North America s Foremost Experts on Patient Adherence Principles of Change: What works and why in problem gambling interventions Grant Corbett Principal Behavior Change Solutions, Inc.
Session Objectives This session will: 1. Look at two types of principles for knowing what works in prevention and treatment. 2. Provide cross-disciplinary examples of evidencebased principles in the form of best practices and common factors. 3. Suggest implications for problem gambling treatment as evidence moves the field from the Age of Experimenting to the Age of Understanding.
Introduction Both frameworks are driven by empirical evidence: While clinical practitioners generally value scientific validity, most clinical practices are not strongly supported by empirical evidence. They are supported by personal experience and strong belief (or faith). Practices that are based on belief and personal experience, while advantageous from several perspectives, are highly prone to error and misuse. Beutler, 2000
Introduction Potential Short-Comings of Empirically Supported Treatments include: Focus is on instruments and theories, not predictors. Structured treatment manuals fail adequately to address therapist judgment or therapeutic relationship. Construct treatment around diagnoses, ignoring nondiagnostic patient dimensions in treatment decisions. Failure to address techniques and procedures adequately. Do not address problem specific findings.
Cross-cutting Principles - Psychotherapy Cross-cutting Principles: The currently available empirical standards are difficult for practitioners to implement. A standard by which clinicians can select and use scientifically tested treatments is needed to bring credibility to the practice of psychotherapy. This article presents an example of an alternative standard that offers the hope of using clinician experience in ways that enhance the application of scientific principles and that advance the generalization of research to clinical practice. The example offered develops cross-cutting principles that can be applied to patients with depression, drawing from both extant literature and new, cross-validation research. Beutler, 2000
Cross-cutting Principles - CACTUS 1. Identify addictive behaviors and intervene early, even if briefly (e.g., in health care and social services). 2. Enhance personal motivation and commitment to change. 3. Make sobriety worthwhile; improve access to non-drug positive reinforcement. 4. Enhance social support for sobriety. 5. For well-established addiction, a period of ensured abstinence helps.
Cross-cutting Principles - CACTUS 6. Use an empathic, listening style of counseling (and hire empathic therapists). 7. Involve the family or social system to reinforce sobriety. 8. Address other social and behavioral health problems. (Implications for providers). 9. Encourage sampling of 12-step groups, and of other sources of drug-free reinforcement. 10. Promote meaningful employment or role.
Cross-cutting Principles - CACTUS 11. Remove/reduce reinforcement for using. 12. Expect gradual progress and reversals, and reinforce all steps and approximations. 13. Think outside the skin: Social risk and protective factors (functional analysis). 14. Make services easily accessible, affordable, attractive, helpful, potent, rapid, and welcoming. 15. Use evidence-based interventions.
Cross-cutting Principles - Gambling Your Experience
Evidence-based Interventions - Gambling Systematic Reviews and Meta-analyses: Oakley-Browne, M. A., Adams, P., Mobberley, P. M. Interventions for pathological gambling. Cochrane Database Systematic Reviews (Withdrawn/Pending 2 nd Quarter 2006) Pallesen, S., Mitsem, M., Kvale, G., et al. (2005). Outcome of psychological treatments of pathological gambling: a review and meta-analysis. Addiction, 100(10), 1412-1422. Toneatto, T., & Ladouceur, R. (2003). Treatment of pathological gambling : A critical review of the literature. Psychol Addict Behav, 17(4), 284-292.
Evidence-based Interventions - Gambling Pallesen, 2005
Cross-cutting Principles 1. Cross-cutting Principles References: What Works: A Series of three volumes by Oxford University Press Nathan, P. E., & Gorman, J. M. (Eds.). (2002). A guide to treatments that work (2nd ed). New York: Oxford University Press. Norcross, J. C. (Ed)(2002). Psychotherapy Relationships that Work: Therapist Contributions and Responsiveness to Patient Needs. New York: Oxford University Press. Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of Therapeutic Change that Work (pp. 353-369). New York: Oxford University Press. CACTUS: Miller, W. R., & Carroll, K. M. (2006). Rethinking substance abuse: What science tells us and what we should do about it.new York: Guilford Press.
