Thomas Nilsson's presentation on "Treatment Online. Does it Work for Problem Gamblers?" Part of a joint-presentation with Dr. Richard Wood. Presented at the New Horizons in Responsible Gambling conference. January 28-30, 2013 in Vancouver, BC.

1. Treatment online? Does it work for problem
gamblers?
Thomas Nilsson, C. Psychologist
Email: thomas@silabs.se

2. Talk about
Online self help programs for problem
gamblers – past present and future
How does it work?
Does it work?
If online self help programs/treatment
programs is the future, what will they
look like?

3. What I like
Accessible
Easy to use
It is something in between
prevention, self help and treatment
It reduces barriers to treatment
We meet a new group of PG
You can try and try
You can follow your own progress
Coast are low

4. It already started back in
2000
We where working on developing the
national help line for problem
gamblers in Sweden.
We wrote a self help book for
problem gamblers 2000 to 2002.
Then we meet professor Per Carlbring
(www.carlbring.se) who is an world
leader in treatment online and made
the book into a online self help
program with CBT therapeutic
support.
We got financial support from The
Swedish National Public Health
Institute.
Then we started 2004!

5. Our work is inspired by:
• Theories on dependencies – gambling, alcohol, drugs…
• Bandura, Jacobs, Hodgins, Ladoucuer, Heaster & Miller…
• CBT in general and for depression and anxiety in particular
• Work and theories around motivational interviewing (MI)
• Clinical experience
• What works!
The self help online program is inspired from:
• Becoming A Winner: Defeating problem Gambling a
gambling self-help manual. Hodgins and Makarchuk Gambling
research project, University of Calgary and Addiction Centre-
Calgary Regional Health Authority
• The self help manual is evaluated by professor, Per Carlbring,
Clinical psychology, University of Umeå, Sweden, his
Background colleagues and students

6. For the patient:
• Read and do exercises described in the module
• Provide answers to essay questions via e-mail
• Post a comment on a bulletin board
• Talk to a CBT therapist on the phone for approximately 25 to 30
minutes/week
For the therapist:
• Therapists judge if a patient is ready to go to the next module,
and gives feedback
A typical week in the program

7. Modules 1- 4 lead to a decision:
Stop all together or cut down?
Modules 5 - 8 are the actual treatment:
Information – e.g. luck, random
Cognitive restructuring
Risk situations – stopping impulses
Sort out the economic situation
Filling the void with meaningful activities
Pace: One module per week
In total eight (8) treatment modules

8. • NODS
• MADRS-S
• HADS-anxiety/-depression
• QOLI
• Help seeking behaviour
• Social situation, education, work etc
• Us of alcohol and drugs
• Readiness to change questionnaire
The screening is
made via the • Self reported gambling (like frequency, magnitude,
computer online intensity, etc)
• Jacobs five questions (dissociation)
• And more (in total 99 questions)
Screening and decision – yes or no

9. Gambling background
Consequences
- economic, relations, health…
Function
-positive/negative reinforcement in short/long
term
Present state
- Why treatment now?
- Actual gambling behaviour?
- Expectations and goals?
Gambling free periods - coping strategies
First telephone session with therapist

10. Module 1 Module 2
Texts about: Last three gambling situations:
• How an addiction develops • Triggers, thoughts, feelings before
and after gambling
• Characteristics for addictions
Questions about: • Wins and losses last 30 days of
• Values and life goals gambling
• Costs per month and year
• Positive and negative
consequences from gambling
• Why gambling

11. Module 3 Module 4
Ask a family member or a dear About:
friend: • Acceptance and mindfulness
- how has my gambling affected as a tool
me? • The importance of
- how has my gambling affected acceptance for the losses
you?
• Dreams of big wins
• Advantages and disadvantages
with either continuing or stop The contract with yourself – stop /
gambling control?
• Make a decision whether you want Tell families and friends about your
to change gambling behaviour or
not gambling problem

12. Module 5 Module 6
• Alternative activities • Make a plan to avoid relapse
• Common negative thoughts • Ask family and friends for help
• Miss consumptions about chance • Strategies for handling urges
and luck • Exercise can be an alternative
• Erroneous beliefs about gambling

13. Module 7 Module 8
• Listing your debts • Reward yourself for job well done
• Making a plan for paying • Laps and relapse
back • A plan for change
• Strategies to control your economic • Look back on goals and contract
• More support?

