Critical Dimensions of Relapse in Problem Gambling David C. Hodgins Nady el-Guebaly Susan Armstrong Nicole Peden C E N T R E Analysis of Relapse Situations (Cummings et al., 1980) Situation Alcoholics Smokers Gamblers Uncontrolled Eaters (N=70) (N=64) (N=19) (N=29) Intrapersonal Determinants 61% 50% 79% 46% Negative Emotional States 38% 37% 47% 33% Negative Physical States 3% 2% -- -- Positive Emotional States -- 6% -- 3% Testing Personal Control 9% -- 16% -- Urges and Temptations 11% 5% 16% 10% Interpersonal Determinants 39% 50% 21% 52% Interpersonal Conflict 18% 15% 16% 14% Social Pressure 18% 32% 5% 10% Positive Emotional States 3% 3% -- 28% High-risk situation No Adaptive Coping Responses Decreased self-efficacy Positive Outcome Expectancies The Process of Relapse Identify High-risk situations Skills Training Prepare for lapse Abstinence Relapse Prevention Interventions For Abstinence Initiation Goal: Identify potential high risk situations and prepare client for coping with them Use Initial use of substance (lapse) Abstinence Violation Effect: Return to Pretreatment Level of Use (Relapse) General Strategies lapses are: "mistakes "unique events "attributable to external, specific controllable factors Specific Strategies "Stop, look, listen "Stay calm "Renew your commitment "Review high risk situations "Make immediate plan for recovery "Use social support ... more. less.
Motivational Enhancement Help client see value of returning to treatment Harm Reduction Help client take steps in the right direction Relapse Prevention Interventions For Relapse Management Goal: Minimize degree of setback and help client take steps in the right direction High-risk situation No Adaptive Coping Responses Decreased self-efficacy Positive Outcome Expectancies Initial use of substance (lapse) Abstinence Violation Effect: Return to Pretreatment Level of Use (Relapse) Process of Relapse Relapse Prevention Interventions for Abstinence Initiation High-risk situation No Adaptive Coping Responses Decreased self-efficacy Positive Outcome Expectancies Identify High-risk situations Skills Training Prepare for lapse Initial use of substance (lapse) Abstinence Violation Effect: Return to Pretreatment Level of Use (Relapse) General Strategies lapses are: " mistakes " unique events " attributable to external, specific controllable factors Specific Strategies " Stop, look, listen " Stay calm " Renew your commitment " Review high risk situations " Make immediate plan for recovery " Use social support Motivational Enhancement Help client see value of returning to treatment Harm Reduction Help client take steps in the right direction Relapse Prevention Interventions for Relapse Management Critical Dimensions of Relapse:Project Aims ! Reasons for quitting gambling !<br><br> Relapse rates and patterns ! Characteristics of relapse ! Validity of self-reports !<br><br> Role of comorbid problems on outcome ! Retrospective and prospective reports of relapse precipitants Design ! Recruited 101 people who recently quit gambling !<br><br> Media recruitment versus treatment sample ! No gambling for 2 weeks ! South Oaks Gambling Screen (SOGS) > 4 !<br><br> Interviewed face to face initially, 3, 6 and 12 months Measures ! Demographics ! Gambling history and severity !<br><br> Gambling frequency and amount ! Mood disorders (SCID) ! Substance abuse/ dependence !<br><br> Relapse Experiences Demographics (N=101) % Female 36 % Married or Cohabiting 29 % Never Married 38 % Some post secondary education 66 % Full-time employment 55 % Unemployed 22 % Current smoker 76 AGE Mean 39 Range 19-77 Gambling Involvement Age of gambling problem Mean 34 South Oaks Gambling Screen Mean 12.2 % DSM-IV Pathological Gambling 89 % Previous quit attempt 75 % Past gambling treatment 50 % Current gambling treatment 25 Mean days abstinent at initial 19 Major problem type of gambling: % Video lottery terminals 49 % Mixed games 34 % Casinos 12 % Bingo 3 % Other 3 Demographics - Comorbidity depression bipolar 1 bipolar 2 dysthymia double depression none Past Mood Disorders reported by 60% of participants ! Lifetime alcohol problems reported by 72% ! Current alcohol problems reported by 7% !