The Efficacy of Individual Community Reinforcement and

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Transcript The Efficacy of Individual Community Reinforcement and

Community Reinforcement and Family Training (CRAFT) with Concerned Significant Others of Problem Gamblers Nicole Peden & David C. Hodgins University of Calgary

Rationale for Working with CSOs

 Engaging CSOs is an excellent way to access problem gamblers who are resistant to treatment  Problem gamblers report that family influence was an important reason why they quit gambling  CSOs are in need of help themselves

Traditional Approaches

 12 Step Programs  Johnson Institute Intervention  Mental Health Counseling  Nothing

12 Step Programs

 Loving detachment  Acceptance of CSOs inability to control IPs behaviour  Group support for CSO

Johnson Institute Intervention

 IP is confronted at a “surprise party”  29% of CSOs complete training and carry out the intervention  Overall success rate: 24% enter treatment


1) Engage addict into treatment 2) Reduce addictive behaviour 3) Decrease CSO distress

CRAFT Theory

 Rooted in Behaviour Theory  Operant Conditioning  Aspects  Problem focused (e.g., problem solving, functional analysis)  Skills based (e.g., communication training, use of positive reinforcement and time out from pr, natural consequences for using)  Active during sessions (e.g., role plays, exercises)  Active between sessions (e.g., assignments, suggesting treatment)

Empirical Support

 Makarchuk, Hodgins, & Peden (2002)


 31 CSOs randomly assigned to CRAFT workbook vs. standard treatment package  3 month follow up


 Gambling behaviour decreased in CRAFT workbook group  Treatment entry rates similar for both groups  CSO distress improved in both groups

Empirical Support

 Hodgins, Toneatto, Makarchuk, Skinner, & Vincent (2004)


 186 CSOs randomly assigned to 1) CRAFT workbook, 2) CRAFT workbook + telephone support, 3) a control package  3, 6 month follow ups


 Fewer days gambled in CRAFT workbook groups  Treatment entry rates similar for all groups  CSO distress improved in all groups

Empirical Support

Population CRAFT Study Substance Abuse

Sisson & Azrin (1986) Miller, Meyers, & Tonigan (1999)

Problem Gambling

Kirby, Marlowe, Festinger, Garvey, & LaMonaca (1999) Meyers, Miller, Hill & Tonigan (1999) Meyers, Miller, Smith & Tonigan (2002) Waldron et al., (2003) Makarchuk, Hodgins, & Peden (2002) Hodgins, Toneatto, Makarchuk, Skinner, & Vincent (2004)

Treatment Engagement CRAFT GOALS Reduce Addictive Behaviour Decrease CSO Distress

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CRAFT Study Conclusions

CRAFT is the only therapy that is aimed at helping both the gambler and the CSO


Has some empirical evidence to support its utility

Study Objectives

Phase I  Modify and deliver the CRAFT intervention in an individual face-to-face format to CSOs of problem gamblers Phase II  Compare CRAFT individual intervention to the CRAFT self-help intervention

Collaboration and Funding

 Collaboration with AADAC Counseling Services in Calgary  Funding support from Alberta Gaming Research Institute


 Department of Psychology Research Ethics Board (DPREB) November 2005  Conjoint Faculties Research Ethics Board (CFREB) January 2006

Development of CRAFT therapist manual, client handouts, and treatment integrity checklist.

Initial telephone contact, screening, and recruitment.

Administration of pre-treatment assessment measures (face-to-face interview).

Assignment to treatment condition.

CRAFT Self-help Workbook CRAFT Individual Intervention Post-treatment assessment (telephone interview).

Six-month assessment (telephone interview) + gift certificate mail out.

Sample Advertisement

Inclusion Criteria

1) 2) 3) 4) 5) 6) 7) 8) CSO be over the age of 18 CSO have a minimum of 3+days/week of contact with the gambler Gambler be resistant to suggestion for treatment Gambler and the CSO must have not attended treatment for gambling related problems in the last 2 months Gambler must meet criteria for problem gambling (as reported by the CSO) and the CSO should be free of problems with gambling Record sessions Provide follow-up data Provide the name of a collateral to help locate them for the post-assessment and 6-month interviews


GAMBLING BEHAVIOURS, MOTIVATIONS, CONSEQUENCES 1. Gambling Behaviour 2. Treatment Involvement 3. Inventory of Consequences for the IP and CSO 4. University of Rhode Island Change Assessment Inventory - Gambler version RELATIONSHIP FUNCTIONING 1. Relationship Happiness Scale 2. Relationship Assessment Scale



Brief Symptom Inventory 2.


Depression Anxiety Stress Scales State-trait Anger Expression Inventory-II REACTIONS TO TREATMENT 1.

Attendance/Workbook adherence 2.


Working Alliance Inventory Satisfaction questions about the program

CRAFT in 7 Modules (8-12 Sessions)

1) 2) 3) 4) 5) 6) 7) Building and sustaining motivation Functional analysis of the gambling behaviour Improving communication skills Positive reinforcements for non gambling behaviour Use of negative consequences Helping the CSO enrich their own lives Suggesting treatment/Termination and additional resources


1) CRAFT individual intervention = less gambling and more gamblers entering treatment 2) CRAFT individual intervention = lower levels of personal distress and better relationship functioning with the gambler

Data Analysis

Hypotheses = group (CI, CW) x time interaction (Pre, Post, 6m) ANOVA will examine differences between groups for each outcome category 1.



Days gambled Treatment engagement CSO functioning

  STRENGTHS  Unique contribution Random assignment Use of treatment manual  Treatment adherence check (non-invested rater)  Blind follow-ups LIMITATIONS   CSO report Less experienced clinicians  Sample size  Limited measurements