14. • Listen, respect and follow each
individual
• Show empathy, normalize
• Reinforce, give hope, encourage
• Encourage self reinforcement
• Increase self confidence/self efficacy
• Encourage acceptance
• Reduce rumination- increase change
of behaviour
• Share knowledge
Key words - telephone support

15. • NODS
• HADS
• Quality of Life Inventory
• Self reported gambling
• Questions on how they experienced the
treatment, contact with the therapist, etc
Follow up – post, 6 months, 18 and 36 months

16. What at do they think
about the program?
• Talk to the therapist
• The content was spot on
• Anonymous
• Internet is everywhere
anytime
• Those with social phobia
• There are no treatment
where they live
• The forum
• Working on there own (most
clients spend between 2-5
hours/week) Client information

17. Problem games Participants
• VLT • Mean age: 33.2
• Internet poker • Male: 81 %
• Female: 19 %
• Poker
• Started playing regularly at 23.7 yrs
• Trotting • Problematic gambling since 5.70
yrs
• Casino Internet
• Debts: M=1354 CAD
From the screening

18. Screening n=464
Excluded n = 148
Pre treatment data n=316
Never showed up n = 32
Started treatment n=284
M 1: n = 275 Post treatment data: n=219
M 2: n = 214
M 3: n = 186 6 month follow up data: n=197
M 4: n = 174
M 5: n = 158 18 month follow up data: n=181
M 6: n = 150
M 7: n = 147 36 month follow up data: n=196
M 8: n = 148
No M: n = 9
Follow up - population

19. Measure Mest SDest dest
NODS
Pre 8.16 2.48
Post 2.09 2.78 2.31
6 2.16 2.95 2.21
18 2.25 3.07 2.13
36 2.04 2.98 2.24
HADS-A
Pre 11.0 4.38
Post 7.25 4.85 0.81
6 6.56 5.11 0.93
18 6.29 5.33 0.97
36 6.35 5.24 0.96
HADS –D
Pre 9.12 3.39
Post 5.53 4.36 0.86
6 4.87 4.60 0.99
18 4.89 4.79 0.97
36 5.05 4.74 0.94
QOLI
Pre 0.30 1.72
Post 1.14 1.94 0.46
6 1.37 2.04 0.57
18 1.50 2.12 0.62
36 1.24 2.07 0.50
Results – some screening instruments

20. Success?
Out of the 196 clients 77
(40 %) was regarded as
successful. They meet
following criteria on the
36 month follow up:
• 0 points on NODS
• no gambling the last
month

21. References
Carlbring, P., Smit, F. (2008). Randomized Trail of
Internet-Delivered Self-Help With Telephone
Support for pathological Gamblers. Journal of
Consulting and Clinical Psychology
Degerman, N. (2010). Internetbaserad
självhjälpsbehandling i kombination med
telefonstöd vid spelmani - En effectiveness-studie
på kort och lång sikt samt prediktion av
behandlingsutfall, avhopp från behandling och
återfall. Linköpings Universitet. Institutionen för
beteendevetenskap och lärande.
Psykologprogrammet.
Statens Folkhälsoinstitut. (2010). Internetbaserat
självhjälpsprogram för spelberoende. Slutrapport.
Carlbring, P., Degerman, N., Jonsson, J., &
Andersson, G. (2012). Internet-Based Treatment of
Pathological Gambling with a Three-Year Follow-
Up. Cognitive Behaviour Therapy. Link:http://
dx.doi.org/10.1080/16506073.2012.689323
Gainsbury, SM & Blaszczynski, A (2011) 'A
systematic review of Internet-based therapy for the
treatment of addictions', Clinical Psychology
Review, vol. 31, no. 3, pp. 490-498. Clinical
Psychology. Available at: www.elsevier.com/
locate/issn/02727358Publisher's version of
article available at http://dx.doi.org/10.1016/
j.cpr.2010.11.007

22. Gambling – the future is
already here
Accessible
Digital
Innovative
Interactive
Global

23. Responsible gambling is
evolving
Player education
Links to treatment/forums
Voluntary/obligatory
Setting limits
Self test
Self exclusion
Block your self
Behavioural tracking systems
Research
Obligatory player card?
Proactive approach to PG?

24. In the future?
Online (treatment) programs –
therapist
no therapist
Forums – large online communities.
No secrets!
Player card connected to both online
and “live” gambling
Gaming will be included in gambling
– more sophisticated and “internet
smart” group
More focus on the player and player
experience - smarter information,
more proactive support teams, more
interactive and multi channelled
information with the players

25. Support online
- what's next?
Our (SI) next step is to test (during
2013) an self help program online
using the knowledge, experience and
research we done so far.
This is how we think:
• Exclude live therapist and include
therapist role in the program
• Develop screening and create
individual “playlists”
• Motivation loop
• Relapse button
• Evaluation
• Cooperate with large forums
• Player education (version 2.0)

26. Brand new!
This is version 1.0 of our totally interactive self help program for
problem gamblers. Launched January 2013 and research is in progress.

27. Wow! Looks simple?

28. Looks simple 2

29. Looks like this

30. What next?
• Online gambling is growing, so must online support
• Integration with gaming companies, direct links
from games to support
• Integration of different online services
• Technology can not be un-invented and the
Internet is impossible to fully control. But
technology can and does offer some solutions

31. For every complex problem there is an easy answer, and it is wrong.
H.L Mencken
THANKS!