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The South Australian Statewide Gambling Therapy Service:
Exposure as the model of therapy
Prof Malcolm BattersbyDirector and Professor of Psychiatry
Flinders Universitywww.sagamblingtherapy.com.au
Acknowledgements• Manager Peter Harvey• Team leader Jane Oakes• Research officers Kate Morefield and David Smith• All SGTS therapists, admin staff and consumer
consultants
South Australian Dept of Families and Communities, Office of Problem Gambling who funds the SGTS
Overview
• Statewide service delivery for increasing numbers of clients
• Graded exposure therapy for problem gambling• Key Performance Indicators 2008-09• Overall service activity
– Client characteristics• Engagement with therapy• Outcomes• Predictors of drop out
SOUTH AUSTRALIA
Adelaide South Australia
SA Gaming Machine Revenue
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Gambling in South Australia
• Prevalence 2 -3 % Australian population Problem gambling rate higher in rural communities
• Adverse affects can be devastating:
– Family breakdown– Significant financial loss– Mental illness & suicide (Delfabro, 2005)
Treatments • Counselling, education, avoidance strategies
• Many CBT treatments are multimodal
• Majority of CBT treatments for PG emphasise the correction of cognitive distortions.
• Overall evidence suggest cognitive therapy is effective in reducing problem gambling (Walker, 2005)
• High attrition and relapse rates
SGTS treatment of problem gambling• Model developed over 14 years
• Pathological (problem) gambling is a psychiatric disorder
• Centre for Anxiety and Related Disorders based on UK program at Maudsley Hospital – Isaac Marks
• Exposure with response prevention: anxiety disorders, phobias, OCD
• Extinction of gambling urge
Gambling machines based on models of classical and operant conditioning
Excitement Heart rate
Anxiety Restlessness
I shouldn’t go Only $20
I might win! My lucky day!
Money Hotel
Bills Negative Affect
Gambling relieves the urge
temporarily
Graded exposure• Graded exposure is a brief and powerful way of de-
conditioning the link between triggers and the urge to gamble
• Graded• Repeated• Prolonged• Focussed
Leads to habituation within session and between sessions
Repeated instances of habituation
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Urge
• When the urge is high the gambler experiences a compulsion to gamble
• If the behaviour is not followed through a noxious state of tension arises which in turn increases the compulsion to perform the behaviour (McConaghy et al, 1988)
• The gambling behaviour removes the condition – “negative reinforcement”
Graded Exposure Therapy
START TX
Cues e
licit
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urge
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ambl
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END T
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gam
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extin
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Considerations when using exposure
• Extinction does necessarily not generalise to different contexts
• Clients are taught exposure in session
• Exercises are repeated between sessions in clients own environment
• Include situations that previously led to gambling
• Creates opportunity to incorporate both external and internal cues e.g. negative affect
Stimulus control• The urge is often uncontrollable and money is a powerful
stimulus
• Clients are advised to remove or limit access to cash during early stages of exposure
• Allows effective grading of tasks and ensures response prevention
CASE STUDY
Annie
Screening
Weekly One-on-One Therapy
Sessions
Inpatient Programme2 Week Admission
Discharged to Follow-Up
Follow-up Program1 month3 months6 months
12 months24 months
Assessment
•60 year old married woman
•Recent suicide of son
•Took on care of 13 year of grandson
•Retired from work
Gambling impacts
•Financial difficulties
•Conflict with husband and daughter
•Depression and suicidal ideation
•Limited social networks
Financial
• Daily loss $100-$1000
• Total losses $100,000
• Approximately 95% of daily income after essential bills paid
Gambling internal triggers
•Negative affect
•Loneliness
•Stress
Gambling external triggers
• Money
• Gambling Venue
• Arguments with husband
Elsie's Problem Statement
When I have money, stress and am alone I have an uncontrollable urge to gamble on the pokies resulting in relationship and financial problems, depression, loss of independence and I can not carry money or enter a gaming venue.
