NCRG Conference on Gambling and Addiction

Monday, November 17, 2008

Seeking a Treatment Standard for Gambling Disorders: Are We There Yet?

According to Dr. Peter Nathan, professor emeritus of community and behavioral health at the University of Iowa, we’re getting there.

While no existing pharmacological (drug) or psychosocial (therapy) treatments for pathological gambling have yet met the usual standards that would establish them as empirically-supported, Nathan said there are treatments that show promise. Nathan asserted that, for empirically-supported treatments to be identified, the field must first complete well-designed, large-scale, multisite randomized-clinical-trial studies of treatments. But there are barriers. One particular that he noted was the fact that it is harder to get pathological gamblers to admit they have a problem, and therefore agree to participate in studies, than it is with other, similar groups, such as alcoholics – perhaps because of a lingering social stigma about gambling disorders.

In the last session of the day, which focused on evidence-based (i.e., empirically supported) treatments for pathological gambling, Nathan laid out several criteria for a treatment to be considered empirically-supported, including studies that have a randomized assignment of patients; compare the experimental treatment with an active comparison treatment, rather than a no-treatment control group; the use of multiple outcome measures; and appropriate treatment follow-up, so that the “staying power” of the experimental and comparison treatments can be evaluated. He also noted that the treatment itself must lead to significantly better outcomes for significantly more patients than comparison treatments, and that these findings must ultimately be replicated by more than a single team of investigators.

In his presentation, Nathan mentioned that “it is only human nature to assume that the treatments we have learned to deliver are the most useful,” and that “there is often a special place in our hearts for the treatments we learned in our early years in the field.” He encouraged his fellow clinicians, however, to familiarize themselves with and consider adopting treatments that have been systematically compared to others and shown their efficacy.

Nathan then led attendees through a detailed overview of the existing treatments used to treat pathological gambling, including psychosocial treatments – such as Cognitive Behavioral Therapy, Motivational Enhancement Therapy and Twelve-Step Facilitation Therapy – and pharmacological treatments – such as antidepressants, mood stabilizers and opioid antagonists. These forms of treatment have been the subjects of increasing study over the past several years, yet, Nathan explained that very few studies have examined the combination of drug and behavioral treatments. Similarly, there have been very few studies on the treatment of pathological gambling in conjunction with comorbid conditions, i.e., other disorders, such as drug- or alcohol-use disorders, that a pathological gambler also suffers from.

Following Nathan’s presentation, Dr. Lisa Najavits, professor of psychiatry at Boston University School of Medicine and president-elect of the American Psychological Association’s Division on Addictions, raised some broader themes that have arisen from psychotherapy research. One consistent finding, she noted, is that good manualized treatments (those administered based on a standard, written manual) will almost always be equal to each other, so she encouraged clinicians to find good treatments of this kind that fit them as clinicians while also fitting their clients’ needs.

Another consistent finding Najavits pointed out was that manual-based treatments almost always out-perform “treatment as usual” (i.e., when a clinician simply “makes it up on the spot”). She also mentioned that, while there has not been a considerable amount of literature on this point, existing research does seem to show that the assignment of a therapist is even more important than assignment to treatment type to patient success. Additionally, Najavits reminded the audience that the criteria for evidence-based treatments haven’t been standardized, which further complicates both identifying and implementing efficacious treatments.

In a question-and-answer session with the audience, the panel discussed the growing interest in the certification of therapists for pathological gambling. Nathan said that, in principle, certification makes a lot of sense. He noted that it has been helpful to the alcohol treatment industry because it sets a standard for people to aspire to. He also noted, however, that he did not think pathological gambling is in the same boat, citing the need for more data about empirically-supported treatments.

Najavits added that the problem with the vast majority of certification programs is that they measure knowledge, but they don’t measure the skills that are connected to outcomes. She recommended having a patient evaluation as part of a certification process, and to find other measures to evaluate – such as empathy and interaction with the client – until assessments that can actually measure the work clinicians do are developed.


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