ATHABASCA UNIVERSITY UNIVERSITY OF CALGARY UNIVERSITY OF LETHBRIDGE RESIDENTIAL TREATMENT FOR INDIVIDUALS WITH A GAMBLING PROBLEM ELLEN R. C.

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1 ATHABASCA UNIVERSITY UNIVERSITY OF CALGARY UNIVERSITY OF LETHBRIDGE RESIDENTIAL TREATMENT FOR INDIVIDUALS WITH A GAMBLING PROBLEM ELLEN R. C. LOEWEN A Final Project submitted to the Campus Alberta Applied Psychology: Counselling Initiative in partial fulfillment of the requirements for the degree of MASTER OF COUNSELLING Alberta November 2006

2 DEDICATION With much love and appreciation, this graduate project is dedicated to my husband, Frank Loewen and special friend Sylvia Fuerbringer. With their support and encouragement, this project has come to life. i

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5 ABSTRACT The purpose of this project was to determine best practices for residential treatment of problem gambling. This was addressed through a comprehensive literature review that examined various theories, models, strategies, and interventions utilized for helping individuals with gambling problems overcome their self-defeating behavioural patterns. The studies available were primarily from the perspective of cognitive behavioural therapy (CBT), motivational enhancement theory (MET), and transtheoretical model (TTM) of change. CBT had the strongest evidence of efficacy, followed by MET and then TTM. The weakest evidence of success was found in studies on psychodynamic psychotherapy, aversion therapy, self-exclusion, pharmacological treatment, and Gamblers Anonymous. Although the studies reviewed were limited in scope, a glimpse into the field of research on gambling behaviour was informative. After reviewing the literature and identifying best practices, the information was synthesized into recommendations for residential treatment for individuals with gambling problems. iv

6 ACKNOWLEDGEMENTS I would like to thank Dr. Gina Wong-Wylie for the diligent effort she put in to help me complete this project. The quality is due to her guidance, patience, and persistence to achieve high academic standards. I would also like to thank my family and friends for their patience and encouragement while I worked on this project. Above all, I Thank God who guided my choices, and carried me when I was tired. v

7 TABLE OF CONTENTS CHAPTER I INTRODUCTIONS 1 History 1 Alberta History 1 Definition of Problem Gambling 2 Structure of this Project 3 Rationale for Project 3 Statistics 3 Psychosocial Affects 4 Procedures 5 CHAPTER II LITERATURE REVIEW 6 Theoretical Foundations 6 Psychoanalytic Theory 6 Behaviour Theory 7 Cognitive Theory 9 Cognitive Behavioural Theory 10 Motivational Enhancement Theory and Transtheoretical Model of Change 11 Summary 12 Approaches 12 Mode of Delivery 14 Current Residential Programs in Alberta 16 Research Review and Findings 19 vi

8 Research Review 20 Cognitive Behavioural Theory and Motivational Theory Studies 25 Pharmacological Treatments 29 Research Findings 30 CHAPTER III SYNTHESIS AND IMPLICATIONS 33 Overview 33 Strengths and Limitations of Literature Review 34 Synthesis and Future Direction for Effective Treatment for Individuals with a Gambling Problem in a Residential Setting 35 Effective Treatment for Individuals with a Gambling Problem 38 Recommendations for Best Practices in a Residential Setting 40 Implications of Project 43 References 45 vii

9 CHAPTER I INTRODUCTION History Gambling behaviour goes back to biblical times (Shafer & Freed, 2005). Various characteristics are used to define gambling behaviour. Gambling is an activity that involves an element of chance where a person places a wager or bet. It may include buying a lottery ticket, investing in the stock market, betting the outcome of a sporting event, playing a casino game, or wagering on a horse race (Brody & Fogg, 2001, Ciarrocchi, 2002). Alberta History AADAC (2005) offers some interesting facts about gambling history: 1. Alberta s first casino opened in 1967 and the Western lottery ticket became available in Following this, the Lotto 6/49 was launched in Video Lottery Terminals (VLTs) started in 1991(Alberta Gaming and Liquor Commission Board, 2005). 4. Then, in 1997 VLTs were being voted out in communities such as Rocky Mountain House, Lacombe, and Sylvan Lake. 5. By 2003 nearly 200 VLTs were removed from seven communities across the province. 6. In 2004, the Alberta Gaming and Liquor Commission replaced 6000 VLTs with updated machines that featured new games and responsible gambling features. 1

10 From the time VLTs were introduced in Alberta, the industry has grown and become the most visible and persistent element for individuals with gambling problems, followed by slot machines and betting in casinos. Definition of Problem Gambling Addictive, compulsive, pathological, and problem gambling are terms used to describe individuals with serious gambling problems (Canadian Centre on Substance Abuse (CCSA), 2005; CCSA National Working Group on Addictions Policy, 1998). These terms are used interchangeably within the literature. Some of the difficulty in identifying accurate treatment lies in the multiple categories researchers and clinicians employ to define and describe gambling behaviour. Such differences breed divisions in research and prevent a global, comprehensive understanding of gambling behaviour (Toneatto & Ladouceur, 2003). One term needs to be used that can be adopted to refer to problem gambling, compulsive gambling, and pathological gambling (Ladouceur, 1996). The CCSA National Working Group on Addictions Policy (1998) defines problem gambling as a recognized psychiatric disorder with the following criteria: 1. Continuous or periodic loss of control over gambling behaviour 2. A preoccupation with gambling and with obtaining money to gamble 3. Irrational thinking 4. Continuation of gambling behaviour despite negative consequences In this project, problem gambling refers to the abovementioned as well as all the patterns of gambling behaviour that damages, compromises, or disrupts major life areas. Problem gambling behaviour includes betting more than one can afford to lose, exceeding pre-set time and spending limits, increasing betting levels to maintain the same 2

