Dr. David Hodgins
Professor, Department of Psychology, University of Calgary,
Researcher, Alberta Gaming Research Institute
Since the beginning of the surge in gambling opportunities and interest around the world in the 1990s, many jurisdictions have struggled with designing and implementing treatment programs for people struggling with problem gambling. In some jurisdictions only basic services are offered such as a toll free helpline that offers referral to Gamblers Anonymous. In other locations, responses have been comprehensive and coordinated with an accessible continuum of interventions of different intensities ranging from outpatient counselling, to mutual support groups such as Gamblers Anonymous (GA) to residential programs and emergency respite beds. I am fortunate to be living in Alberta, Canada, one of the jurisdictions with a comprehensive system. But even in our system, it is clear that when you compare the results of our prevalence surveys with our treatment attendance data, most of people who are suffering significant problems with gambling are not choosing to attend our treatment programs. It is essential that we gain a better understanding of this paradox. Why don’t more people seek treatment? What can we do about it?
Our research group is tackling this issue from a number of perspectives. One line of research involves designing and evaluating ways of promoting self-recovery among individuals with gambling problems (Hodgins, 2004). We know that many individuals recover from significant gambling difficulties using their own resources. In fact the processes that they describe using are remarkably similar to those used by individuals with treatment-assisted recoveries (Hodgins, 2001; Hodgins & el-Guebaly, 2000). We have found that providing telephone and self-help workbook brief interventions can be an attractive and helpful option for some people who wish to tackle recovery on their own (Hodgins et al., 2001; Hodgins et al., 2004). Offering such alternatives to traditional forms of treatment may be one way to increase treatment uptake.
A second line of research involves verifying some of the assumptions we hold about gambling addictions that we have imported from substance abuse treatment. Specifically we have been interested in the process of relapse after a person has attempted to stop gambling. To explore this issue we recruited a group of 101 pathological gamblers who had recently quit gambling and tracked them for a five year period (Hodgins & el-Guebaly, 2004). During the first year we conducted regular interviews to obtain detailed descriptions about what led individuals back to gambling. Remarkably, 92% of individuals relapsed. Unlike in substance abuse where negative feelings (e.g., anxiety, depression, anger) are most likely to precipitate relapses, the gamblers were just as likely to report that positive feelings (e.g., happy, active, relaxed) preceded their return to gambling. The most common situation associated with relapse was a resurgence in optimism about winning – People retuned to gambling because they believed they could win. This difference from substance abuse relapse, which is more likely associated with negative experiences, supports a strong focus on cognitive restructuring of gambling fallacies in gambling treatment (e.g.,(Ladouceur et al., 2001; Wulfert et al., 2003). The second most frequent high risk situation for relapse was boredom, supporting the need for behavioural strategies to increase involvement in activities incompatible with gambling.
Our sample of 101 was recruited using media announcements and, therefore, some participants were involved in either treatment or GA (25%) and some were not (75%). Analysis revealed that involvement in treatment or GA was associated with less gambling over the five year follow-up (Hodgins et al., 2005). People did better with their goal of quitting gambling if they attended treatment or aftercare but only one in four made this choice. We were challenged with the question of what to do with the other 75% to help them improve their outcomes. Based upon a model that has been successfully used in smoking relapse prevention (Brandon et al., 2000), we designed a series of relapse prevention booklets to send to people through the mail about once per month. The first booklet was an overview booklet that described a variety of relapse prevention strategies such as dealing with urges, predicting high risk situations, managing money, identifying concurrent problems such as depression and substance abuse and developing leisure activities. The other booklets were expanded versions of these topics. Each booklet contained information about local treatment services such as counselling centres and GA groups.
We conducted a clinical trial of these relapse prevention booklets with 169 pathological gamblers who had recently quit gambling but who did not want to attend treatment or aftercare(Hodgins et al., 2007). Half received simply the overview booklet and half received all the booklets. People who received all the booklets were more likely to report that they achieved their goal over the next 12 months and were more likely to maintain a stringent goal of abstinence from all types of gambling. When interviewed at 12 months, about half of both groups no longer met the diagnostic criteria for pathological gambling and 44% had been abstinent for a least the past two months. We were particularly pleased that almost a quarter of the sample had engaged in some type of treatment or support.
A limit of this clinical trial was the lack of a “no treatment” control group. All participants received either the single booklet or the series of booklets, which limits our ability to attribute improvements to the intervention versus natural recovery. Nonetheless, this low cost intervention appeared attractive to individuals reluctant to seek treatment. Moreover, we speculate, based upon our other brief intervention projects, that a more clear focus on motivation in the relapse prevention materials would improve their impact even more.
It is clear that there are numerous other reasons that individuals with gambling problems do not seek treatment including stigma, cost, and readiness of the individual to tackle the issue. However, our creative efforts to provide treatment in non-traditional formats, promoting self-recovery, are likely to be rewarded.
References
Brandon, T. H., Collins, B. N., Juliano, L. M., & Leavey, S. B. (2000). Preventing relapse among former smokers: A comparison of minimal interventions through telephone and mail. Journal of Consulting and Clinical Psychology, 68, 103-113.
Hodgins, D. C. (2001). Processes of changing gambling behaviour. Addictive Behaviors, 26, 121-128.
Hodgins, D. C. (2004). Workbooks for individuals with gambling problems: Promoting the natural recovery process through brief intervention. In L.L’Abate (Ed.), Using workbooks in mental health: Resources in prevention, psychotherapy, and rehabilitation for clinicians and researchers (pp. 159-172). Bingham, NY: The Haworth Reference Press.
Hodgins, D. C., Currie, S. R., el-Guebaly, N., & Peden, N. (2004). Brief motivational treatment for problem gambling: A 24-month follow-up. Psychology of Addictive Behaviors, 18, 293-296.
Hodgins, D. C., Currie, S. R., & el-Guebaly, N. (2001). Motivational enhancement and self-help treatments for problem gambling. Journal of Consulting and Clinical Psychology, 69, 50-57.
Hodgins, D. C., Currie, S. R., el-Guebaly, N., & Diskin, K. M. (2007). Does providing extended relapse prevention bibliotherapy to problem gamblers improve outcome? Journal of Gambling Studies.
Hodgins, D. C. & el-Guebaly, N. (2000). Natural and treatment-assisted recovery from gambling problems: A comparison of resolved and active gamblers. Addiction, 95, 777-789.
Hodgins, D. C. & el-Guebaly, N. (2004). Retrospective and prospective reports of precipitants to relapse in pathological gambling. Journal of Consulting and Clinical Psychology, 72, 72-80.
Hodgins, D. C., Peden, N., & Cassidy, E. (2005). The association between comorbidity and outcome in pathological gambling: A prospective follow-up of recent quitters. Journal of Gambling Studies, 21, 255-271.
Ladouceur, R., Sylvain, C., Boutin, C., Lachance, S., Doucet, C., Leblond, J. et al. (2001). Cognitive treatment of pathological gambling. Journal of Nervous & Mental Disease, 189, 774-780.
Wulfert, E., Blanchard, E. B., & Martell, R. (2003). Conceptualizing and treating pathological gambling: A motivationally enhanced cognitive behavioral approach. Cognitive and Behavioral Practice, 10, 61-72.