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General selection: Is voluntary self-exclusion a good proxy measure for problem gambling?

A couple of months ago, Dr. Michael Auer and I published a short paper in the Journal of Addiction Medicine and Therapy (JAMT) critically addressing a recent approach by researchers that use voluntary self-exclusion (VSE) by gamblers as a proxy measure for problem gambling in their empirical studies. We argued that this approach is flawed and is unlikely to help in developing harm-minimization measures.

For those who don’t know, self-exclusion practices typically refer to the possibility for gamblers to voluntarily ban themselves from playing all (or a selection of) games over a predetermined period. The period of exclusion can typically be chosen by the gambler although some operators have non-negotiable self-exclusion periods. Self-exclusion in both online sites and offline venues has become an important responsible gambling practice that is widely used by socially responsible operators.

There are many reasons why players self-exclude. In a 2011 study in the Journal of Gambling Studies by Dr. Tobias Hayer and Dr. Gerhard Meyer, players frequently reported excluding as a preventive measure and annoyance with the gambling operator as reasons for VSE. Furthermore, only one-fifth of self-excluders reported to be problem gamblers (21.2%). A recent 2016 (conference) paper by Dr. Suzanne Lischer (2016) reported that in a study of three Swiss casinos, 29% of self-excluders were pathological gamblers, 33% were problem gamblers, and 38% were recreational gamblers. Given that many voluntary self-excluders do not exclude themselves for gambling-related problems, Dr. Lischer concluded that self-exclusion is not a good indicator of gambling-related problems. In line with these results, a 2015 study published in International Gambling Studies led by Simo Dragicevic compared self-excluders with other online players and reported no differences in the (i) mean number of gambling hours per month or (ii) minutes per gambling session. The study also reported that 25% of players self-excluded within one day of their registration with the online operator. This could also be due to the fact that online players can self-exclude with just a few mouse-clicks.

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Most studies to date report that the majority of voluntary self-excluders tend to be non-problem gamblers. Additionally, in 2010, the Australian Productivity Commission reported 15,000 active voluntary self-exclusions from 2002 to 2009 and that this represented only 10-20% of the population of problem gamblers. This means that in addition to most self-excluders being non-problem gamblers, that most problem gamblers are not self-excluders. This leads to the conclusion that there is little overlap between problem gambling and self-excluding.

Over the decade, analytical approaches to harm minimization have become popular. This has led to the development of various tracking tools such as PlayScan (developed by Svenska Spel), Observer (developed by 888.com), and mentor (developed by neccton and myself). Furthermore, regulators are increasingly recognizing the importance of early risk detection via behavioural tracking systems. VSE also plays an important role in this context. However, some systems use VSE as a proxy of at-risk or problem gambling.

Based on the findings from empirical research, self-exclusion is a poor proxy measure for categorizing at-risk or problem gamblers and VSE should not be used in early problem gambling detection systems. The reasons for this are evident:

  • There is no evidence of a direct relationship between self-exclusion and problem gambling. As argued above, self-excluders are not necessarily problem gamblers and thus cannot be used for early risk detection.
  • There are various reasons for self-exclusion that have nothing to do with problem gambling. Players exclude for different reasons and one of the most salient appears to be annoyance and frustration with the operator (i.e., VSE is used as a way of venting their unhappiness with the operator). In this case, an early detection model based on self-exclusion would basically identify unhappy players and be more useful to the marketing department than to those interested in harm minimization
  • Problem gamblers who self-exclude are already actively changing their behaviour. The trans-theoretical ‘stages of change’ model (developed by Dr. Carlo DiClemente and Dr. James Prochaska) argues that behavioural change follows stages from pre-contemplation to action and maintenance. One could argue that the segment of players who self-exclude because they believe their gambling to be problematic are the ones who already past the stages where assistance is usually helpful in triggering action to cease gambling. These players are making use of a harm-minimization tool. The ones actually in need of detection and intervention are the ones who have not yet reached this stage of change yet and are not thinking about changing their behaviour at all. This is one more argument for the inappropriateness of self-exclusion as a proxy for problem gambling.

But what could be done to prevent the development of gambling-related problems in the first place? For the reasons outlined above, we would argue that the attempt to identify problem gambling via playing patterns that are derived from self-excluders does not assist harm minimization. Firstly, this approach does not target problem gamblers, and secondly it does not provide any insights into the prevention of such problems.