11 degree of excitement, returning quickly to win back losses, borrowing money or selling property to pay gambling debts or to obtain money to gamble, lying and hiding evidence of gambling activities, and committing illegal acts such as theft to get money to gamble (Smith & Wynne, 2002). Structure of this Project My purpose in this project was to determine best practices for residential problem gambling treatment. This was addressed through a comprehensive literature review that examined various theories, models, strategies, and interventions utilized for helping individuals with gambling problems overcome their self-defeating behavioural patterns with a specific focus on residential settings. Following this chapter, which included history, definitions, statistics, psychosocial affects, and procedures utilized to conduct literature review; Chapter II involved a discussion of the theoretical foundations for this project, including the factors that influence the direction of treatment and examines a review of the literature. Finally, within Chapter III, the writer discussed effective treatment for individuals with gambling problems in a residential setting, recommendations, future implications as well as the limitations of the literature review. Rationale for Project Statistics Recent studies suggest that individuals who are at most risk for gambling problems include: Aboriginal people, men, people with less education, and Video Lottery Terminal (VLT) players (Statistics Canada, 2003). There are over 80 permanent casinos, an estimated 40,000 slot machines, 40,000 VLTs, 70 racetracks, and over 20,000 bingos 3

12 played every year in Canada (CCSA, 2005). Gambling revenue has increased from $4.5 billion in revenue in 1995 to $5.5 billion in 2000, close to what is paid out in taxes for alcohol and tobacco use. Although gambling is a popular form of entertainment, between 3% and 5% of Canadians develop a gambling addiction. This means that 600,000 to one million Canadians are struggling with gambling issues. When individuals and families impacted by problem gambling are added, the number rises to 3 million. Researchers conducting a provincial study funded by the Alberta Gaming Research Institute suggested that 5.2 % of the population or over 15,000 Albertans have a problem with gambling at any given time and 3.9% of the population has a severe problem with gambling (Alberta Alcohol and Drug Commission (AADAC), 2003). Alberta has the highest prevalence of problem gambling compared to other provinces with the exception of Saskatchewan, which leads with 5.9% of the population experiencing problems with gambling. Psychosocial Affects of Problem Gambling Problem gambling can lead to serious health and social effects such as mental health issues, substance abuse issues, loss of financial stability, criminal activity, or interpersonal issues (Azmier, 2001; National Council of Welfare, 1996). For example, costs associated with gambling include domestic violence, family fragmentation, child abuse, neglect, and threat and completion of suicide by the individual with the gambling problem. Furthermore, Azmier estimates that the emotional distress the families experience involve $5000 to $15,000 in costs per year. As such, this project is a timely and important investigation of effective interventions for individuals with gambling problems in a residential setting. 4

13 Procedures This project involved a literature review, which was carried out to investigate the interventions that contribute to the recovery of individuals with gambling problems in residential treatment and to identify interventions that are less successful. A systematic electronic search included references from a wide variety of sources including databases from Alberta Government Library such as Medline, PsychINFO, and Sociological abstracts for information on gambling and interventions specific to residential gambling services. Services provided by AADAC, as well as books from well-known authors in the field of gambling behaviour, were also included. Key words included: gambling, problem gambling, compulsive gambling, pathological gambling, treatment for gambling, gambl* interventions, cognitive behavioural treatment and gambling, gambling and residential treatment. The search focused on 1995 present day and included English-only writing. 5

14 CHAPTER II LITERATURE REVIEW Theoretical Foundations The wellbeing of all Canadians is impacted by the atrocities created by problem gambling behaviours. The costs are astounding not including loss of a loved one through suicide or poor health, or the emotional and mental strain of those associated with problem gambling (Azmier, 2001; Collins & Lapsley, 2003). Theorists are working to help understand, assess, and treat individuals with gambling problems. Within this Chapter, I reviewed the theories that created a foundation for research and clinical interventions in the area of problem gambling. Psychoanalytic theory is briefly mentioned due to the historical beginnings; however, the more common theories are behavioural theory, cognitive theory, cognitive behavioural theory (CBT), motivational enhancement therapy (MET), and the transtheoretical model (TTM) of change, which I discuss to provide groundwork for the literature review. Psychoanalytic Theory In 1914, Von Hattingberg became the first psychoanalytic theorist and researcher to conduct studies of problem gambling (Moreyra, Ibanez, Saiz-Ruiz, Nisseson, & Blanco, 2000). Von Hattingberg providedthe groundwork for Freud and Bergler who, in the early 1950s, described gambling as a form of addiction related to the Oedipus complex. Freud and Berger s theories remained the prevailing psychoanalytic explanations for problem gambling until the middle of the 1980s. Then, in 1986, Rosenthal identified problem gambling as a consequence of narcissistic personality traits. He identified omnipotence and denial as two defence mechanisms characteristic of individuals with gambling 6

