Adding Contingency Management to Treatment as Usual for Disordered Gambling.
Condition: Gambling, Pathological
MeSH terms: Gambling
Study type: Interventional

Summary: 
      The aim of this study is to conduct a trial to investigate the efficacy of adding Contingency
      Management (CM) to Treatment as Usual (TAU) for the treatment of Disordered Gambling. Results
      from this experiment will provide the first evidence of the additional efficacy of
      best-practice CM and whether it can be easily integrated into a clinical environment.
      Additionally, this study will correlate clinical outcomes with psychological measures and
      participant responses to develop new predictive treatment outcome measures.
    

Detailed description: 
      Hypothesis Behavioural approaches are direct and powerful ways of modifying problematic
      behaviours. The prediction is that adding best-practice CM treatments to TAU will reduce
      gambling behaviour and gambling urges to a greater degree than standard counselling
      practices.

      Background Problematic gambling is a significant Canadian public health concern that causes
      harm to the gambler, their families, and society at large (Huang & Boyer, 2007).
      Approximately 4% of Albertans gamble in problematic ways resulting in significant financial
      losses, personal distress, relationship break-downs, and in some cases suicide (Williams et
      al., 2011; Problem Gambling Institute of Ontario, 2014). However, recent trends appear to
      show a decline in those seeking treatment despite the relatively consistent
      problem/disordered gambling prevalence rates (Williams et al., 2011). Further, 33% - 50% of
      treatment seekers drop out prior to the issue resolving (Leblonde et al., 2003), where those
      with the most severe gambling problems have the highest drop-out rates (ibid). One possible
      reason for these issues is the lack of immediate benefits clients gain from treatment
      attendance.

      One treatment approach that provides immediate benefit for treatment attendance and superior
      treatment efficacy for substance and alcohol dependence is contingency management (Petry,
      2010). Contingency management uses motivational incentives, typically vouchers that are
      exchangeable for retail goods and services, as rewards that participants receive for
      providing evidence of the target behavior and withholding them when the participant fails to
      perform the behaviour. This treatment has been used successfully in several countries in the
      treatment of various addictive substances (Garcia-Rodriguez et al., 2009; Peirce et al.,
      2006), and to promote healthy behaviours (Petry et al., 2011). Meta-analyses have
      consistently found contingency management to report improved clinical outcomes and the
      highest of treatment effect sizes (Dutra et al., 2010; Prendergast et al., 2006). Further,
      contingency management programs typically report a greater likelihood of program completion
      than standard care (Lott & Jencius, 2009), where the positive effects of the treatment
      persist many months after treatment completion (Petry & Martin, 2002).

      Researchers are now suggesting that contingencies can be important mechanism in the treatment
      of gambling (Petry et al., 2006; Christensen, 2013), as the variable but regular nature of
      the receipt of gambling wins have been associated with the development of problematic
      gambling (Blaszczynski & Nower, 2002), where contingency management uses the same approach to
      reverse these associations. Moreover, recent research suggests that the development of
      non-gambling reinforcement can successfully compete with the gambling experience resulting in
      reductions in gambling behaviour and increases in alternative, and pro-social, behaviours
      (Jackson et al., 2013).

      Although CM appears very successful, it has only been previously applied once to problematic
      gambling (West, 2008). However, there were issues with the pilot procedure (Christensen,
      2013), as the program implemented was non-standard, notably the reinforcers were delayed,
      infrequent, of a low level, resulting in modest CM treatment outcomes (Petry, 2010). This
      proposal will use techniques that have been shown to improve the efficacy of a CM program.
      These are; 1) increasing the rate of incentives for sustained performance of the target
      behaviour and resetting following a lapse (Petry et al., 2006), 2) providing incentives at
      regular intervals (Christensen, 2013), 3) providing incentives as soon as practicable after
      evidence of the target behaviour is provided (Zeiler, 1977; Griffith et al., 2000), and 4)
      providing sufficiently meaningful incentives (Dallery et al., 2001). These additions to the
      standard CM procedure, which are typically used in successful treatments for substance
      dependence (Chopra et al., 2011), will hopefully improve the treatment efficacy of CM for
      disordered gamblers.
    

Intervention name(s): Contingency Management; Treatment as Usual
Intervention type(s): Behavioral; Behavioral
Intervention description(s): See arm description.; See arm description
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment