Focus on Anger in the Treatment of Gambling Problems Lorne Korman, Ph.D., C.Psych. Director of...

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Transcript of Focus on Anger in the Treatment of Gambling Problems Lorne Korman, Ph.D., C.Psych. Director of...

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  • Focus on Anger in the Treatment of Gambling Problems Lorne Korman, Ph.D., C.Psych. Director of Research BC Provincial Youth Concurrent Disorders Program
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  • Jane Collins BC Provincial Youth Concurrent Disorders Program
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  • What is Anger? Anger is a primary, basic emotion, with characteristic appraisal and action tendency 1 Anger is the blueprint for aggression, violence 2 Anger and violence frequently co-occur 3 Violence can also occur in the absence of anger 1 Fridja, 1986; Ekman, 1984; Ekman & Friesen, 1975, Izard 1977 2 Averill, 1993 3 Kassinove & Sukhodolsky, 1995
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  • Self-Reported Anger and Aggression among Substance-Using Clients Self-Reported Anger and Aggression among Substance-Using Clients 18-month Period at ARF and CAMH 4995 new patients seeking addictions tx 40% reported anger problems at intake 19% reported acts of physical aggression related to substance use 9.7% reported acts of physical aggression in the last 90 days From Collins, Skinner, & Toneatto, 2005
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  • Canadian Forensic Data: Violence and S.U. % of Alcohol and Drug Intoxication at Time of Perpetration of Index Violent Crime Source: Pernanen et al., 2002. Canadian Centre on Substance Abuse
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  • The Co-occurrence of Substance Use and Violent Crime Summary of 26 studies in 11 countries found on average, 61.5% of offenders drank at time of committing violent crime 1 Recent Swedish study found a 13.2-fold increase in the risk of criminal violence within 24 hours of alcohol consumption 2 1 Murdoch, Pihl, & Ross, 1990 2 Haggard-Grann, Hallqvist, Langstrom, & Moller, 2006
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  • Substance Use and Intimate Partner Violence Very high rates of co-occurrence of substance abuse among perpetrators of IPV, particularly among male perpetrators 1 The relationship between substance use and IPV has been established both in cross- sectional and longitudinal studies 2 1 c.f. Quigley & Leonard, 2000 2Heyman, OLeary, & Jouriles, 1995; Leonard & Senchak, 1996; Quigley & Leonard, 2000
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  • Substance Use and Intimate Partner Violence: Recidivism IPV recidivism higher among relapsed alcoholics than among remitted alcoholics 1 Following batterer intervention programs, individuals more likely to re-assault if they have substance use problems 2 1 Stuart et al., 2003; Maiden, 1997 2DeMaris & Jackson, 1987; Gondolf, 1997; Jones & Gondolf, 2001
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  • Anger and Addictions High rates of co-occurrence of: substance use and anger substance use (especially alcohol) and violent crime substance use and domestic violence What about the co-occurrence of pathological gambling and anger/violence?
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  • Anger Problems among Substance-Using Problem Gamblers higher proportion of problem gamblers (61%) report anger management problems than non- problem gamblers (40%) 1 severity of gambling problems associated with greater hostility in treatment-seeking substance users 2 1 Collins, Skinner, & Toneatto, 2005 2 McCormick, 1993
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  • Intimate Partner Violence and Problem Gambling Research relatively sparse Survey of 144 spouses of compulsive gamblers: 43% reported their spouses had physically or verbally abused them 1 1.Lorenz and Shuttlesworth, 1983
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  • Intimate Partner Violence and Problem Gambling (continued) In interviews with pathological gamblers, 23% reported having hit or thrown things at their partners at least once 1 Survey of 300 women attending E.R. in Nebraska: those with spouses who had gambling problems more likely to be victims of IPV 2 1Bland, Newman, Orn, & Stebelski, 1993 2Muellerman, DenOtter, Wadman, Tran, & Anderson, 2002
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  • Treating Comorbid Anger and Addictions Much known about the high prevalence of concurrent anger, aggression and substance use (e.g., domestic violence & alcohol) Many anger treatments screen out clients with active addictions Lack of empirically tested integrated treatments for comorbid anger and addictions
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  • Treat Concurrent Anger & Addictions Problems Concurrently? Are there benefits to addressing concurrent anger and addictions in an integrated treatment? Theories posit emotion dysregulation as an underlying problem of (separately) gambling, anger, substance use problems 1 Is there utility in targeting emotion dysregulation for people with concurrent anger, gambling, and substance use problems? 1 Dutton, 1995; Greenberg & Paivio, 1997; Khantzian, 1985, 1997; Levinson, Gernstein & Maloff, 1983; Miller, 1980; Moran, 1970
