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
The ACT Question
Contact with the
Present Moment
Willing to show
up to whatever
Acceptance
you are
experiencing
without defenses
In this moment
are you
Values
Psychological
Freely chose a
direction you
want to head in
Flexibility
See things for
what they are,
and not what
Defusion
they say they are
Not the stories
Self as
you tell about
yourself, but you Context
Committed
Action
And gently
return to that
direction when
you find yourself
off track
Number of ACT Empirical Publications
Cummulative Outcome Publications
70
50
ACT
40
30
20
10
0
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
20
03
20
05
20
07
Number of Publications
60
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
20
03
20
05
20
07
Number of Publications
Number of ACT
RCTs
Cummulative RCTs
25
20
15
10
ACT
5
0
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
Initial Scanning
in fMRI at
Hospital
Completion of
battery of
psychometric
tests and actual
gambling
exposure
8 hours of
1:1 therapy
delivered in
clinic
Final Scanning
in fMRI at
Hospital
GFA
Subject
Age
Gender
Attempts
to Quit
4836
24
M
2
6
T
4841
52
F
1
7
S/A*
4338
56
F
1
7
T
1
18
M
2
9
A
S/A
2
20
M
2
9
A
S
3
20
M
1
4
A
9
19
M
2
6
A
A
T
T
Control 1
23
M
1
6
T
T
Control 14
19
M
1
5
S
A/S
Control 12
18
M
2
9
T
T
SOGS
Pre
Post
T
30
25
GFA component score
20
GFA_ATTENTION
GFA_ESCAPE
GFA_TANGIBLE
15
GFA_SENSORY
Linear (GFA_ATTENTION)
Linear (GFA_ESCAPE)
Linear (GFA_TANGIBLE)
10
Linear (GFA_SENSORY)
5
0
0
2
4
6
8
SOGS
10
12
14
Component analysis;
frequency count
Component
Wk
1
Wk 2
Wk 3
Wk 4
Wk 5
ACCEPTANCE
1
1
3
4
2
DEFUSION
2
1
SELF AS
CONTEXT
1
VALUES
3
COMMITTED
ACTION
Wk 6
1
1
2
1
2
2
1
2
1
1
1
1
1
1
OTHER
1
1
1
1
Wk 8
Total %
exposure
1
22.64%
3
1
PRESENT
MOMENT
Wk 7
11.32%
4
1
11.32
2
18.87
4
9.43
11.32
1
1
15.09
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
11%
16%
ACCEPTANCE
14%
18%
DEFUSION
14%
7%
20%
SELF AS CONTEXT
VALUES
COMMITTED ACTION
PRESENT MOMENT FOCUS
OTHER
484
1
Treatment Content Assessment
ACCEPTANCE
11.29%
19.35%
25.81%
DEFUSION
14.52%
SELF AS CONTEXT
8.06%
6.45%
14.52%
VALUES
COMMITTED ACTION
PRESENT MOMENT FOCUS
OTHER
Treatment Content Assessment
4338
14%
18%
ACCEPTANCE
24%
15%
5%
9%
DEFUSION
15%
SELF AS CONTEXT
VALUES
COMMITTED ACTION
PRESENT MOMENT FOCUS
OTHER
Sub ID
AAQ
PRE
AAQ
POST
MAAS
PRE
MAAS
POST
VLQ
PRE
VLQ POST
GSAS
PRE
GSAS
POST
4836
40
40
54
50
37.5
39.3
3
7
4841
41
45
58
56
36.9
61.9
13
13
4338
38
36
51
55
36.9
41.4
20
22
1
2
28
36
58
62
34.7
23.6
11
6
22
37
49
51
33.5
43.7
15
10
3
55
50
76
65
65.2
52.2
6
13
9
69
51
75
63
82.1
97
21
0
Control 1
64
62
70
68
49.7
49.5
10
13
CONTROL 2
19
17
48
61
71.6
65.5
15
20
CONTROL 3
62
50
71
57
55.3
69.8
29
27
Average NM Rating pre/post 8
hr ACT
5
4.5
Pre
4
Post
Average Rating
3.5
3
2.5
2
1.5
1
0.5
0
4836 4841 4338
1
2
3
9
C1
C2
C3
Treatment: Wins - Losses
Pre
Post
631
642
644
652
643
653
Treatment: Near-Misses - Losses
Pre
Post
631
642
644
652
643
653
P<0.05
Treatment: Losses - Wins
Pre
Post
631
642
644
652
643
653
Pre (648)
Wins Losses
Near-Misses Losses
Losses Wins
Control
Post (654)
Treatment: Wins - Losses
Pre
Post
631
642
644
652
643
653
Treatment: Near-Misses - Losses
Pre
Post
631
642
644
652
643
653
P<0.05
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
I just spent my kid’s
lunch money
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