15 problems. This supported the gambler s belief in the competence to win despite logical arguments that suggest otherwise (Blanco, Ibanez, Saiz-Ruiz, Blanco-Jerez, & Nunes, 2000; Ladouceur, Sylvain, Boutin, & Doucet, 2002; Moreyra et al., 2000.) Behaviour Theory As support for psychoanalytic theories diminished, behavioural theories became more prominent in the 1960s and remained popular until the 1980s (Ladouceur et al., 2002). Hence, gambling as a learned behaviour disputed the idea that childhood issues and internal conflict influenced problem gambling as in psychoanalytic theory. In this perspective, a learned behaviour becomes a strong habit, which is influenced by the gambler s environment and genetic disposition. Although learning is the principle for behavioural theory, there are a number of variables that behaviourists use to explain the process of learning. Some behaviourists believe the intermittent reinforcement of gambling creates a temperament for the development of problem gambling habits while others believe problem gambling is a coping mechanism for those seeking a form of arousal or excitement. Behavioural theorists purported that the stimulating environment of gaming creates an atmosphere some people learn to rely on as a source of arousal and excitement (Blanco et al., 2000; Ladouceur et al., 2002). Behaviour theorists explained how gambling behaviour is shaped and maintained by winnings delivered on variable ratio (VR) schedules of reinforcement (Knapp, 1998; Wulfert, Blanchard, & Martell, 2003). It is impossible to predict when a bet will pay off because the probability of reinforcement on VR schedules remains identical across trials. Thus early wins reinforce persistence to continue to gamble. Wulfert et al. suggested 7

16 gamblers persist in spite of heavy losses for three reasons. The first is the thrill of coming close to winning. For example, seeing the two out of three Lucky Sevens on a slot machine gives a brief feeling of excitement even though it is followed with disappointment. The second reason comes from the automatic arousal associated with gambling. Winnings promote excitement that generalizes to a stimuli; the arousal associated with expectation of winning which reinforces behaviour on losing trials. Third, negative reinforcement potentially may stimulate the individual with gambling problems to continue regardless of losses (Blanchard, Wulfert, Freidenberg, & Malta, 2000; Hartley & Wulfert, 2001). Blaszcynski (1998) suggested habitual patterns are a result of imprints of neuronal patterns in the central nervous system. Thus, if individuals act on a drive to perform a habit, and the habit matches the neuronal representation in the brain; any further drive to complete the habit is repressed, thus fostering a sense of gratification (Blaszcynski & Nower, 2002). On the other hand, if individuals are unable to fulfil the whole behavioural pattern they experience anxiety, which leads to an urge to continue the behavioural pattern. The researchers suggested that upon completing the habit, the state of aversion is suspended and the behaviour pattern is reinforced. Similarly, Wulfert, Greenway, and Dougher (1996) suggested that a number of individuals with addictive disorder engage in the behaviour predominately to seek relief from stressful or painful experiences. Hand (1998) agreed suggesting that individuals with gambling problems continue to gamble for the same reasons. According to his theory, negative mental states are not a result of incomplete behavioural patterns rather; they are the result of daily life problems due to reduced coping skills and environmental 8

17 stresses (Moreyra et al., 2000). Hand explained that when individuals stop gambling, he or she experiences negative emotional states and will engage in gambling to reduce the negative affect. In this way, the individual depends on gambling to provide respite from negative emotions, which makes the addiction to gambling difficult to break. Cognitive Theory Tavares, Zilberman, and el-guebaly (2003) proposed cognitive theory is useful when treating problem gambling in that it adds to behaviour theory. Although behaviour theorists described the nature of learning, reinforcement, and arousal, they failed to explain the nature of internal processes that contribute to problem behaviours. Clinicians, who utilize the cognitive framework, believe distortions in one s thinking perpetuate the cycle of problem gambling. Most researchers seemed to agree that individuals with gambling problems experience four common cognitive distortions and perhaps these cognitive biases provide the foundation for cognitive interventions (Coman, Evans, & Burrows, 2003; Labrador & Fernadez-Alba, 2002; Ladouceur et al., 2002; Milton, Crino, Hunt, & Prosser, 2002; Sylvain, Ladouceur, & Boisvert, 1997; Tavares et al., 2003; Toneatto & Millar, 2004). The first bias is known as the illusion of control, which refers to the gambler s belief that one is able to control the randomness of gambling. The next bias, trust in luck represents the collection of beliefs and rationale gamblers hold. This is the result of overestimating the possibility of winning independent of any action the gambler carries out. The third bias known as the gambler s fallacy occurs when the gambler creates an association among successive events that are independent of one another. For example, if a gambler loses a series of bets at a casino, one is likely to continue gambling because the belief that 9

