is room for improvement. • Contingency management is one way to improve treatment attendance and adherence. • 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