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  • RCT on Integrated Treatment for Comorbid Anger and Addictions RCT study compared integrated gambling, anger and substance use treatment to a specialized addictions-only treatment
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  • Research Team Lorne Korman Jane Collins Nina Littman-Sharp Shelley McMain Wayne Skinner Project Consultant Tony Toneatto With Assistance from: T herapists of the Problem Gambling Service & the Anger and Addiction Clinic at CAMH Research Assistant Virginia Mercado Funded by a grant from The Ontario Problem Gambling Research Centre Randomized Control Trial of an Integrated Treatment for Concurrent Anger and Addictions
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  • Participants: Problem gamblers (CPGI 8), all with self-identified anger problems, with or without concurrent substance use problem RCT, 42 participants stratified by substance dependence disorder Assessment periods: Intake (T1), 14 weeks (T2), 12-week follow-up (T3) Study Design
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  • Treatment Conditions Integrated Treatment Targeted both Anger & Addictions @ an Integrated Anger & Addiction Clinic Addictions-Only Treatment-as-Usual (TAU) Only Targeted Addictions Gambling & SU @ Specialized Gambling Clinic
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  • Study Treatments Integrated Condition : Max. 12 individual weekly sessions (1 hour) Diary card of target behaviours Analyses of reported target behaviours (30-40 min.) Skills training, as relevant (20-30 min.), and exposure, response prevention, rehearsal
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  • Study Treatments Addictions-Only TAU Treatment length varied as needed, 1 hour individual sessions Focused primarily on problem gambling and substance use using CBT relapse prevention
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  • Study Measures Canadian Problem Gambling Index (CPGI) PGSI (9 items, 9-point lykert scale) State-Trait Anger Expression Inventory (STAXI) 44 items, yielding 2 scales, 6 subscales Drug Use History Questionnaire (type, frequency and amount of substances used past 3 months) SCID Substance Use/Substance Dependence Sections (T1 only)
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  • Demographics Integrat. n=20 TAU n=22 age44.5 (sd= 11.9) 50.4 (sd=9.85) sex18 Male 2 Female 18 Male 4 Female income$ 33,579$ 30,810
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  • Treatment Engagement: % subjects attended at least 1 session
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  • # Sessions Attended by Group
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  • Sessions Attended = Covariate Integrated treatment significantly better at engaging clients than addictions-only TAU Because # of sessions attended in Integrative condition was greater, # of treatment sessions attended was used as a covariate in analyses of outcome. Therefore observed treatment effects on all major outcome variables were not dependent on the number of treatment sessions attended Also, patterns of change same for participants in TAU who had 4 or more sessions
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  • Gambling: PGSI
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  • % Meeting Criteria for Problem Gambling (PGSI8)
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  • Gambling: % monthly income spent gambling
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  • STAXI Trait Anger
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  • STAXI Anger Expression
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  • Clinical Significance of Changes: STAXI Anger Expression (expressed in percentiles, based on a standardized normal population) Problem Anger Threshold
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  • Substance Use (at intake) Integrt. n=20 TAU n=22 Dependence88 Abuse21 Use not meeting disorder criteria 33 No use in past 90 days 710
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  • Substance Use: Days Used
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  • Discussion An integrated approach treating concurrent anger & gambling appears to improve both addictions & anger outcomes The presence of anger may make gambling treatment less effective if anger not addressed. Addictions clinicians need to assess & treat concurrent anger & other addictions problems. Anger treatments need also to screen & target addictions.
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  • Discussion Addressing concurrent anger may provide a big bang for the buck in gambling treatment Findings underscore importance of using engagement strategies with clients with concurrent anger and gambling problems Integration & flexibility important- i.e., the ability to target multiple relevant problems concurrently.
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  • Response to the Study(I) Sample size (20/22 per group) TAU was not a manualized treatment Follow-up was relatively short (3 months)
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  • Integrated Anger and Addiction Treatment Study: RCT # 2 Just starting N = 80 youth (40 per condition) TAU is a ma