David C. Hodgins Nady el-Guebaly Susan Armstrong Nicole Peden

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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 ! Relapse rates and patterns ! Characteristics of relapse ! Validity of self-reports ! Role ofcomorbid problems on outcome ! Retrospective and prospective reports of relapse precipitants Design ! Recruited 101 people who recently quit gambling ! Media recruitment versus treatment sample ! No gambling for 2 weeks ! South Oaks Gambling Screen (SOGS) > 4 ! Interviewed face to face initially, 3, 6 and 12 months Measures ! Demographics ! Gambling history and severity ! Gambling frequency and amount ! Mood disorders (SCID) ! Substance abuse/dependence ! Relapse Experiences Demographics (N=101) % Female36 % Married or Cohabiting29 % Never Married38 % Some post secondary education66 % Full-time employment55 % Unemployed22 % Current smoker76 AGEMean39 Range19-77 Gambling Involvement Age of gambling problemMean34 South Oaks Gambling ScreenMean12.2 % DSM-IV Pathological Gambling89 % Previous quit attempt75 % Past gambling treatment50 % Current gambling treatment25 Mean days abstinent at initial19 Major problem type of gambling: % Video lottery terminals49 % Mixed games34 % Casinos12 % Bingo3 % Other3 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% ! 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?71% 7 days in a row?40% plan?53% ! Suicide attempt? 33% -required medical help in 62% of attempts ! Attempt related to gambling? -21% of those attempting or 7% of sample Goals and Confidence Goal Quit all forms of gambling33% Quit problem type of gambling67% Confidence to achieve goalScale 1-10 (10 most confident) in the next weekM=8 in the next monthM=7 in the next yearM=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 concerns64%Lack of financial resources8% Negative emotion32%Legal influence6% Incompatible with desired32%Confrontation by others6% self-image or goalsDistraction with other things2% Family influence30%Environmental change2% Cognitive appraisal20%Social support0% Rational appraisal10% Fear of future negative 8% Other % of people consequencesUnclear13% Hitting rock bottom6%Out of awareness0% Spiritual influences2% Reasons for Quitting Gambling Checklist method Financial problems97% Emotional factors95% Family/children72% Hit rock bottom60% Major life-style change57% Pros and cons evaluation57% Physical health55% Humiliating event54% Work-related problems47% Traumatic event44% Problems with spouse44% Confrontation40% Legal problems28% Change in another addictive behavior26% Religious involvement22% 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. ! 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). 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 BeforeDuring Gambled 00%19% 12%24% 2-733%43% 8 or more65%14% . Gambling Outcome: Conclusions ! Relapse rates are very high " 94% relapsed " almost half gambled most of the year ! 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 Morning12% Noon21% Early afternoon15% Late afternoon/early evening21% Late evening (after 10pm)31% Weekday50% Weekend(after noon on Friday)50% Alone67% With friends/family33% Dominant Form of Gambling: VLT 9s57% Casinos25% Scratch tickets7% Bingo7% Sports select2% Slots2% Characterization of Relapses Engaged in task prior to relapse49% No task engagement51% Characterization of Relapses Main Reason for Relapse -open ended responses Thought I could win20% Boredom/killing time18% Giving into urges/habit/opportunity15% Dealing with negative situations/emotions15% Make money10% Socializing/fitting in10% Seeking excitement/ enjoyment5% Giving up3% Control issues/testing2% Access to money2% Characterization of Relapses Emotional State Prior to Gambling % Thinking about finances77 Frustrated51 Happy49 Bored46 Active45 Tired42 Sad36 Relaxed36 Quiet35 Irritable34 Lonely33 Angry29 Nervous29 Peppy19 Characterization of Relapses Consequences of the Relapse 16% 14% 12% 51% 0% 10% 20% 30% 40% 50% 60% Family LifeSocial LifeWork LifeFinancial Situation Characterization of relapses ! 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. 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 WeeksWeeksWeeks 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/partner35% Other immediate family29% Friend29% Roommate3% Other5% 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 gambled29% 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. Irritable Angry Frustrated Sad NervousHappy Lonely Tired Bored Relaxed QuietPeppy ActiveFinances 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 EmotionPassive Negative Emotion Energetic Mood IrritableLonelyPeppy FrustratedBoredActive NervousQuiet*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 ! 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 ! used to describe specific relapse ! coverage and content validity examined ! 24 items ! 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 ! 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%) ! 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. ! Most relapses were minor (1 day duration) but half had an extremely negative consequence Major Conclusions ! Comorbidity rates were high ! 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.

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