It is evident that any gambling environment should strive to minimize gambling-related harm and reduce the amount of gambling among vulnerable groups. It is also known that information that is given to individuals to enable behavioural change should encourage reflection because research has shown that self-monitoring can enable behavioural change in the desired direction. Dr. Jim Orford has also stated that attempts to explain such disparate gambling types from a single theoretical perspective are essentially a fool’s errand. This also complements the notion that problem gambling is not a homogenous phenomenon and there is not a single type of problem gambler (as I argued in my first book on gambling back in 1995). This also goes in line with the belief of Dr. Auer and myself that gambling sites have to personalize communication and offer the right player the right assistance based on their individual playing history. Recent research that Dr. Auer and I have carried out supports this line of thinking.

Studies have also shown that dynamic feedback in the form of pop-up messages has a positive effect on gambling behaviour and gambling-related thoughts. For instance, research from Dr. Michael Wohl’s team in Canada have found that animation-based information enhanced the effectiveness of a pop-up message related to gambling time limits. Our own research has found that an enhanced pop-up message (that included self-appraisal and normative feedback) led to significantly greater number of players ending their session than a simple pop-up message. In a real-world study of online gamblers, we also found that personalized feedback had a significant effect in reducing the time and money spent gambling.

Personalized feedback is a player-centric approach and in addition to gambling-specific research, there is evidence from many other areas that shows the beneficial effects on behavioural change. For instance, personalized messages have shown to enable behavioural change in areas such as smoking cessation, diabetes management, and fitness activity. Contrary to the self-exclusion oriented detection approach, we concluded in our recent JAMT paper that personalized feedback aims to prevent and minimize harm in the first place and is a much better approach to the prevention of problem gambling than using data from those that self-exclude from gambling.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

 Further reading

Auer, M. & Griffiths, M. D. (2014). Personalised feedback in the promotion of responsible gambling: A brief overview. Responsible Gambling Review, 1, 27-36.

Auer, M. Griffiths, M.D. (2015). The use of personalized behavioral feedback for online gamblers: an empirical study. Frontiers in Psychology, 6, 1406.  doi:10.3389/fpsyg.2015.01406

Auer, M., Griffiths, M.D. (2015). Testing normative and self-appraisal feedback in an online slot-machine pop-up in a real-world setting. Frontiers in Psychology. 6, 339 doi: 10.3389/fpsyg.2015.00339

Auer, M., Littler, A., Griffiths, M. D. (2015). Legal Aspects of Responsible Gaming Pre-commitment and Personal Feedback Initiatives. Gaming Law Review and Economics. 19, 444-456.

DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295-304.

Dragicevic, S., Percy, C., Kudic, A., Parke, J. (2015). A descriptive analysis of demographic and behavioral data from Internet gamblers and those who self-exclude from online gambling platforms. Journal of Gambling Studies. 31, 105-132.

Gainsbury, S. (2013). Review of self-exclusion from gambling venues as an intervention for problem gambling. Journal of Gambling Studies, 30, 229-251.

Griffiths, M. D. (1995). Adolescent gambling. London: Routledge.

Griffiths, M.D. & Auer, M. (2016). Should voluntary self-exclusion by gamblers be used as a proxy measure for problem gambling? Journal of Addiction Medicine and Therapy, 2(2), 00019.

Hayer, T., & Meyer, G. (2011). Self-exclusion as a harm-minimization strategy: Evidence for the casino sector from selected European countries. Journal of Gambling Studies, 27, 685-700

Kim, H. S., Wohl, M. J., Stewart, M. K., Sztainert, T., Gainsbury, S. M. (2014). Limit your time, gamble responsibly: setting a time limit (via pop-up message) on an electronic gaming machine reduces time on device. International Gambling Studies, 14, 266-278.

Lischer, S. (2016, June). Gambling-related problems of self-excluders in Swiss casinos. Paper presented at the 16th International Conference on Gambling & Risk Taking, Las Vegas, USA.

Suurvali, H., Hodgins, D. C., Cunningham, J. A. (2010). Motivators for resolving or seeking help for gambling problems: A review of the empirical literature. Journal of Gambling Studies, 26, 1-33

Cured meets: Treating addictive behaviours

Addiction is a highly prevalent problem within today’s society and there is a lot of time and many spent in trying to prevent and treat the behaviour. There has also been a move towards getting addicts motivated to want to change their behaviour. The most influential model worldwide is probably the ‘stages of change’ model by Dr. James Prochaska and Dr, Carlo Di Clemente that identifies an individual’s ‘readiness for change’ and tries to get a person to a position where they are highly motivated to change their behaviour. The individual stages of this model are:

  • Precontemplation – This is where the person unaware of the consequences of his or her own behaviour and no change in behaviour is foreseeable.
  • Contemplation – This is where the person aware problem exists and is contemplating change.
  • Preparation – This is where the person has decided to change in the near future (e.g., New Year resolution).
  • Action – This is where the person effects change (e.g., gets rid of all association items related to the behaviour).
  • Maintenance – This is where the person consolidates behaviour change over time.
  • Relapse – This where the person reverts to a former behaviour pattern (e.g., contemplation, preparation).

People can stay in one stage for a long time and it is also possible for unassisted change such “maturing out” or “spontaneous remission”. Various techniques can be used to help people prepare for readiness include motivational techniques, behavioural self-training, skills training, stress management training, anger management training, relaxation training, aerobic exercise, relapse prevention, and lifestyle modification. The goal of treatment can be either abstinence or simply to cut down.

The intervention and treatment options for the treatment of addiction include, but are not limited to counselling/psychotherapies, behavioural therapies, cognitive-behavioural therapies, self-help therapies, pharmacotherapies, residential therapies, minimal interventions and combinations of these (i.e., multi-modal treatment packages). The most important of these are outlined below.

Pharmacotherapy: Pharmacological interventions basically consist of addicts being given a drug to help overcome their addiction. These are mainly given to those people with chemical addictions (e.g., nicotine, alcohol, heroin, etc.) but are increasingly being used for those with behavioural addictions (e.g., gambling, sex, work, exercise, etc.). For instance, some drugs produce an unpleasant reaction when used in combination with the drug of dependence, replacing the positive effects of the drug of dependence with a negative reaction. For instance, alcoholics are sometimes prescribed disulfiram (more commonly known as Antabuse), that when combined with alcohol may produce nausea and vomiting. Other common therapies include methadone and the use of opioid antagonists (such as nalaxone or naltrexene) for heroin addiction. The methadone prevents withdrawal symptoms, block the effects of heroin use, and decreases craving. The main criticism of all these treatments is that although the symptoms may be being treated, the underlying reasons for the addictions may be being ignored. On a more pragmatic level, what happens when the drug is taken away? Often, the addicts return to their addiction if this is the only method of treatment used.

Behavioural therapy: Behavioural therapies are based on the view that addiction is a learned maladaptive behaviour and can therefore be ‘unlearned’. These have mainly been based on the classical conditioning paradigm and include aversion therapy, in vivo desensitisation, imaginal desensitisation, systematic desensitisation, relaxation therapy, covert sensitisation, and satiation therapy. All of these therapies focus on cue exposure, and relapse triggers (like the sight and smell of alcohol/drugs, walking through a neighbourhood where casinos are abundant, pay day, arguments, pressure, etc.). The theory is that through repeated exposure to ‘relapse triggers’ in the absence of the addiction, the addict learns to stay addiction free in high-risk situations. It could be argued that if the addiction is caused by some underlying psychological problem, (rather than a learned maladaptive behaviour), then behavioural therapy would at best only eliminate the behaviour but not the problem. This therefore means that the addictive behaviour may well have been curtailed but the problem is still there so the person will perhaps engage in a different addictive behaviour instead.

Cognitive-behavioural therapy: A more recent development in the treatment of addictive behaviours is the use of cognitive-behavioural therapies (CBT). There are many different CBT approaches that have been used in the treatment of addictive behaviours including rational emotive therapy, motivational interviewing, and relapse prevention. The techniques assume that addiction is a means of coping with difficult situations, dysphoric mood, and peer pressure. Treatment aims to help addicts recognise high-risk situations and either avoid or cope with them without use of the addictive behaviour. In relapse prevention, the therapist helps to identify situations that present a risk for relapse (both intrapersonal and interpersonal). Relapse prevention provides the addict with techniques to learn how to cope with temptation (positive self statements, decision review, and distraction activities), coupled with the use of covert modelling (i.e., practicing coping skills in one’s imagination). It also provides skills for coping with lapses (by redefining what is happening), and utilizes graded practice (a desensitization technique where addicts encounter real life situations slowly). Overall, CBT approaches are better researched than the other psychological methods in addiction but are probably no more effective (Luty, 2003).

