Integrative Couple Treatment for Pathological Gambling (ICT-PG)

Integrative Couple Treatment for Pathological Gambling or Individual Treatment: A Comparison of Efficacy

The aim of the study is to compare marital treatment to individual treatment for pathological gambling.

The study as two goals: evaluate the efficacy of couple treatment for pathological gambling and develop a better understanding of the individual (substance use, mental health) and couple dimensions (communication, marital satisfaction, violence) as intermediate variables explaining this efficacy. Couples will be randomized between the couple treatment and the treatment as usual (individual or group). The experimental couple treatment is offered over 8 to 12 sessions of 90 minutes. The couple treatment called (Integrative Couple Therapy for Pathological Gambling - ICT-PG) is inspired by the "Alcohol Behavior Couple Therapy" from Epstein and McCrady, to which the team added diverse components to adjust to gamblers. During the sessions, the focus is on a) reducing/stopping gambling behaviors, b) helping the partner to stop behaviors facilitating gambling habits and rise the frequency of behaviors incompatible with gambling habits and c) improve marital components (communication, sharing positive moments, negotiation, mutual support). The control group receives individual or group treatment as already offered by the specialized centers in addiction. Their partner can receive individual intervention if desired. All participants are recruited in Specialized Addiction Treatment Centers in Quebec province, Canada. Evaluation of participants is done at admission, three, nine and 18 months post-admission. Repeated measures ANOVA will be used to compared evolutions of groups over time. Multiple regression will allow the estimation of components roles into as intermediate variables to predict rehabilitation.

Couple therapy: The experimental couple treatment is offered over 8 to 12 sessions of 90 minutes. The couple treatment called (Integrative Couple Treatment for Pathological Gambling - ICT-PG) is inspired by the "Alcohol Behavior Couple Therapy" from Epstein and McCrady, to which the team added diverse components to adjust to gamblers. During the sessions, the focus is on a) reducing/stopping gambling behaviors, b) helping the partner to stop behaviors facilitating gambling habits and rise the frequency of behaviors incompatible with gambling habits and c) improve marital components (communication, sharing positive moments, negotiation, mutual support).

Usual individual/group treatment: The control group receive individual or group treatment as already offered by the specialized centers in addiction.Their partner can receive individual intervention if desired.

The experimental couple treatment is offered over 8 to 12 sessions of 90 minutes. The couple treatment called (Integrative Couple Therapy for Pathological Gambling - ICT-PG) is inspired by the "Alcohol Behavior Couple Therapy" from Epstein and McCrady, to which the team added diverse components to adjust to gamblers. During the sessions, the focus is on a) reducing/stopping gambling behaviors, b) helping the partner to stop behaviors facilitating gambling habits and rise the frequency of behaviors incompatible with gambling habits and c) improve marital components (communication, sharing positive moments, negotiation, mutual support).

The control group receive individual or group treatment as already offered by the specialized centers in addiction.Their partner can receive individual intervention if desired.

Outcome measure for Gamblers The G-SAS is a 12-item self-rated scale designed to assess gambling symptom severity and change during treatment. Each 12-item scale has a score ranging from 0 - 4 (adjective anchors for 0 and 4 vary for each item but "0 means no symptoms" and "4 means extreme symptoms"). All items ask for an average symptom based on the past 7 days (average urge, frequency, duration and control,thoughts associated with gambling,time spent on gambling,anticipatory tension and/or excitement, emotional distress). The total score ranges from 0 to 48. A score between 8 and 20 is an indicator of low urges to gamble, between 21 and 30, moderate urges, between 31 and 40 severe urges and a score of over 40 reveals the presence of extreme urges in the player.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers Among 12 types of gambling activities, the highest frequency of gambling behaviors for the past 6 months (never = 0; every or almost every day=5). Maximum score is 5. The higher is the score, the higher is the frequency.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Detection of Gambling Problems and Services Need ("Détection et Besoin d'Aide en Regard du Jeu Excessif- DÉBA-Jeu")

Outcome Measure for Gamblers The DEBA-Jeu is a very brief screening grid comprising eight Likert-type items in five points (never = 0, always = 4). The eight items form a scale where the total score varies between 0 and 32. The suggested breaking points are as follows: 0 to 1 = No problem gambling; 2 to 5 =Problem gambling ; 6 to 24 = High probability of problem gambling.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers The Canadian Problem Gambling Index (CPGI) is a 9-item measure with a 4-point Likert-type scale (0 = Never, 3 = Almost always).It asks questions about an individual's gambling habits in the last three months from four categories: Gambling involvement; Problem gambling behaviour; Adverse Consequences; Correlates of problem gambling. Scores for the nine items are summed, and the results are interpreted as follows: 0 = non-problem ; 1-4 = low risk; 5-7 = moderate risk; 8 and + (maximum 27) = probable pathological player.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers Total Money spent in canadian dollars for all gambling activities during the last 3 months previous each research interview.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers The ICOG is used to measure two aspects of control related to the JHA processes, namely the level of control over the desire to start playing (e.g., when I decide not to play, I watch stick to that decision) as well as the level of control once the game has started (e.g., when I knew I had little time to play, I would limit myself to the scheduled time). This questionnaire has a total of 10 items and uses a 5-point Likert-type scale ranging from "Never = 1" to "Always = 5", with 4 inverted items. The total score varies between 10 and 50. A high control represents a score between 10 and 16, a moderate control between 17 and 23 and a score of 24 and more presents a low control in the player.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Inventory of Erroneous Beliefs Related to Gambling ("Inventaire Des Croyances liées Aux Jeux" - ICROLJ)-Gambler