18 he or she is due to win. The fourth bias, flexible attribution is the final cognitive bias that maintains the cycle of problem gambling. This cognition requires gamblers to attribute successes in gambling to one s skills, and losses in gambling to other influences. Often, the successes increase the expectations more than the failures diminish them. The gambling industry capitalizes on flexible attribution by giving games of chance the illusion of skill-based events. Examples include: giving lotto players the choice of picking their own numbers or randomly selecting them; or putting levers on slot machines to give the false impression that the results can be influenced by how they pull the lever, or offering casino games such as roulette, black jack or craps multifaceted features to give the impression that outcomes depend on strategic decisions. Thus, cognitive therapy is defined as a set of interventions that focus on the beliefs and thoughts individuals have about gambling. By replacing faulty or erroneous beliefs and thoughts with healthy and rational ones, it is believed by cognitive theorists that individuals will experience emotions that are collaborative with their new sense of reality, and therefore, will not engage in gambling behaviour to cope with their thoughts and feelings. Cognitive Behavioural Theory Cognitive-Behavioural theorists merged cognitive and behavioural constructs to provide a comprehensive understanding of both the cognitions and behaviours of gamblers. Proponents of CBT argued that behavioural explanations do not adequately explain the persistence of problem gambling because such rationales do not address the contextual and cognitive influences that perpetuate gambling (Aasved, 2002). Therefore, to comprehend the pervasive nature of gambling, one must examine the patterns of 10

19 behaviour while simultaneously uncovering and challenging the faulty cognitions of individuals with gambling problems including environmental triggers (Brent & Nicki, 1997; Echeburua et al., 1996; Freidenberg, Blanchard, Wulfert, & Malta, 2002, Wulfert et al., 2003). Some triggers could be receiving pay checks, gambling advertisements, money pressures, interpersonal problems like conflict, family pressures and intrapersonal variable like cognitive biases, negative mood state, heightened arousal and excitement (Aasved, 2002). Motivational Enhancement Theory and Transtheoretical Model of Change It is well known among behavioural theorists that ambivalence about change is the norm rather than the exception for individuals struggling with addictive behaviour, which includes problem gambling (Shaffer, 1997). The individual has trouble staying motivated because of the difficulty of moving from an ambivalence stance. Furthermore, Prochaska and DiClemente conducted studies on smokers or alcohol abusers or drug abusers throughout the 1980s and early1990s to better understand this process. Guided by there empirical observations they developed the TTM of change (Wulfert et al., 2003). This model suggests that an addictive individual cycles back and forth through various stages of change. Simplified, these five cycles include pre- contemplation (I don t have a problem), contemplation (I may have a problem), preparation (I am going to change), action (quitting), and maintenance or relapse. In this approach the individual with gambling problems is often conflicted between the illusion to control, coupled with a strong arousal thus making it difficult to readily seek help. Individuals with gambling problems rarely seek help voluntarily; thus, it is generally the external pressures, (for example, pressure from, spouses, employers, or 11

20 the law) which heighten the awareness of the gambler to get treatment. Furthermore, the gambler is often resistant at first and this is can be an invitation to utilize motivational interviewing (MI) as a resource to help the individual with gambling problems move from one stage of change to the next. In MI the clinician engages the client in treatment by meeting the client at their current stage of readiness. Using an empathetic, non-judgemental style the clinician can help facilitate change by providing feedback to the client regarding the impact their lifestyle is having on their present situation and then the client has the opportunity to selfevaluate if desired and decide how change can happen (Miller & Rollnick, 2002; Wulfert et al., 2003). Additionally, Wulfert and colleagues indicated brief MI leads to positive results with substance abusers in residential setting and outpatient treatment with alcoholusing pregnant women; cigarette smoking, and alcohol using adolescents. Summary Among all theories presented here, CBT appears to remain the dominant theory researchers and clinicians use to explain and treat problem gambling. Gambling intervention guides, self-help books and approaches are all CBT based materials (AADAC, 2000; Aasved, 2002; Blanco et al., 2000; Blaszczynski, 1998; Ladouceur et al., 2002; Moreyra et al., 2000) and to date, CBT also guides research that utilizes both randomization and controlled interventions. Therefore, much of the research is focused on CBT based interventions. Approaches This section updates the approaches to treatment and identifies current treatment practices and locations of current residential gambling treatment programs in Alberta. 12

21 According to Davis, (2002) there are five main conceptual models of treatment for individuals with gambling problems. 1. Behavioural model. This may involve aversion therapy, in-vivo exposure, imaginal desensitization, relaxation training, behavioural monitoring, contracts and contingency management and reinforcement (Daughters, Lejuez, Lesieur, Strong, & Zvolensky, 2003). 2. Cognitive model. This may involve strategies to reduce erroneous thinking and gain knowledge of problem solving skills. By replacing faulty or erroneous beliefs and thought with healthy and rational ones, it is believed by cognitive theorists that individuals will experience emotions that are collaborative with their new sense of reality, and therefore, will not engage in gambling behaviour to cope with their thoughts and feelings (Coman, Evans, & Burrows, 2003; Labrador & Fernadez-Alba, 2002; Ladouceur et al., 2002; Milton et al., 2002; Sylvain et al., 1997; Tavares, Zilberman, & el-guebaly, 2003; Toneatto & Millar, 2004). 3. Addiction model. Treatment is based on total abstinence. It is similar to alcohol and substance abuse treatment. This may involve Gamblers Anonymous, education about addiction, family therapy, family origin issues, training, problem solving, coping skills; relapse prevention, and recovery planning (AADAC, 2006). 4. Neurobiological model. Pharmacological treatment is used to correct malfunctioning neurotransmitters through the use of fluvoxamine and other selective serotonin reuptake inhibitors (SSRIs). Naltrexone is used to 13