Psychotherapy: Psychotherapy can include everything from Freudian psychoanalysis and transactional analysis, to more recent innovations like drama therapy, family therapy and minimalist intervention strategies. The therapy can take place as an individual, as a couple, as a family, as a group and is basically viewed as a ‘talking cure’ consisting of regular sessions with a psychotherapist over a period of time. Most psychotherapies view maladaptive behaviour as the symptom of other underlying problems. Psychotherapy often is very eclectic by trying to meet the needs of the individual and helping the addict develop coping strategies. If the problem is resolved, the addiction should disappear. In some ways, this is the therapeutic opposite of pharmacotherapy and behavioural therapy (which treats the symptoms rather than the underlying cause). There has been little evaluation of its effectiveness although most addicts go through at least some form of counselling during the treatment process.

Self-help therapy: The most popular self-help therapy worldwide is the Minnesota Model 12-Step Programme (e.g., Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Sexaholics Anonymous, etc.). This treatment programme uses a group therapy technique and uses only ex-addicts as helpers. Addicts attending 12-Step groups involves them accepting personal responsibility and views the behaviour as an addiction that cannot be cured but merely arrested. To some it becomes a way of life both spiritually and socially and compared with almost all other treatments it is especially cost-effective (even if other treatments have greater success rates) as the organization makes no financial demands on members or the community. For the therapy to work, the 12-Step Programme asserts that the addict must come to them voluntarily and must really want to stop engaging in their addictive behaviour. Further to this, they are only allowed to join once they have reached “rock bottom”. To date there has been little systematic study of 12-Step groups but drop out rates are very high (typically 80-90%). There are a number of problems preventing evaluation, particularly anonymity, sample bias, and what the criterion for success is. The empirical evidence suggests that self-help support groups’ complement formal treatment options and can support standardized psychosocial interventions.

When examining all the literature on the treatment of addiction, there are a number of key conclusions that can be drawn. These include that: (i) treatment must be readily available, (ii) no single treatment is appropriate for all individuals., (iii) it is better for an addict to be treated than not to be treated, (iv) it does not seem to matter which treatment an addict engages in as no single treatment has been shown to be demonstrably better than any other, (v) a variety of treatments simultaneously appear to be beneficial to the addict, (vi) individual needs of the addict have to be met (i.e., the treatment should be fitted to the addict including being gender-specific and culture-specific), (vi) clients with co-existing addiction disorders should receive services that are integrated, (vii) remaining in treatment for an adequate period of time is critical for treatment effectiveness, (viii) medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies, (ix) recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment, (x) there is a direct association between the length of time spent in treatment and positive outcomes, and (xi) the duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1996). Pathological gambling and its treatment. British Journal of Clinical Psychology, 35, 477-479.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Griffiths, M.D. & H.F. MacDonald (1999). Counselling in the treatment of pathological gambling: An overview. British Journal of Guidance and Counselling, 27, 179-190.

Hayer, T. & Griffiths, M.D. (2015). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition) (pp. 539-558). New York: Kluwer.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

Luty, J. (2003). What works in drug addiction? Advances in Psychiatric Treatment, 9, 280–288.

National Institute on Drug Abuse (1999). Principles of drug addiction treatment: A research-based guide. NIDA.

Potenza, M. & Griffiths, M.D. (2004). Prevention efforts and the role of the clinician. In J.E. Grant & M. N. Potenza (Eds.), Pathological Gambling: A Clinical Guide To Treatment (pp. 145-157). Washington DC: American Psychiatric Publishing Inc.

Prochaska, J.O. and DiClemente, C.C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Melbourne, Florida: Krieger Publishing Company

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

United Nations Office on Drugs and Crime/World Health Organization (2008). Principles of Drug Dependence Treatment: Discussion paper. UN/WHO.