And now for “real treatment”… Development of an 8-week 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 reinforcers Learning how to control urges (by thinking of alternative behaviors) Avoidance of gambling establishing operations

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 control

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 severity

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?

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 Fred

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 track

Number of ACT Empirical Publications

Number of ACT RCTs

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.

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)

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 Hospital

SubjectAgeGender Attempts to QuitSOGS GFA PrePost M26T F17S/A*T F17T 118M29AS/A 220M29AS 3 M14AA 919M26AT Control 123M16TT Control 1419M15SA/S Control 1218M29TT T

Component analysis; frequency count ComponentWk 1 Wk 2Wk 3Wk 4Wk 5Wk 6Wk 7Wk 8Total % exposure ACCEPTANCE % DEFUSION % SELF AS CONTEXT VALUES COMMITTED ACTION PRESENT MOMENT OTHER

Valued Living Questionnaire – Rate on Scale 1-10

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 pleasurable

483 6 Treatment Content Assessment

484 1 Treatment Content Assessment

4338 Treatment Content Assessment

Sub IDAAQ PRE AAQ POST MAAS PRE MAAS POST VLQ PRE VLQ POSTGSAS PRE GSAS POST Control CONTROL CONTROL

Average NM Rating pre/post 8 hr ACT Pre Post C1C2C3

Treatment: Wins - Losses Pre Post

Treatment: Near-Misses - Losses Pre Post P<

Treatment: Losses - Wins Pre Post

Control Pre (648) Post (654) Wins - Losses Near-Misses - Losses Losses - Wins

Treatment: Wins - Losses Pre Post

Treatment: Near-Misses - Losses Pre Post P<

Wins – Losses Pre-Treatment (Both Groups Combined)

Wins – Losses Post-Treatment (Treatment Group)

Wins – Losses Post-Treatment (Control Group)

Near Misses – Losses Pre-Treatment (Both Groups Combined)

Near Misses – Losses Post-Treatment (Treatment Group)

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 person

I almost won Keep playing I will feel better soon A win is coming soon

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 marriage

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.

Bridging the Gap between Research and Practice Mark R. Dixon & Alyssa Wilson Southern Illinois University