22 inhibit the euphoric effects of gambling. Lithium used to treat bipolar disorders, may also be used to treat problem gambling (Shaffer, LaBrie, LaPlante, & Kidman, 2002). 5. Alternative model. A combination of approaches is used. Treatment includes providing greater access for women regarding mental health, finances, abuse issues, access to services and referrals for rural individuals who may need to go to the city to avoid the stigma of being labelled a gambler. Additionally, the treatment process could include providing other forms of recreation and removing access to gambling venues. Researchers continue to assess the value of all these treatments (Davis, 2002). Modes of Delivery There are also numerous modes of treatment including outpatient, day treatment, residential, and inpatient care. Often time these modes of delivering treatment use a combination of the approaches outlined above. The purpose of this project was to examine treatment from a residential mode of delivery within the province of Alberta. Residential treatment is defined as a service that provides clients with structured experiences in a safe environment focused on developing awareness and skills necessary to start recovery (AADAC, 2006). Generally, residential treatment programs are for individuals who experience significant disruption in their life as a result of their substance abuse and/or gambling, lack of support networks, resources and structure, and are willing to practice at utilizing recovery skills. These clients are often accommodated in semi-private rooms within the treatment centre residence (AADAC, 2006). Program components include assessment, 14

23 individual and group counselling, skill development and informational workshops, nursing support and participation in leisure activities designed to enhance recovery. All program components are designed to reinforce the individual s capacities for living an abstinent lifestyle. Clients are introduced to and participate in self-help meetings such as Alcoholics Anonymous, Gamblers Anonymous, and Narcotics Anonymous (AADAC, 2006). Residential gambling treatment programs also provide services that benefit individuals with gambling problems who have a history of concurrent disorders such as depression, mania, insomnia, anxiety attacks, peripheral thinking, extreme grandiosity, suicidal ideation, frequent dissociate experiences and /or substance abuse behaviour (McCowan & Chamberlain, 2000). Additionally, those recovering from gambling behaviour often have cravings to gamble and give in to their cravings more often than a substance abuse client thus warranting the need for clients to be in a safe environment to recover (Bellinger, 1999). Furthermore, in residential treatment the client can access full therapeutic treatment and benefit from involvement of family as well as address emotional issues in a moderately short period of time (McCowan & Chamberlain, 2000). However, some limitations for clients in a residential setting may include the fact that if the client is being treated away from their family and social environment, it may give the client a false sense of security regarding ability to abstain from gambling behaviour. The client may not be prepared to face reality as much as they thought they would when they leave treatment and go back to their everyday living experiences. In residential treatment, the client is in a safe place away from all the previous stresses and thus does not have to actively deal with gambling and triggers on a daily basis. 15

24 Additionally, when the client goes home, families and friends may very well feel angry, resentful and betrayed and have little or no support to understand the nature and dynamics of problem gambling behaviours. Often they only see themselves as being left with the responsibility of everyday life once more (Kalischuk & Cardwell 2004). Another disadvantage could be the financial cost of treatment and the inconvenience, or a wait list that is often the case when applying for residential treatment. Frequently the individual with gambling problems has no money and residential gambling specific services are not locally accessible (AADAC, 2002) Current Residential Programs in Alberta There are five short-term (fewer than 4 weeks) residential treatment services for individuals with gambling problems in Alberta. Four residential services are non-profit agencies funded by AADAC and one is a pilot residential program opened January 2005, by AADAC. The costs for these programs are $15.00 a day and potential clients are referred to appropriate funding resources if they needed. These residential programs include: 1. South Country Treatment, Lethbridge, Alberta. This 21-day program uses the Life skills Educational Model delivered essentially as a stand-alone program for individuals with gambling problems. Clients are encouraged to develop skills and strategies that allow them the opportunity to gain control over their lives. The goal of this program is to introduce lasting changes through learning and practicing new way of thinking and behaving, with a focus on self-awareness. Clients participate in experiential learning exercises to help develop coping skills, such as decision-making, problem solving, anger 16

25 management, communication skills, stress management and relapse prevention (AADAC, 2002). 2. Walter A. Slim Thorpe Recovery Centre, Lloydminster, Alberta. This is a stand-alone program approach for individuals with gambling problems. This program is offered once a month for a week, when the alcohol and drug clients are not there. It is designed as a three-phase program. Phase 1 and Phase II are dedicated to the client directly while Phase III is for the family. Clients who have completed the first two phases may attend the third phase with their significant other and/or with their children. Phase III is offered in the summer months. In the first phase a maximum of 20 problem gambling clients stay for one week. Phase I focus mostly on gambling addiction dynamics and then return home for 3 weeks for integrated learning. Clients are given a 12 page Aftercare Planning Booklet to complete while at home. The booklet incorporates MET in the content and includes exercises that encourage reflective journaling. In Phase II the focus is more on effects of gambling on other aspects of life function and on relapse prevention. Their program is also based on the Durand Jacobs General Theory of Addiction model, with much emphasis on trauma work however the 12-step model (Gamblers Anonymous) meetings are included a treatment twice a week (AADAC, 2002). 3. Poundmaker s Lodge Treatment Centre, St. Alberta. This is a 2 week, 12-step aboriginal oriented program for all adults. These clients are integrated with the alcohol and drug abuse clients. The clients are encouraged to journal, follow 17