<br><br> Lifetime drug problems reported by 49% ! Current drug problems reported by 7% Current mood reported by 20% (all major depressive disorder) Comorbidity: Suicidal Ideation ! Suicidal ideation ever?<br><br> 71% 7 days in a row? 40% plan? 53% !<br><br> Suicide attempt? 33% - required medical help in 62% of attempts ! Attempt related to gambling?<br><br> - 21% of those attempting or 7% of sample Goals and Confidence Goal Quit all forms of gambling 33% Quit problem type of gambling 67% Confidence to achieve goal Scale 1-10 (10 most confident) in the next week M=8 in the next month M=7 in the next year M=6 Follow up rates 3 months - 83% 6 months - 80% 12 months -79% Reasons for Quitting Gambling Open-ended method Internal % of people External % of people Financial concerns 64% Lack of financial resources 8% Negative emotion 32% Legal influence 6% Incompatible with desired 32% Confrontation by others 6% self-image or goals Distraction with other things 2% Family influence 30% Environmental change 2% Cognitive appraisal 20% Social support 0% Rational appraisal 10% Fear of future negative 8% Other % of people consequences Unclear 13% Hitting rock bottom 6% Out of awareness 0% Spiritual influences 2% Reasons for Quitting Gambling Checklist method Financial problems 97% Emotional factors 95% Family/children 72% Hit rock bottom 60% Major life-style change 57% Pros and cons evaluation 57% Physical health 55% Humiliating event 54% Work-related problems 47% Traumatic event 44% Problems with spouse 44% Confrontation 40% Legal problems 28% Change in another addictive behavior 26% Religious involvement 22% Participants identified significantly more reasons for quitting using the multi-item checklist than the open ended question (7.9 versus 2.3) Reasons for Quitting Gambling Gender and Treatment Correlates ! No differences in gender were found between the type of reasons or number of reasons identified. !<br><br> Those involved in treatment identified more reasons with the open- ended method (3 reasons) than those not involved in treatment (2 reasons). ! Those in treatment identified more reasons on the checklist for quitting gambling (9 reasons) than those not in treatment (7 reasons).<br><br> work-related problems physical health hitting bottom Gambling Over Year Follow-up Relapse - resumption of gambling after a period of 2 weeks Over the entire follow up period: 6% remained completely abstinent 37% were abstinent 2/3 of the time 17% were abstinent 1/2 of the time 29% gambled 2/3 of the time 7% continued gambling Days Gambled over the Year Mean = 42 days Median = 27 days Mode = 0 days (7%) Range: 0 to 244 days Monthly Gambling Days Before & During the Follow-up Year Days Before During Gambled 0 0% 19% 1 2% 24% 2-7 33% 43% 8 or more 65% 14% . Gambling Outcome: Conclusions ! Relapse rates are very high " 94% relapsed " almost half gambled most of the year !<br><br> overall general improvement within the sample " 8+days per month reduced from 65% to 14% of people Assessment of Relapse ! Open-ended interview audiotaped # based on Marlatt 9s interview # extensive description of context, thoughts, feelings, circumstances # mood ratings before, during, and after # consequences # reasons and strategies for terminating ! Reasons for Gambling Scale Mode Mean SD Range Days gambled 1 12 30 1-142 Length of relapse (days) 1 40 83 1-372 Money spent on first day -200 -83 532 -3000 - +2000 Money spent per relapse -200 -368 875 -3000 - +4000 Frequency and amount gambled Relapse Rates and Patterns Characterization of Relapses Morning 12% Noon 21% Early afternoon 15% Late afternoon/early evening 21% Late evening (after 10pm) 31% Weekday 50% Weekend(after noon on Friday) 50% Alone 67% With friends/family 33% Dominant Form of Gambling: VLT 9s 57% Casinos 25% Scratch tickets 7% Bingo 7% Sports select 2% Slots 2% Characterization of Relapses Engaged in task prior to relapse 49% No task engagement 51% Characterization of Relapses Main Reason for Relapse - open ended responses Thought I could win 20% Boredom/killing time 18% Giving into urges/habit/opportunity 15% Dealing with negative situations/emotions 15% Make money 10% Socializing/fitting in 10% Seeking excitement/ enjoyment 5% Giving up 3% Control issues/testing 2% Access to money 2% Characterization of Relapses Emotional State Prior to Gambling % Thinking about finances 77 Frustrated 51 Happy 49 Bored 46 Active 45 Tired 42 Sad 36 Relaxed 36 Quiet 35 Irritable 34 Lonely 33 Angry 29 Nervous 29 Peppy 19 Characterization of Relapses Consequences of the Relapse 16% 14% 12% 51% 0% 10% 20% 30% 40% 50% 60% Family Life Social Life Work Life Financial Situation Characterization of relapses !