Outcome Measure for Gamblers This questionnaire measures people's beliefs about gambling. The ICROLJ has 29 items and uses a 4-point Likert-type scale ranging from "Strongly disagree" = 0 to "Strongly agree"=4. To compute a total score, all item' score are summed. The total score ranges from 0 to 116.Higher the score is, more it indicates the presence of erroneous beliefs.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers Short questionnaire of 10 items, assessing to what extent the respondent considers his gambling habits in the last 6 months have harmed various aspects of his life (financial, living conditions, marital, physical health, professional life, social, legal and family). A 5-point Likert-type scale is used "Not at all = 0" to "Extremely = 4". To compute a total score, all item' score are summed. The total score ranges from 0 to 40.Higher the score is, more it's indicate that the respondent is experiencing negative impacts because of his gambling habits.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners Short questionnaire of 10 items, assessing to what extent the respondent considers that his partner's gambling habits have harmed various aspects of his life in the last 6 months (financial, living conditions, marital, physical health, professional life, social, legal and family). A 5-point Likert-type scale is used "Not at all = 0" to "Extremely = 4". To compute a total score, all item' score are summed. The total score ranges from 0 to 40. Higher the score is, more it's indicate that the respondent is experiencing negative impacts because of his partner's gambling habits.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Inventory of Erroneous Beliefs Related to Gambling ("Inventaire Des Croyances liées Aux Jeux" - ICROLJ)-Partner

Outcome Measure for Partners This questionnaire measures people's beliefs about gambling. The ICROLJ has 29 items and uses a 4-point Likert-type scale ranging from "Strongly disagree" = 0 to "Strongly agree"=4. To compute a total score, all item' score are summed. The total score ranges from 0 to 116. Higher the score is, more it indicates the presence of erroneous beliefs.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This questionnaire measure the quality of the support received and given perceived by the two members of the couple. It consists of a total of 8 questions, with a 5-point Likert scale (1 = never; 5 = always). The total score shows support received and support gave, higher is the result, more it indicates that the member of the couple gave support and receives it (score min = 0 and score max=40).

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This instrument is used to measure psychological distress, including symptoms of depression and anxiety. We used the version of the questionnaire with 14 items. A Likert-type scale ranging from "never = 1" to "very often = 3" is used and the respondent must respond according to their condition during the last seven days. To compute a total score, all item' score are summed. The total score ranges from 0 to 42. A score of 26 and above indicates a high level of psychological distress.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This instrument is used to measure depressive symptoms in an individual. It measures these symptoms as defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV) for depressive episodes.This questionnaire has 20 items and it assesses how the psychological well-being of the person during the last week. A 4-point Likert-type scale is used ranging from "0 = Never, very rarely (less than a day)" to a rating of "3 = Frequently, all the time (5 to 7 days)" The score can therefore vary from 0 to 60, the higher it is the higher the risk of depression. For a man, a threshold of 17 indicates a risk of depression and for a woman the same threshold is 23.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers This instrument is used to measure psychological distress, including symptoms of depression and anxiety. We used the version of the questionnaire with 14 items. A Likert-type scale ranging from "never = 1" to "very often = 3" is used and the respondent must respond according to their condition during the last seven days. To compute a total score, all item' score are summed. The total score ranges from 0 to 42. A score of 26 and above indicates a high level of psychological distress.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers This instrument is used to measure depressive symptoms in an individual. It measures these symptoms as defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV) for depressive episodes.This questionnaire has 20 items and it assesses how the psychological well-being of the person during the last week. A 4-point Likert-type scale is used ranging from "0 = Never, very rarely (less than a day)" to a rating of "3 = Frequently, all the time (5 to 7 days)" The score can therefore vary from 0 to 60, the higher it is the higher the risk of depression. For a man, a threshold of 17 indicates a risk of depression and for a woman the same threshold is 23.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers This questionnaire makes it possible to measure the quality of the support received and given perceived by the two members of the couple. It consists of a total of 8 questions, with a 5-point Likert scale (1 = never; 5 = always). The total score shows support received and support gave, higher is the result, more it indicates that the member of the couple gave support and receives it (score min = 0 and score max=40).