26 the 12 step model, and to participate in aboriginal traditional ceremonies and attend lectures (AADAC, 2002). 4. Aventa, a program based in Calgary, Alberta (for women). This is a 3-week residential treatment program and the problem gambling clients are integrated with the drug and alcohol client programs. The main focus is psychoeducational groups, journaling, relapse prevention and group counselling (AADAC, 2002). 5. AADAC Northern Addiction Centre, Grande Prairie, Alberta. Currently this is a stand-alone 13-day pilot program based on a cognitive behavioural model and MET that opened January There are only accommodations available for four adults per program. Psycho-educational sessions focus on types of gamblers; acceptance of problem, identifying underlying stressors, enhancing coping skills; identifying and clarifying the rationality of thought processes when gambling; facilitate building support systems; help with the structuring of time; create debt repayment plan and relapse prevention plan. A family program is run the first weekend following admission. Significant others, family, friends and youths over 16 are encouraged to join the clients for an educational program that helps the client and invited guest learn more about how the gambling behaviour has impacted the relationships and what they can do to improve their current situation. In the latter part of 2006, this program will be expanded to a 20-day program. Groups and some of the substance abuse psycho-educational program will be integrated with the substance abuse programs. However, most of the psycho educational 18

27 programs will remain stand-alone programs for individuals with gambling problems. Additionally, the family program will be eliminated due to low attendance and families will be offered to join the weekend program offered on a quarterly basis for all interested families impacted by another person s addiction (AADAC, 2006). AADAC Henwood Treatment Centre, Edmonton, Alberta (AADAC, 2002) and AADAC Northern Addiction Centre, (NAC) Grande Prairie, Alberta (AADAC, 2006) have a gambling stabilization program for individuals with gambling problems wanting a safe environment for up to 5 days. Individual assessments and referrals are made and educational material is provided. Currently, there are no long term (2-6 months) residential problems gambling specific programs in Alberta (AADAC, 2002) and at present there appears to not be a need; however, due to the increasingly number of casinos and gambling venues opening up in Alberta, statistically the number of individuals with gambling problems will also increase. Alberta s population is continuing to grow and people are becoming more aware of the symptoms of problem gambling and are more likely to seek treatment. For these reason, treatment for problem gambling is expected to continue to grow along with the costs associated with treatment (AADAC & Alberta Gaming and Liquor Commission Board, ). Consequently in the not so far future there may well be a need for long term gambling specific residential treatment programs. Research Review and Findings In this section I reviewed and described the literature that examines the effectiveness of interventions for individuals with gambling problems. Based on the fact 19

28 that there is no empirically based research that focuses on residential services for individuals with gambling problems, I reviewed the most common studies that have been conducted since From the review, I discussed findings that suggested effective treatment for individuals with gambling problems and determined whether treatments could be generalized to supporting individuals with gambling problems in a residential setting. The studies included CBT treatment, CBT and MET treatment and pharmacological treatment. Research Review In their review of gambling literature, Sylvain and colleagues (1997) suggested that previous researchers did not sufficiently assess the effectiveness of treatment interventions due to reliance on case study designs. Additionally, Toneatto and Ladouceur (2003) suggested that due to methodological flaws, such as small sample sizes and uncontrolled interventions, researchers were not been able to generalize treatment outcomes to a broader continuum of gamblers. Hencefore, it is difficult to determine best practices for individuals with gambling problems in a residential setting. Nevertheless, a reserved number of researchers employed randomization and controlled interventions in their studies to increase both the validity and reliability of their outcomes. For example, Echeburua et al., (1996) explored the effectiveness of CBT with individuals with gambling problems. The researchers compared a waiting list control group with three treatments: individual exposure-response prevention, group cognitive restructuring, and combined treatment. Exposure-response prevention, a behavioural treatment, taught participants how to manage money and how to manage high-risk gambling situations, while the group cognitive restructuring challenged the participant s 20

29 irrational cognitions and replaced them with rational ones. The combined treatment included both individual exposure-response prevention and group cognitive therapy. The same authors assessed participants as pathological gamblers by the DSM-III criteria and randomly assign them to one of the four groups. Individuals in each group were assessed pretreatment, during treatment, immediately following treatment, and then again at 1, 3, 6, and 12 months posttreatment. Those in the combined treatment group received twice as much therapy as those in the other two treatment groups, while those in the control group received no treatment in order to act as a control and to determine the phenomenon of natural recovery. Consequently, Echeburua and colleagues (1996) determined that at 6 months posttreatment all of the treatment groups had higher rates of abstinence than the control group. Based on the data it appears the participants in the control group gambled more often and spent more money than the other groups. This indicated the control group contained more severe characteristics of individuals with gambling problems than the other groups; however, it did not determine if these differences were statistically different. At 12 months posttreatment, the response-prevention treatment was more effective than the group cognitive treatment and combined treatment in maintaining abstinence rates. Yet, there were no significant differences among the groups on other dependent variables including money spent gambling, time spent gambling, and frequency of gambling. The similar outcomes in both the cognitive and combined groups suggest the group component of the treatment may be ineffective because it does not improve the outcomes of those who received individual counselling in the response-prevention group. 21