Principles of Change TM The Principles of Change TM derive from: A ten+ year review of addiction, communication, consumer-behavior, medical, psychology and socialpsychology research. A focus on studies that changed behaviors, independent of theory. Identification of common factors in interventions that worked.
Principles of Change TM The Principles of Change TM 1. The Principle of Discrepancy 2. The Principle of Accessibility 3. The Principle of Expectancy 4. The Principle of Social Investment
1. The Principle of Discrepancy The Principle of Discrepancy: Unexpected, personally-relevant information that signals threat or reward motivates attention.
Impulse The pathological gambling section of DSM-IV identifies the disorder as a "failure to resist an impulse, drive, or temptation."
Impulse Source: Goudriaan et al, 2006
Impulse Question: A failure to resist (inhibit) what impulse or drive? The Principle of Discrepancy proposes that the failure is in controlling the perceived threat posed by unexpected non-wins (not just losses, but even outcomes).
Discrepancy, Unexpected & Outcomes Discrepancy, Unexpected and Outcomes: In the present (gambling) experiment feedback negativity (i.e., feedback indicating incorrect performance or monetary loss) was sensitive also to an even outcome that was not associated with any monetary gain or loss and was in fact independent of the magnitude of the bet. Our results suggest that feedback negativity reflects the simple and rapid evaluation of external events along an expected/ unexpected dimension, and as a result this negativity is not specific to monetary loss or incorrect outcome Toyomaki & Murohashi, 2005
1. The Principle of Discrepancy What causes losses or breaking even to seem unexpected? The Principle of Discrepancy says: The Amygdala
The Amygdala Amygdala{
The Amygdala and Addiction The Amygdala and Addiction: I suggest that addiction is the product of an imbalance between two separate, but interacting, neural systems that control decision making: an impulsive, amygdala system for signaling pain or pleasure of immediate prospects, and a reflective, prefrontal cortex system for signaling pain or pleasure of future prospects. After an individual learns social rules, the reflective system controls the impulsive system via several mechanisms. However, this control is not absolute; hyperactivity within the impulsive system can override the reflective system. Bechara, 2005
Amygdala, Control and CBT Amygdala, Control & Cognitive-Behavioral Therapy: "The amygdala helps us to recognize things as being emotional. In some people...the amygdala doesn't turn off as fast as it should after it recognizes something as being negative. The subgenual cingulate cortex regulates emotions and plays a part in turning the amygdala on and off," said Dr. Siegle. "If the amygdala doesn't get 'turned off' when exposed to negative information, the person may ruminate, going over this information again and again. Cognitive behavioral therapy teaches people techniques to stop this rumination, so it makes sense that it would be a good treatment option for those people who can't turn off their amygdala," said Dr. Siegle. Press release for Siegel et al, 2006
Summary: The Principles of Change TM The foregoing is one example of how the Principles of Change TM can help us to understand prevention and treatment of problem gambling. In summary, the Principle of Discrepancy proposes: Increased amygdala activity motivates attention. Problem gamblers inability to turn the amygdala off from feedback negativity following monetary losses and even outcomes is a possible cause of impulsivity. CBT, that has good evidence in the treatment of problem gambling, reduces impulsivity.
Principles of Change TM Techniques relevant per Principles: 1. The Principle of Discrepancy Unexpected information about gambling risks Imaginal Desensitization 2. The Principle of Accessibility Motivational Interviewing (Miller & Rollnick, 2002) 4. The Principle of Social Investment Integrity Therapy (Lander & Nahon, 2005) Mindfulness and Acceptance Therapies
Behavior Change Solutions, Inc. I would be please to speak with you about questions or training, call or write: Grant Corbett Principal Behavior Change Solutions, Inc. 52 Cherie Road St. Catharines, ON CANADA L2M 6L7 Tel: 905-937-1441 Fax: 905-937-5858 Email: