Internet - based treatment for problem gamblers Discovery 2012 Thomas Nilsson Spelinstitutet, Sweden Email: thomas@spelinstitutet.se
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We were, and are, inspired by: CBT technique in general and for depression and anxiety Motivational Interviewing. 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 Background (2)
The main channel for recruitment was internet! But they could find the link via: Google Gambling operators Step 1 Recruitment
Meet criteria for pathological gambling Not being too depressed or suicidal + 18 years of age Living in Sweden Accepted that we stored there personal data Internet access Step 2 Inclusion criteria
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) Step 3 Screening
Modules 1-4 lead to a decision: Stop all together or just 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 Step 4 In total eight (8) treatment modules
Gambling background Consequences for the 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 First telephone session
Texts about: how an addiction develops characteristics for addictions Questions about: values and life goals positive and negative consequences from gambling why they gamble MODULE 1
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 2
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 stopping gambling Make a decision whether you want to change gambling behaviour or not Module 3
Texts about: acceptance and mindfulness as a tool the importance of acceptance for the losses dreams of big wins Make a contract with yourself Tell families and friends about their gambling problem Module 4
Alternative activities Common negative thoughts Miss consumptions about chance and luck Erroneous beliefs about gambling Module 5
Make a plan to avoid relapse Ask family and friends for help Strategies for handling urges Exercise can be an alternative Module 6
Listing your debts Making a plan for paying back Strategies to control your economic Module 7
Reward yourself for job well done Laps and relapse A plan for change Look back on goals and contract More support? Module 8
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 Telephone support
NODS HADS Quality of Life Inventory Self reported gambling Questions on how they experienced the treatment, contact with the therapist, etc Step 5 Follow up
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 For the therapist: Therapists judge if a patient is ready to go to the next module, and gives feedback A typical treatment week
Why/what at do the clients like about the manual? Talk to the therapist Anonymous Internet is every where 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)
VLT (Vegas) Internet poker Poker Trotting Casino Internet Most gamblers have more then one problematic game Problem games data from screening
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 Participants data from 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
Measure M est SD est d est 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
Success? Out of the 196 clients 77 (40 %) was regarded as successful. They meet the criteria on the 36 month follow up: 0 on NODS and no gambling the last month
Predicting success at post treatment Satisfaction at work QOLI Out of seven predictors three could predict success: Satisfaction at work Alcohol use Dissociation Strongest, in combination, is: Alcohol (>2 ) use and dissociation (never, very occasionally, less the 50 % and sometimes) Gambling debts Network Income Alcohol consumption Motivation Dissociation Questionnaire Questionnaire Questionnaire AUDIT RFCQ Jacobs
Predicting success after 36 months Satisfaction at work QOLI Only one variable, out of seven, could significant predict a successful result having gambling debts. That factor doubled the chance for success. Gambling debts Network Income Alcohol consumption Motivation Dissociation Questionnaire Questionnaire Questionnaire AUDIT RFCQ Jacobs
Predicting drop out Drop out was defined as not doing all modules. 284 started treatment, 138 completed all modules. Dissociation - always High on anxiety Playing poker or VLT Low or no income Very bad working condition Contemplation
What's next? Self help books can be bought in book stores and online. PDF files can be down loaded from Internet. But they are not very smart. Our next step is to build an interactive self help program online using the knowledge, experience and research we done so far. This is how we think and are currently working on.
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. http://www.fhi.se/publikationer/allapublikationer/internetbaserat-sjalvhjalpsprogam-forspelberoende-slutrapport/