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners The MSI is used to measure marital stability in a couple. It comprises a series of 14 items (with inverted items) in a "true" or "false" format thus aiming to assess the risk of separation in this couple (e.g., I very often have ideas of divorce, until once a week or more). Marital distress is measured in terms of concrete actions taken by members of the couple in order to end their union. The total score is between 0 and 14. The higher the scores, the higher the risk of separation and marital distress. A threshold of 8 is considered to be a severe indicator of separation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers The MSI is used to measure marital stability in a couple. It comprises a series of 14 items (with inverted items) in a "true" or "false" format thus aiming to assess the risk of separation in this couple (e.g., I very often have ideas of divorce, until once a week or more). Marital distress is measured in terms of concrete actions taken by members of the couple in order to end their union. The total score is between 0 and 14. The higher the scores, the higher the risk of separation and marital distress. A threshold of 8 is considered to be a severe indicator of separation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners The Dyadic Adjustment Scale is an ultra-brief measure degree of marital satisfaction within the couple. The short version is made up of only 4 items (considered divorce, estimation of the quality of the relation, confide to mate, degree of happiness): three of which are on a 6-point Likert scale ranging from 0 (all the time) to 5 (never) , while the final item is on a 7-point scale ranging from 0 (extremely happy) to 6 (perfect). Theoretically possible maximum score of 21, and minimum 0. Scores lower than 11 indicating relationship distress, scores between 12 and 14 corresponding to medium satisfaction and scores upper 15 indicating good marital satisfaction.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers The Dyadic Adjustment Scale is an ultra-brief measure degree of marital satisfaction within the couple. The short version is made up of only 4 items (considered divorce, estimation of the quality of the relation, confide to mate, degree of happiness): three of which are on a 6-point Likert scale ranging from 0 (all the time) to 5 (never) , while the final item is on a 7-point scale ranging from 0 (extremely happy) to 6 (perfect). Theoretically possible maximum score of 21, and minimum 0. Scores lower than 11 indicating relationship distress, scores between 12 and 14 corresponding to medium satisfaction and scores upper 15 indicating good marital satisfaction.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers The psychological violence suffered is a subscale of the CTS-2 questionnaire which aims to assess the manifestations of psychological violence committed against the Gambler in the last 3 months. It is made up of 14 items that are rated on a 7-point Likert scale (never happened = 0, 1 time = 1, 2 times = 2, 3 to 5 times = 3, 6 to 10 times = 4, 11 to 20 = 5, more than 20 times = 6). To compute a total score, all item' score are summed. The total score ranges from 0 to 84. The higher it is, more it indicates that the respondent has suffered episodes of violence.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This lists of skills consist of 17 items that expressed in statements representing observable verbal behaviors.Participants were asked to report frequency estimates of their own use of such verbal behaviors using a 4 point likert scale (0 = almost never, 4 = almost always). To compute a total score, all item' score are summed. The total score ranges from 0 to 68. The higher the score is, more it indicates the presence of good communication skills.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers This instrument has 9 items, using a 7-point Likert-type scale. It is used in order to better understand the negotiation and conflict resolution skills that the couple members have used within their marital relationship in the last three months. The score varies between 9 and 63. A high score indicates a greater degree of perceived problem-solving skill within the marital relationship.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers This questionnaire is used to identify the coping strategies used to cope with gambling's habits in the last three months. The subscale is made up of 6 items marked from 0 to 3 (0 = not used; 3 = used a lot). To compute a total score, all item' score are summed. The total score ranges from 0 to 18. Higher the score is, more it indicates the respondent's tendency to adopt the behaviors described by the subscale when he is in a stressful situation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers Number of alcohol standard units (Canada, 1 unit = 13,6g of alcohol) per week during the last three months.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers Frequency of cannabis use per week in the last three months with a 5-point Likert-type scale (never = 0, 3 times a week or more = 4). Higher the score is, more it indicates a high frequency of cannabis use.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers The physical violence suffered is a subscale of the CTS-2 questionnaire which aims to assess the manifestations of physical violence committed against the Gambler in the last 3 months. It is made up of 18 items that are rated on a 7-point Likert scale (never happened = 0, 1 time = 1, 2 times = 2, 3 to 5 times = 3, 6 to 10 times = 4, 11 to 20 = 5, more than 20 times = 6). The total score corresponds to the average obtained on the 18 items, the higher it is, more it indicates that the respondent has suffered episodes of violence.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for the Partner The physical violence suffered is a subscale of the CTS-2 questionnaire which aims to assess the manifestations of physical violence committed against the partner in the last 3 months. It is made up of 18 items that are rated on a 7-point Likert scale (never happened = 0, 1 time = 1, 2 times = 2, 3 to 5 times = 3, 6 to 10 times = 4, 11 to 20 = 5, more than 20 times = 6). The total score corresponds to the average obtained on the 18 items, the higher it is, more it indicates that the respondent has suffered episodes of violence.