PRACTICE GUIDELINES FOR THE TREATMENT OF GAMBLING PROBLEMS

Massachusetts Department of Public Health’sPractice Guidelines for TreatingGambling-Related ProblemsAn Evidence-Based Treatment Guide for CliniciansDavid A. KornUniversity of TorontoHoward J. ShafferHarvard Medical School, Division on AddictionsDeveloped by the Massachusetts Council on Compulsive GamblingJanuary, 2004

Table of ContentsTABLE OF TABLES .4PRACTICE GUIDELINES FOR THE TREATMENT OF GAMBLING-RELATED PROBLEMS .5PRACTICE GUIDELINES FOR THE TREATMENT OF GAMBLING-RELATED PROBLEMS .5AN EVIDENCE-BASED TREATMENT GUIDE FOR CLINICIANS .5INTRODUCTION: THE PURPOSE OF PRACTICE GUIDELINES.5INCLUSION CRITERIA FOR GATHERING EVIDENCE .6CLASSIFYING THE EVIDENCE .6GAMBLING, GAMBLING DISORDERS AND GAMBLING TREATMENT: AN INTRODUCTION .6APPROACH TO PRACTICE GUIDELINES .7GUIDING PRINCIPLES FOR CLINICAL INTERVENTIONS.9TREATMENT OBJECTIVES .11CONCEPTS THAT SHAPE TREATMENT INTERVENTIONS .11Public Health Model: A Framework for the Spectrum of Gambling Behavior .11Gambling Addiction .12Pathways into Disordered Gambling.12Natural History of Pathological Gambling.13Framework for Selecting Clinical Interventions .13ASSESSMENT OF PATHOLOGICAL GAMBLING AND RELATED DISORDERS .13Assessment, Diagnosis and Treatment: General Considerations .13Screening.14Diagnosing Pathological Gambling.15Assessing Motivation and Readiness for Change.16Assessing the Severity of Disordered Gambling .16Formulating a Treatment Plan.16TREATMENT MODALITIES & SETTINGS .16Caring for a Syndrome.16Counseling Interventions .17Strength of Evidence .17Promising Interventions and Complementary Services .18INTERVENTIONS: STRONG EVIDENCE.19Cognitive Behavior Therapy and Related Techniques .19Cognitive Restructuring . 19Problem Solving Training. 20Social and Coping Skills Training . 20Behavioral Therapy.20Imaginal Desensitization Technique . 21INTERVENTIONS: MODERATE EVIDENCE .21Relapse Prevention and Recovery Training.21INTERVENTIONS: WEAK EVIDENCE .22Psychodynamic Psychotherapy .22Self-Help: Gamblers Anonymous .22Aversion Therapy .23Self-Exclusion .23INTERVENTIONS: PROMISING AND COMPLEMENTARY SERVICES .23Promising Interventions .23Brief Therapy. 23Motivational Enhancement Strategies. 24

Matching Motivational Strategies to Stage of Change. 25Complementary Services.26Financial Management. 27Leisure Substitution . 27Twelve Step Facilitation . 27Other Psychological Therapies . 28Psychopharmacology . 28Opioid Antagonists (OA). 29Selective Serotonin Reuptake Inhibitors (SSRIs) . 29Mood Stabilizers. 30Other Drugs . 30Integrated Treatment Strategies: Combining Psychotherapy and Pharmacotherapy.30TREATMENT OF DISORDERED GAMBLING IN SPECIAL POPULATIONS.30Youth .31Older Adults .31Women.32Aboriginal People / Indians / First Nations .32Ethno-cultural Minorities.32The Homeless .32Gambling Disorders Among Patients with Comorbid Mental Disorders .33Families.33GAMBLING TREATMENT EMERGENCIES .33THE NATURAL HISTORY OF GAMBLING TREATMENT: STAGES OF EVENTS AND ACTIVITIES.33ADMINISTRATIVE MATTERS FOR CLINICIANS .34ACKNOWLEDGEMENTS .35REFERENCES .35APPENDICES.46APPENDIX 1: PRINCIPLES OF DRUG ADDICTION TREATMENT: A RESEARCH-BASED GUIDE .46APPENDIX 2: COMMONLY USED SCREENING INSTRUMENTS .47PROBLEM GAMBLING .47South Oaks Gambling Screen (SOGS) .47South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA).47Massachusetts Gambling Screen (MAGS) .47Diagnostic Interview Schedule (DIS).47Composite International Diagnostic Interviewing (CIDI) .48READINESS TO CHANGE .48University of Rhode Island Change Assessment (URICA) .48SUICIDALITY .48Beck Scale for Suicide Ideation (BSS).48Suicide Intent Scale (SIS) .49Beck Hopelessness Scale (BHS).49ANXIETY DISORDERS.49Manifest Anxiety Scale (MAS).49Hamilton Anxiety Rating Scale (HARS) .49Clinical Anxiety Scale (CAS) .50Beck Anxiety Inventory (BAI).50Fear Questionnaire (FQ) .50DEPRESSIVE DISORDER.50Beck Depression Inventory (BDI) .50Hamilton Rating Scale for Depression (Ham-D) .513

