Development of an 8week managed care model 1 session per week 50 min in length 8 weeks Traditional Cognitive Behavioral Therapy Focus on identifying triggers or antecedents Developing strategies for engaging in alternative behaviors that lead to similar ID: 588432
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Slide1Slide2Slide3
And now for “real treatment”…
Development of an 8-week managed care model
1 session per week
50 min in length
8 weeksSlide4
Traditional Cognitive Behavioral Therapy
Focus on identifying “triggers” or antecedents
Developing strategies for engaging in alternative behaviors that lead to similar
reinforcers
Learning how to control urges (by thinking of alternative behaviors)
Avoidance of gambling establishing operationsSlide5
Pathological Gamblers
w
/ co-occurring Brain Injury
Brain injury often results in development of impulse control disorders
Our data have shown that in a survey of over 200 persons with brain injury the rate of problem gambling was 20%
Unsure if gambling problems were in life prior to brain injury or as a result of the injury
Captive population allowing for cleaner experimental controlSlide6
Guercio
, Johnson, & Dixon (in press, JABA)
Participants: 3 participants with acquired brain injury
Method:
Baseline: Trips taken to casino and lab-casino and given 20 dollars to gamble
Intervention: 8 weeks of 1 hour therapy sessions. Allowed lab-casino gambling immediately after therapy session.
DV: money spent on gambling, self-reports of gambling severitySlide7Slide8Slide9Slide10
Behavioral Treatment Works
Does it work well enough?
Have we really “fixed” the problem?
Is CBT the “best” we can do?
When compared to alternative behavioral models it often falls short
Avoidance of gambling related stimuli is harder to do as gambling opportunities continue to expand
Is there an alternative to “avoiding” life?Slide11
Acceptance and Commitment Therapy
Alternative to traditional CBT
Acceptance not suppression of thoughts
(forced exposure to private events and aversive stimuli)
Contacting life in the moment
(responding relationally to temporal relations of here-now; not before-after)
Creating distance between your discrimination of “self”
(and overt/covert verbal behavior that describes yourself)
Move Over FredSlide12
Psychological
Flexibility
The ACT Question
Freely chose a direction you want to head in
Not the stories you tell about yourself, but you
Willing to show up to whatever you are experiencing without defenses
See things for what they are, and not what they say they are
In this moment are you
And gently return to that direction when you find yourself off trackSlide13
Number
of ACT Empirical PublicationsSlide14
Number of ACT
RCTsSlide15
ACT Outcomes
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcome.
Behaviour Research and Therapy, 44,
1-25
.Slide16
Present Study
Participants
7 pathological gamblers seeking treatment
3 wait-list control gambler seeking treatment
Paid total of 200 dollars for participating in study
Setting
Gambling therapy clinic
Carbondale Memorial Hospital
Procedure
Pre-screening
Baseline evaluation (behavioral/neurological)
8 hours of 1:1 ACT therapy
Treatment evaluation (behavioral/neurological)Slide17
Setting and Experimental Task
Self-referral to treatment Program
Intake with therapist in clinic within
aprox
7 day of call
Completion of battery of psychometric tests and actual gambling exposure
Initial Scanning in
fMRI
at Hospital
8 hours of 1:1 therapy delivered in clinic
Final Scanning in
fMRI
at HospitalSlide18
Subject
Age
Gender
Attempts
to Quit
SOGS
GFA
Pre
Post
4836
24
M
2
6
T
4841
52
F
1
7
S/A*
T
4338
56
F
1
7
T
1
18
M
2
9
A
S/A
2
20
M
2
9
A
S
3
20
M
1
4
A
A
9
19
M
2
6
A
T
Control 1
23
M
1
6
T
T
Control 14
19M15SA/SControl 1218M29TT
TSlide19Slide20
Component analysis;
frequency count
Component
Wk
1
Wk 2
Wk 3
Wk 4
Wk 5
Wk 6
Wk 7
Wk
8
Total
% exposure
ACCEPTANCE
1
1
3
4
2
1
22.64%
DEFUSION
2
1
3
11.32%
SELF AS CONTEXT
1
1
4
11.32
VALUES
3
1
1
212
18.87
COMMITTED
ACTION
1
2
2
1
4
9.43
PRESENT MOMENT
1
1
1
2
1
11.32
OTHER
1
1
1
1
1
1
1
1
15.09Slide21
Valued Living Questionnaire –
Rate on Scale 1-10Slide22
fMRI
Scanner Task
5 blocks of exposure to 2.5 sec of slot machine reels spinning & 2.5 sec of slot machine outcome
20 near-miss outcomes
20 total loss outcomes
20 win outcomes
Participants asked to rate on scale of 1-5 how pleasurable each outcome was.