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners The psychological violence suffered is a subscale of the CTS-2 questionnaire which aims to assess the manifestations of psychological violence committed against the partner in the last 3 months. It is made up of 14 items that are rated on a 7-point Likert scale (never happened = 0, 1 time = 1, 2 times = 2, 3 to 5 times = 3, 6 to 10 times = 4, 11 to 20 = 5, more than 20 times = 6). To compute a total score, all item' score are summed. The total score ranges from 0 to 84. The higher it is, more it indicates that the respondent has suffered episodes of violence.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers This questionnaire is used to identify the coping strategies used to cope with gambling's habits in the last three months. The subscale is made up of 9 items marked from 0 to 3 (0 = not used; 3 = used a lot). To compute a total score, all item' score are summed. The total score ranges from 0 to 27. Higher the score is, more it indicates the respondent's tendency to adopt the behaviors described by the subscale when he is in a stressful situation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Gamblers This questionnaire is used to identify the coping strategies used to cope with gambling's habits in the last three months. The subscale is made up of 6 items marked from 0 to 3 (0 = not used; 3 = used a lot). To compute a total score, all item' score are summed. The total score ranges from 0 to 18.Higher the score is, more it indicates the respondent's tendency to adopt the behaviors described by the subscale when he is in a stressful situation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This instrument has 9 items, using a 7-point Likert-type scale. It is used in order to better understand the negotiation and conflict resolution skills that the couple members have used within their marital relationship in the last three months.The score varies between 9 and 63. A high score indicates a greater degree of perceived problem-solving skill within the marital relationship.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Gamblers This lists of skills consist of 17 items that expressed in statements representing observable verbal behaviors.Participants were asked to report frequency estimates of their own use of such verbal behaviors using a 4 point likert scale (0 = almost never, 4 = almost always). To compute a total score, all item' score are summed. The total score ranges from 0 to 68.The higher the score is, more it indicates the presence of good communication skills.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This questionnaire is used to identify coping strategies to cope with stressful situations caused by their spouse's gambling habits in the last three months. The subscale is made up of 6 items marked from 0 to 3 (0 = not used; 3 = used a lot). To compute a total score, all item' score are summed. The total score ranges from 0 to 18.Higher the score is, more it indicates the respondent's tendency to adopt the behaviors described by the subscale when he is in a stressful situation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This questionnaire is used to identify coping strategies to cope with stressful situations caused by their spouse's gambling habits in the last three months. The subscale is made up of 6 items marked from 0 to 3 (0 = not used; 3 = used a lot). To compute a total score, all item' score are summed. The total score ranges from 0 to 18.Higher the score is, more it indicates the respondent's tendency to adopt the behaviors described by the subscale when he is in a stressful situation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome Measure for Partners This questionnaire is used to identify coping strategies to cope with stressful situations caused by their spouse's gambling habits in the last three months. The subscale is made up of 9 items marked from 0 to 3 (0 = not used; 3 = used a lot). To compute a total score, all item' score are summed. The total score ranges from 0 to 27.Higher the score is, more it indicates the respondent's tendency to adopt the behaviors described by the subscale when he is in a stressful situation.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Partners Number of alcohol standard units (Canada, 1 unit = 13,6g of alcohol) per week during the last three months.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Outcome measure for Partners Frequency of cannabis use per week in the last three months with a 5-point Likert-type scale (never = 0, 3 times a week or more = 4). Higher the score is, more it indicates a high frequency of cannabis use.

Admission, 3, 9 and 18 month post-admission (The first admission was March 2011 and the last admission will be June 2016)

Inclusion Criteria: Living together for at least 1 year Diagnosis of pathological gambling (WMH-CIDI) during the last 12 months The gambler has not received treatment for their gambling for at least 6 months (excluding GA) Presence of gambling behavior in the past 3 months Degree of commitment to the couple indicating a desire to continue the relationship (score of 7 - MSI) Exclusion Criteria: Alcohol/Drug Dependence gambler/partner (Severity of Alcohol Dependence Data questionnaire - SADD >17 included in DEBA-A; Severity of Dependence Scale - SDS > 5 Included in DEBA-D) Gambling problem for the partner (DEBA-Jeu > 10) Presence of serious acts of violence endangering the safety of both spouses (CTS-2) Disorder and serious mental health unstabilized one of two members of the couple (ASI: psychological scale) Antisocial personality disorder or severe limit ( GAIN: 9 + Scale BCS / CDS) Scenario with strong suicidal ideation or attempt in the last 30 days or less in the partner (ASI: psychological scale) Low degree of commitment in the relationship of a risk of separation (8 + MSI)