Elsie's end of treatment goals
• Sit alone in a venue with $10 in a gaming machine, twice weekly for 1 hour and leave without gambling
• To save $40 per week off bills and towards a family holiday
Treatment outcomes
3 year follow up
South Oaks Gambling ScreenSouth Oaks Gambling Screen
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Elsie’s treatment goals
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Financial Goal
Elsie’s Outcomes• Total sessions: two week inpatient intensive and 4 treatment
sessions
• 3 year follow up positive treatment gains
• Foster mother
• Consumer consultant
• Functioning family and social
Statewide Service Delivery• 4 metropolitan sites
– Southern, Northern, Western
– Central office• Flinders Medical Centre 580
bed teaching hospital
• Regional services– Visiting services
• Fly / drive in
– Telecounselling
– 1 local therapist in regional area
Increasing client numbers
2008-09 Key Performance Indicators
Targets Achievements400 clients will be provided with a direct service each year
524 gamblers were provided with therapy during 2008-09
80% of clients will be comprehensively assessed within 3 weeks of referral
92% of clients saw a therapist within 3 weeks of making contact, almost all assessed same day
50% of clients report reduced gambling within 6 months of the first intervention
Over 70% of clients report reduced gambling behaviour or expenditure within 6 months where data available
50% of registered clients complete a course of treatment
48% of clients completed a course of treatment
80% of clients who complete treatment substantially or fully achieving their goals
96% of clients who completed a course of treatment fully or substantially achieved their goals
Client Characteristics
• 524 gamblers received face to face therapy• 51.5% male• Mean age 45.1 years• 41.8% married/defacto• 35.5% had at least one dependent child• 74.8% Australian born
Age distribution
Employment circumstances
Income
Duration for which gambling had been problematic
Engagement with therapy
Self-rated severity of gambling problem
Strength of urge to gamble
Hours spent gambling (past month)
Reduced gambling
Satisfaction with financial management
Improved finances
K10: Psychological Distress
Suicidal Ideation
Improved psychological wellbeing
Helping people who attend treatment in support of problem gamblers
N = 70 non gamblers – 74.2% female– Mean age 45 yrs – Most commonly the
partner of gambler (49.2%)
– 80% attend one treatment session
Parent 26.2%
Child 7.7%
Friend 3.1%
Other relative 4.6%
Sibling 4.6%
Other 4.6%Partner 49.2%
Indigenous client numbers increasing
Treatment outcomes and predictors of drop out for problem gamblers in South Australia: a cohort study
The South Australian Statewide Gambling Therapy Service
Study Design
• Treatment seeking problem gamblers recruited through the South Australian Statewide Gambling Therapy Service (SGTS) in 2008
• Repeated outcome measures included problem gambling
screening, gambling related cognitions and urge at 1, 3, 6, and 12 months
• Dropout based on SGTS clinicians derived cut-off of 3 sessions or less including first screening
• Candidate predictors of treatment dropout included perceived social support, anxiety and sensation seeking traits
Participant enrolment• Participants recruited from consecutive referrals (n = 240) to SGTS
during study recruitment period March to September 2008
• Reasons for non-participation:
Non-eligible persons- 23 met exclusion criteria for unstable mental state
Eligible persons (n = 217)- 50 (23%) declined to participate- 25 (11.5%) administration error- 11 (5.1%) unknown- 3 (1.4%) limited English- 1 (0.3%) homeless
Participant enrolment and flow
• 127 persons consenting to participate
• Median time for participants enrolment in the study was 8.9 months with 50% of participants having times between 7.4 and 9.7 months
• 91 (71.7%) completed measures at 3 months or more
• 80 (63%) completed measures at 6 months or more
Baseline demographics
• 69 (54%) males
• mean age 43.09 years (SD=12.65 years)
• 65 (52%) duration of problem gambling greater than 5 years
• Moderate to severe depression, anxiety and stress compared to normal population scores