Inventory of Depressive Symptomatology (IDS) .51Raskin Scale (Three-Area Severity of Depression Scale).51Zung Self-Rating Depression Scale (Zung SDS) .51SUBSTANCE USE DISORDERS.51Alcohol Use Disorders Identification Test (AUDIT).51Addiction Severity Index (ASI) .51Drug Abuse Screening Test (DAST).52Fagerstrom Test for Nicotine Dependence (FTND).52Michigan Alcoholism Screening Test (MAST) .52Alcohol Dependence Scale (ADS) .52Obsessive Compulsive Drinking Scale (OCDS).52Brief Screen for Adolescent Substance Abuse (CRAFFT).53APPENDIX 3: SERVICES OF THE MASSACHUSETTS COUNCIL ON COMPULSIVE GAMBLING .54About the Massachusetts Council on Compulsive Gambling.54APPENDIX 4: SELECTED RESOURCES FOR HELP WITH GAMBLING PROBLEMS .5512 STEP SUPPORT GROUPS.55Gamblers Anonymous. 55Bettors Anonymous . 55Gam-Anon . 55Massachusetts Treatment Resources.56National Treatment and Education Resources.56APPENDIX 5: CERTIFICATION FOR TREATMENT PROVIDERS: RECOMMENDATIONS AND RESOURCES .57AMERICAN ACADEMY OF HEALTH CARE PROVIDERS IN THE ADDICTIVE DISORDERS .57NATIONAL GAMBLING COUNSELOR CERTIFICATION BOARD.57APPENDIX 6: CRITERIA FOR TREATMENT MATCHING .58CRITERIA FOR ACUTE INPATIENT HOSPITAL CARE .58CRITERIA FOR NON-HOSPITAL RESIDENTIAL CARE.58CRITERIA FOR PARTIAL HOSPITALIZATION OR DAY TREATMENT CARE.59CRITERIA FOR OUTPATIENT CARE .59APPENDIX 7: SPECIAL NOTE ON TAKING A SUBSTANCE USE OR GAMBLING HISTORY .60Table of TablesTABLE 1: COMPONENTS OF COMPREHENSIVE ADDICTION TREATMENT*.9TABLE 2: DIAGNOSTIC CRITERIA FOR PATHOLOGICAL GAMBLING .15TABLE 3: CLASSIFYING THE EVIDENCE .18TABLE 4: THE GA TWELVE STEPS .284

Practice Guidelines for the Treatment of Gambling-Related ProblemsAn Evidence-Based Treatment Guide for CliniciansIntroduction: The Purpose of Practice GuidelinesSackett reminds us that evidence-based practice is the conscientious, explicit, and judicious use of current“best evidence” in making decisions about delivering care to an individual (e.g., patient/client) or group(e.g., family). Working in an evidence-based practice means that clinicians integrate personal clinical expertise with the best available

Miller, 1999). For example, Hubble et al. (1999) advise that common factors significantly influence treatment outcome. In addition to the specific effects associated with the treatment model or techniques, they suggest that non-specific to treatment technique factors include: (1) the extra-therapeutic attributes