30 Then again, the similar outcomes may be a reflection of poor interventions, but this is not possible to determine, as Echeburua and colleagues confounded the study by offering cognitive therapy in the group setting and response prevention in an individual counselling setting. An examination could have been made if comparing the individual treatments were overseen. However, based on the results of their last study, Echeburua and colleagues (2000) examined the efficacy of stimulus control and in vivo exposure followed by response-prevention. Thus, 69 participants recieved the same treatment, utilizing stimulus control and in vivo exposure. Treatment continued until all were abstinent from gambling. At the time, all of the participants were randomly assigned to one of three relapse prevention treatments: individual, group, or control. Comparable to the previous study conducted by Echeburua and colleagues (1996), the participants were assessed pretreatment, during treatment, and then again posttreatment. They were also assessed at 1, 3, 6, and 12 months posttreatment. A review of treatment outcomes demonstrated that no significant differences were detected between the groups until 3 months posttreatment. Then the two treatment groups displayed significant differences in rates of abstinence when compared with the control group. By 12 months of posttreatment, the rate of relapse for the control group was 47.8%, compared with 17.4% for the individual treatment, and 22.7% for the group treatment (Echeburua et al. 2000). These results indicated moderate success for the relapse prevention treatment; yet, the strict definition of abstinence may have impacted such interpretations. The same authors defined abstinence as no gambling or one or two episodes of mild gambling, while relapse included more than two episodes of gambling. Consequently, significant improvements in 22

31 one s gambling would not be considered meaningful unless they were consistent with the study s criterion. In another study, Sylvain, and colleagues (1997) conducted a controlled study of pathological gamblers to determine the efficacy of a cognitive-behavioural treatment program. Research participants assessed as pathological gamblers were randomly assigned to individual treatment or to a control group that is defined as delayed treatment. Treatment participants were exposed to four treatment components comprising of cognitive correction, problem-solving training, social skill training, and relapse prevention. However, individuals in the control group were told they were on a 4-month waiting list but were contacted by the therapists twice a month. Differences between the treatment and control group at pretest were compared on five dependent variables: DSM-III-R criteria met, South Oaks Gambling Scores (SOGS), perception of control, and desire to gamble, self-efficacy perception, and frequency of gambling (Sylvain et al., 1997). There were no significant differences between the groups on the five dependent variables; however, the frequencies of gambling scores displayed a high amount of variability. Therefore the researchers performed a number of nonparametric tests of variance and once these analyses were complete, they interpreted that there were no differences between the groups with respect to frequency of gambling. Sylvain and colleagues (1997) also carried out tests of simple effects including determining the means, standard deviations between the treatment and control group on five dependent variables. They found significant differences on all variables: the treatment group had fewer DSM-III-R criteria, a lower SOGS score, less desire to gamble, and higher perceptions of control and efficacy. Also they found participants in 23

32 the treatment group gambled significantly less often and spend significantly fewer hours gambling than the control group. The final points of comparison were completed at 6 and 12 months after completion of treatment. Of the treatment group participants, four did not complete the follow-up and the remaining participants did not display significant changes from posttest to follow-up. Yet, clinical changes indicated 80% of the treatment group attained criterion scores for five variables, and 90% attained them for three of the variables. As a result, Sylvain and colleagues (1997) identified that their cognitivebehavioural treatment program improved the results in the treatment group on all variables. They indicated the results were substantiated over time thus indicating the efficacy of cognitive-behavioural treatment. Yet, the researchers did not identify the impact the crossover design had upon the treatment outcomes. Additionally, they did not determine if the final variable, frequency of gambling, had changed over time. Instead, they relied on the DSM-III-R criterion, which did not indicate abstinence from gambling behaviour. In the end, there were a significant number of participants who either refused treatment or dropped out of the study, which impacted the ability to detect genuine significant differences and limited the ability to generalize the findings. In reviewing the articles, it becomes apparent that CBT may be effective in treating problem gambling. Yet, despite its effectiveness, there is a repeatedly high rate of treatment refusal and attrition present in research outcomes. In responding to these criticisms, researchers utilized the TTM coupled with the principles of MI to lessen treatment refusal and attrition when applying CBT interventions (Hodgins et al., 2001; Freidenberg et al., 2002; Milton et al., 2002; Wulfert et al., 2003). Although there is no 24