• 31% classified as either moderate or high risk alcohol use
Main results
• Linear Mixed Models performed to assess change over time for each outcome variable
• 68% treatment completers (4 or more sessions)• Significant reduction (improvement) in scores for
– Victorian Gambling Screen (VGS)– Gambling Related Cognitions Scale (GRCS)– Gambling Urge Scale (GUS)– Depression Anxiety and Stress Scale (DASS21)– Work and Social Adjustment Scale (WSAS)
• Non-significant change over time– Alcohol Use Disorders Identification Test (AUDIT)
(n=86)(n=41) (n=48) (n=10) (n=57) (n=13) (n=59)(n=13) (n=32) (n=7)
1020
3040
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Mea
n V
GS
sco
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Baseline 1 month 3 months 6 months 12 months
Time
Treatment completers
Treatment dropouts
Mean self-harm Victorian Gambling Screen (VGS) Scale scores with 95% confidence intervals as a function of treatment completion status*
*Lower scores indicate improvement (i.e. a reduction) in problem gambling symptoms
Mean Gambling Related Cognition Scale (GRCS) scores with 95% confidence intervals as a function of treatment completion status*
*Lower scores indicate improvement (i.e. a reduction) in problem gambling symptoms
(n=86) (n=41) (n=47) (n=9) (n=55) (n=11) (n=54) (n=11) (n=31) (n=6)30
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n G
RC
S s
core
Baseline 1 month 3 months 6 months 12 months
Time
Treatment completers
Treatment dropouts
(n=86) (n=41) (n=53)(n=11) (n=56) (n=14) (n=59) (n=13) (n=32) (n=7)
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n G
US
sco
re
Baseline 1 month 3 months 6 months 12 months
Time
Treatment completers
Treatment dropouts
Mean Gambling Urge Scale (GUS) scores with 95% confidence intervalsas a function of treatment completion status*
*Lower scores indicate improvement (i.e. a reduction) in gambling related urge
Potential predictors of treatment dropout
– Demographics, – Trait Anxiety Inventory (Speilberger TAI), – Arnett Inventory of Sensation Seeking (AISS), and – Multidimensional Scale of Perceived Social Support
(MSPSS)
• Logistic regression used to assess extent which potential predictor variables were related to treatment dropout
• Sensation seeking traits significantly predicted treatment dropout
Multivariate prediction of treatment completion status
Variable OR* (95% CI) Waldstatisitc
p-value
Trait Anxiety Inventory (TAI) 0.99(0.95-1.02) -0.70 0.486
Marital status**
separated/divorced 0.25(0.07-0.98) -1.99 0.047
single 0.78(0.34-1.78) -0.60 0.551
Arnett Inventory of Sensation Seeking (AISS) 1.06(1.00-1.11) 2.12 0.034
*Odds Ratio = e β
**Married/de facto is the base category
Current research
• Naltrexone pilot study
• Nerophysiological study
• RCT Cognitive Therapy & Behaviour Therapy
Gambling Publications • Harvey, P.W. (2008). "Self-management and the treatment of gambling addiction: a rationale."
Health Issues, Summer 2008 (97), 34-38.
• Oakes, J., M. Battersby, R. G. Pols and P. Cromarty (2008). "Exposure therapy for problem gambling via videoconferencing: A case report." Journal Gambling Studies 24(1): 107-118.
• Tolchard, B., L. Thomas, M. Battersby (2007). "GPs and Problem Gambling: Can they Help with Identification and Early Intervention?" Journal of Gambling Studies 23: 499-506.
• Battersby, M. W., B. Tolchard, M. Scurrah and L. Thomas (2006). "Suicide ideation and behaviour in people with pathological gambling attending a treatment service." International journal of mental health and addiction 4(3): 233-246.
• Tolchard, B., L. Thomas and M. W. Battersby (2006). "Single-Session Exposure Therapy of Problem Gambling: A Single Case Experimental Design." Behaviour Change 23(2): 148-155.
• Battersby, M. W., J. Oakes, B. Tolchard, A. Forbes and R. G. Pols (2008). Cognitive Behavioural Treatment for Problem Gamblers. In the pursuit of winning. M. Zangeneh, A. Blaszczynski and N. E. Turner, Springer US: 179 -197
ContactStatewide Gambling Therapy
Service Flinders Medical Centre
E2 The Flats, Flinders Drive Bedford Park SA 5042
Tel: + 61 8 8204 6982 Website: Website: www.sagamblingtherapy.com.au
Email; [email protected]@flinders.edu.au
