Clinical Translation: Understanding and Addressing Premature Termination from Psychotherapy for Gambling Disorder

            Clinical Translation: Understanding And Addressing Premature Termination From Psychotherapy For Gambling Disorder

Samuel C. Peter, Ph.D. and Rory A. Pfund, Ph.D.

Psychotherapeutic interventions are efficacious treatments for problem gambling and gambling disorder, and participants who attend more intervention sessions generally show more favorable outcomes. Studies on these interventions often report participant “dropout,” which is typically defined as occurring when a participant discontinues an intervention prior to its completion. However, there is a lack of consensus on how dropout is defined and measured across studies, and the lack of consensus is often cited as a reason that the field struggles to identify a consistent set of risk factors for dropout.

We recently published a systematic review and meta-analysis in Psychology of Addictive Behaviors to strengthen consensus on the definition of dropout. Specifically, we estimated the prevalence of dropout in psychotherapeutic treatments for problem gambling and gambling disorder, examined potential biopsychosocial risk factors, and summarized how researchers measured dropout. Overall, we found that 39% of individuals dropped out of psychotherapy, and the prevalence of dropout was significantly lower among participants who were married. Furthermore, we found that researchers measured dropout in three ways: attending less than all sessions of an intervention protocol, attending less than a prespecified number of sessions different from the total number in a protocol, and subjectively judging participants to be dropouts. The prevalence of dropout was significantly higher when defined as attending all sessions (64%) than a minimum number of sessions (33%) and therapist judgment (27%).

Based on these findings, several important clinical recommendations follow.

• Clinicians should incorporate motivation-enhancing interventions into psychotherapy and discuss what participants expect as an adequate therapy duration. Research indicates that incorporating motivation-enhancing interventions into therapy, as well as discussions about treatment duration, significantly increases motivation and the number of sessions attended (Milton et al., 2002; Peter et al., 2019; Swift & Callahan, 2011).
• Clinicians should incorporate motivation-enhancing interventions and discuss expectations for therapy duration as early as the first psychotherapy session. Research on the timing of dropout suggests that most participants will discontinue therapy before attending the third session (Pfund et al., 2018).
• Clinicians should discuss the role of social support in motivating participants to attend psychotherapy. Research indicates that the involvement of concerned significant others in a participant’s psychotherapy increases the number of sessions attended (Jiménez-Murcia et al., 2017).
• Clinicians should seriously consider whether the term “dropout” is clinically useful. Given the significant heterogeneity in researchers’ measurements of dropout, we suspect there is also heterogeneity in how clinicians judge the occurrence of dropout.
• Clinicians should use more concrete terms to describe behaviors related to participants’ engagement in psychotherapeutic interventions. Rather than use terms like “dropout,” “noncompliance,” or “nonadherence,” clinicians should objectively describe the number of sessions that participants attended (Pfund et al., 2021).
• Clinicians should ask participants about their goals during psychotherapy, adopt session-by-session indicators of treatment progress, and discuss the progress with patients to determine how much treatment is adequate. The current definitions of dropout assume that therapists can accurately judge when a participant drops out of treatment and that all participants need to attend a specific number of sessions to make clinically meaningful changes in their behavior. However, definitions of dropout rarely consider participants’ actual treatment progress, and, when treatment progress is considered, many participants are found not to need the dose of therapy specified by clinicians. (Pfund et al., 2018).
• We urge clinicians to consider how these findings and recommendations may apply to the treatment of other types of addictive behaviors, including substance use disorders. The concepts of therapy duration, discontinuation, clinical progress, and the ways in which patient behaviors are described are certainly relevant in the context of substance use disorder treatment as well.

Original article: Pfund, R. A., Peter, S. C., McAfee, N. W., Ginley, M. K., Whelan, J. P., & Meyers, A. W. (2021). Dropout from face-to-face, multi-session psychological treatments for problem and disordered gambling: A systematic review and meta-analysis. Psychology of Addictive Behaviors, 35(8), 901-913. https://doi.org/10.1037/adb0000710

References

Jiménez-Murcia, S., Tremblay, J., Stinchfield, R., Granero, R., Fernandez-Aranda, F., Mestre-Bach, G., Steward, T., Pino-Gutiérrez, A. Del, Baño, M., Moragas, L., Aymamí, N., Gomez-Pena, M., Tarrega, S., Valenciano-Mendoza, E., Giroux, I., Sancho, M., Sanchez, I., Mallorquí-Baqué, N., Gonzalez, V., … Menchón, J. M. (2017). The Involvement of a Concerned Significant Other in Gambling Disorder Treatment Outcome. Journal of Gambling Studies, 33(3), 937–953. https://doi.org/10.1007/s10899-016-9657-z

Milton, S., Crino, R., Hunt, C., & Prosser, E. (2002). The effect of compliance-improving interventions on the cognitive-behavioural treatment of pathological gambling. Journal of Gambling Studies, 18, 207–229. https://doi.org/10.1023/a:1015580800028

Peter, S. C., Brett, E. I., Suda, M. T., Leavens, E. L. S., Miller, M. B., Leffingwell, T. R., Whelan, J. P., & Meyers, A. W. (2019). A meta-analysis of brief personalized feedback interventions for problematic gambling. Journal of Gambling Studies, 35, 447–464. https://doi.org/10.1007/s10899-018-09818-9

Pfund, R. A., Peter, S. C., Swift, J. K., & Witkiewitz, K. (2021). Nonstigmatizing and precise terminology to describe processes and outcomes in addiction medicine. Journal of Addiction Medicine, 1–3. https://doi.org/10.1097/adm.0000000000000885

Pfund, R. A., Peter, S. C., Whelan, J. P., & Meyers, A. W. (2018). When does premature treatment termination occur? Examining session-by-session dropout among clients with gambling disorder. Journal of Gambling Studies, 34, 617–630. https://doi.org/10.1007/s10899-017-9733-z

Swift, J. K., & Callahan, J. L. (2011). Decreasing treatment dropout by addressing expectations for treatment length. Psychotherapy Research, 21(2), 193–200. https://doi.org/10.1080/10503307.2010.541294