33 concrete evidence to support the effectiveness of the TTM, researchers utilized the stages of change because they believed ambivalence about change is a core feature of addictive behaviours. Additionally, researchers believed including M.I. strategies prepared research subjects for CBT. Cognitive Behavioural Theory and Motivational Enhancement Theory Studies My review of the literature produced four studies that examined treatment refusal, attrition, and an outcome when MET was added to CBT interventions (Freidenberg et al., 2002; Hodgins et al., 2001; Milton et al., 2002; Wulfert et al., 2003). These studies were relevant to determining the most effective treatment for individuals with gambling problems in a residential setting. In the first study review, Freidenberg and colleagues carried out a study for pathological gamblers that examined changes in physiological arousal when applying motivationally enhanced cognitive-behaviour therapy. There were nine individuals in the study and they completed a three-phase problem gambling treatment program. This program, involved 2-3 MET sessions, sessions of CBT, and 2 sessions of gambling-specific relapse prevention. The effectiveness of the treatment interventions were determined by changes in the research participant s pre and posttest SOGS scores, in addition to changes in heart rate when exposed to auditory gambling vignettes before and after treatment. The SOGS scores were used to calculate generally the nature of change in the participants gambling behaviour and related concerns, while the changes in heart rate were used to confirm the argument that CBT effectively reduced reactivity, which was often present when gamblers were exposed to gambling cues. Through the use of a repeated measure MANOVA, Freidenberg et al. (2002) demonstrated a significant effect across time for the heart rate (HR) reactivity scores and 25

34 a significant decrease in the SOGS scores from pre- to posttreatment. There was a notable correlation between the pre to posttreatment change in the HR reactivity scores for the second gambling vignette and a moderate one between the two for the first gambling vignette. While Freidenberg and colleagues demonstrated the effectiveness of combined MET and CBT interventions, the results should be interpreted carefully. Due to the small size of the sample, the ability to detect genuine significant differences was reduced and the ability to generalize the findings was limited. Moreover, without the presence of a control group, one cannot be certain if an alternative or no treatment would have been effective in reducing the HR reactivity of clients. In another study, Milton and colleagues, (2002) examined the effect of compliance-improving interventions when utilizing CBT with pathological gamblers in an effort to decrease the rate of attrition in CBT studies. In their study, 40 research participants were randomly assigned to either CBT or CBT combined with interventions to increase compliance (Milton et al., 2002). All participants completed a 90-minute assessment session where they received information on the nature of the study and gave written consent to participate in the study. The next 4sessions were 1 hour in duration and were offered weekly, while the remaining 4 sessions were spaced 2 weeks apart. The final, follow-up session was held 9 months after session eight. All of the research participants received two phone calls and were sent letters reminding them of the followup session. Participants in the CBT group received outpatient treatment that consisted of four components. To challenge their irrational thoughts and beliefs about gambling and to explore the concept of randomness, the participants were provided psycho education 26

35 sessions. Throughout the sessions cognitive restructuring was utilized, thus enabling the participants to link their cognition, feelings, and gambling behaviour, and to challenge their dysfunctional gambling thoughts and beliefs. Problem solving was offered to the participants to reveal the relationship between poor problem-solving skills and gambling behaviour and to teach new problem-solving strategies. Lastly, relapse prevention was introduced to the participants, which enabled them to identify high-risk situations, to cope with urges and cravings to gamble, and to develop a more balanced lifestyle. Participants in the CBT and compliance intervention (CI) group received treatment similar to the CBT group. However, they also received interventions that encouraged compliance, which was a design to enhance and maintain their motivation to change their gambling behaviour throughout the treatment. Examples of these interventions included: positive reinforcement for attending sessions; positive prospects at the end of the assessment session; follow-up if participants missed appointments; the use of the decisional-balance between each session; supporting self-efficacy of the participant; and identifying hurdles and obstacles to overcome. Treatment outcomes were determined by three variables, which entailed structured clinical interviews, SOGS scores, and percentage of net monthly income lost gambling in the past month (Milton et al., 2002). In order to predict compliance and outcome, Milton and colleagues utilized the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Alcohol Use Disorders Identification Test, the Drug Abuse Screening Test, the contemplation ladder, and problem gambling duration. After determining there were no significant differences between the groups on any of the dependent variables, Milton and colleagues (2002) found a significantly higher 27

36 proportion of participants in the CBT and CI condition completed treatment compared to the CBT condition. The results of this study supported the short-term efficacy of CBT and CI interventions. However, it is still unclear whether treatment compliance is irrelevant to pathological gamblers or whether the treatment compliance interventions need revisions in order to ensure long-term effectiveness. Again, due to sample demographics and the size of the sample, the authors caution against generalizing to other populations (Milton et al., 2002). Furthermore, Wulfert and colleagues (2003) conducted a study that examined CBT and MET. Through the use of a detailed case study, a client, identified as Mr. J., was able to abstain from gambling. They attributed his success to 2 motivational enhancement sessions, 12 sessions comprised of cognitive motivational behaviour therapy, and 2 termination sessions that consisted of relapse prevention and follow-up. However, only one case study was provided, which could be construed as a weakness of this study. This does not mean that the existing evidence did not support the efficacy of these interventions; however, it indicated that there was little evidence available (Shaffer et al., 2002). In another study, Hodgins and colleagues (2001) assigned 102 self-identified individuals with gambling problems with one of three conditions: a workbook based selfhelp treatment with or without a brief motivational telephone interview and a wait-list control. Immediate positive effects were identified for individuals with gambling problems after one month in the motivational condition reported group compared to the self help group or the wait list group. However, over a 12-month study, the results did not last. Researchers in this study suggested that motivational interviewing alone may have 28