1 not at all pleasurable
5 very pleasurableSlide23Slide24Slide25Slide26Slide27Slide28Slide29Slide30Slide31Slide32Slide33Slide34Slide35Slide36Slide37Slide38Slide39Slide40Slide41Slide42Slide43Slide44Slide45Slide46Slide47Slide48
4836
Treatment Content AssessmentSlide49
4841
Treatment Content AssessmentSlide50
4338
Treatment Content AssessmentSlide51
Sub ID
AAQ PRE
AAQ POST
MAAS PRE
MAAS POST
VLQ PRE
VLQ POST
GSAS PRE
GSAS
POST
4836
40
40
54
50
37.5
39.3
3
7
4841
41
45
58
56
36.9
61.9
13
13
4338
38
36
51
55
36.9
41.4
20
22
1
28
36
58
62
34.7
23.6
11
6
2
22
37
49
51
33.5
43.7
15
10
3
55
50
76
65
65.252.261396951756382.197210Control 16462706849.749.51013CONTROL 21917486171.665.51520CONTROL 36250715755.369.82927Slide52
Average NM Rating pre/post 8
hr
ACT
Pre
Post
4836
4841
4338
1
2
3
9
C1
C2
C3Slide53
Treatment: Wins - Losses
Pre
631
642
Post
644
652
643
653Slide54
Treatment: Near-Misses - Losses
Pre
631
642
Post
644
652
643
P<0.05
653Slide55
Treatment: Losses - Wins
Pre
631
642
Post
644
652
643
653Slide56
Control
Pre (648)
Post (654)
Wins - Losses
Near-Misses - Losses
Losses - WinsSlide57
Treatment: Wins - Losses
Pre
631
642
Post
644
652
643
653Slide58
Treatment: Near-Misses - Losses
Pre
631
642
Post
644
652
643
P<0.05
653Slide59
Wins – Losses Pre-Treatment (Both Groups Combined)Slide60
Wins – Losses Post-Treatment (Treatment Group)Slide61
Wins – Losses Post-Treatment (Control Group)Slide62
Near Misses – Losses Pre-Treatment (Both Groups Combined)Slide63
Near Misses – Losses Post-Treatment (Treatment Group)Slide64
In Summary
Therapy was effective at changing:
Self-ratings of what a valued life was to each person
Reducing the near-miss effect in terms of degree of “pleasure” in therapy context & in
fMRI
scanner
Brain activation patterns
Gambling stimuli are not “seen” by the client as the “same” following therapy
Multiple novel functions have entered into the relationship between the stimuli and what they “mean” to the personSlide65
I almost won
Keep playing
I will feel better soon
A win is coming soonSlide66
This is just another loss
My values in life are not being met by playing anymore
I never really win
Near-misses are
a trick
I
just spent my kid’s lunch money
I am trying to escape from the pain of my life
This is destroying my
marriageSlide67
Final Thoughts
Gambling is not the problem – it is the outcome of the problem.
Treat the language mess that got the client in the mess they are in.
Move beyond contingencies and we will move beyond the limited changes we have made in treatment for the pathological gambler.Slide68
Bridging the Gap between Research and Practice
Mark R. Dixon & Alyssa Wilson
Southern Illinois University