<br><br> About half of relapses (54%) had at least one extreme consequence (family, social, work, finances) ! typical relapse occurred in the late evening, when alone, equally likely to be related to negative or positive mood state, related to financial pressure ! lasted one day, loss of $200.<br><br> With VLTs 60 50 40 30 20 10 0 -10 .7 .6 .5 .4 .3 .2 .1 0.0 -.1 Comorbid Substance and Mood Disorders and Relapse 60 50 40 30 20 10 0 -10 .8 .6 .4 .2 0.0 -.2 Three outcome variables were identified when Cox Regression Survival Analysis was performed to assess the impact of comorbidity on time to achieve 3 months of continuous abstinence from gambling Lifetime Mood Current Treatment Substance Abuse 60 50 40 30 20 10 0 -10 1.0 .8 .6 .4 .2 0.0 -.2 Weeks Weeks Weeks Yes No Yes No Yes No Proportion achieving recovery Proportion achieving recovery Proportion achieving recovery Validity of Self-Reports Collaterals for gambling were contacted Spouse/partner 35% Other immediate family 29% Friend 29% Roommate 3% Other 5% Gambler and collateral reports on the number of days gambled were correlated . Overall agreement was fair Spouses showed poor agreement Non-spouses showed good agreement Collaterals who under-reported days gambled 55% Collaterals who over-reported days gambled 29% Collaterals who correctly identified days gambled 16% Retrospective and Prospective Reports of Relapse Precipitants METHOD - Half of participants were contacted weekly for reports of mood, gambling and treatment. Mood reports of the following 14 adjectives were obtained.<br><br> Irritable Angry Frustrated Sad Nervous Happy Lonely Tired Bored Relaxed Quiet Peppy Active Finances on mind Retrospective and Prospective Reports of Relapse Precipitants RESULTS - Principal Component Analysis of the 14 adjectives isolated 3 summary scores accounting for 66% of the variance. Active Negative Emotion Passive Negative Emotion Energetic Mood Irritable Lonely Peppy Frustrated Bored Active Nervous Quiet *Reverse of Tired Angry Sad *Reverse of Happy *Reverse of Relaxed Retrospective and Prospective Reports of Relapse Precipitants CONCLUSIONS ! Results suggest that retrospective reports are generally valid !<br><br> Good overall agreement on dimensions of active negative emotions and passive negative emotions ! Energetic mood was unreliable and influenced by current mood at the time of the retrospective report Reasons for Gambling Scale ! Modified from Reasons for Drinking Scale !<br><br> used to describe specific relapse ! coverage and content validity examined ! 24 items !<br><br> Confidence and Temptation versions cluster into four factors Reasons for Gambling Relapse ! Emotional/ relationship frustrated, angry, sad, tense, worried, others being critical, happy (reversed) ! Winning wanting to win, wanting to win, pressured by debts, feeling lucky, to see what would happen Reasons for Gambling Relapse !<br><br> Opportunity/ habit out of the blue, saw others gamble, habit ! Social influences being with others, someone invited me Major Conclusions ! Relapse rates were extremely high (94%) !<br><br> Relapses were most likely to occur during late evening (and least likely to occur in the morning), on the weekend and when the individual was alone. ! Positive and negative moods were equally likely to precede gambling.<br><br> ! Most relapses were minor (1 day duration) but half had an extremely negative consequence Major Conclusions ! Comorbidity rates were high !<br><br> Stable abstinence from gambling for a 3 month period was more likely in participants without a past mood disorder, in those involved current treatment and in those with a current substance use disorder. ! Retrospective descriptions of mood were not negatively biased.<br><br>