The Mohegan Tribe, which owns the Mohegan Sun Casino in Uncasville, in May announced its funding of an effort by the Yale University School of Medicine (YSM) to develop an app that could apply cognitive behavioral therapy to the treatment of problem gambling.
According to the YSM, the project “ will include developing digital therapeutic tools, such as a CBT-based mobile app, to ensure greater access to care for traditionally underserved populations, giving them skills and techniques to treat their problem.”
The tribe will contribute over $2 million through the completion of Yale’s research and development of the treatment and tools.
Global Gaming Business News interviewed two key researchers involved in the project, Dr. Marc Potenza, director of the Division on Addictions Research at Yale and director of the Yale Center of Excellence in Gambling Research; and Dr. Brian Kiluk, associate professor of psychiatry at the Yale School of Medicine.
“We think it will be important,” said Potenza. “Many people are now using digital technology in many ways in their lives. Telehealth delivery on mental conditions is an important and growing area. However, making sure that the interventions delivered via digital are helpful is important. Here we are taking an empirical cognitive behavioral therapy and encapsulating it into a digital platform that has the benefit of people accessing it remotely without going into an office and they can use it when they need to use it: when they are struggling with urges, to help them make better choices.”
Potenza has treated hundreds of people who have problems with casino gambling and the lottery.
“The approach we plan to take follows an approach that has been used for about 15 years by our psychotherapy developers,” he said. The app could be considered a descendent of the computer program developed in 2009 by Yale researcher Dr. Kathleen Carroll, called Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT).
Cognitive behavioral therapy (CBT) helps the patient develop increased awareness of potential triggers and incorporates better strategies for coping with them. It also helps them recognize that certain people they associate with may also have these behaviors. Once you recognize what triggers that behavior, you move closer to being able to change that behavior.
“Initially this approach focused on people with substance abuse disorders,” said Potenza. “For instance, what are factors that are linked to cocaine use? What was the situation that triggered it? An example might be, ‘I got into an argument with my wife.’ Helping the patient to think about what things he might do differently. How to resolve conflicts. How to manage emotions.”
Potenza added, “It goes back fifteen to twenty years when [professor of psychiatry] Nancy Petry modified the approach for substance use disorders and created a cognitive behavioral therapy for people with gambling disorders. In that study the CBT arm had the best treatment. That suggested that cognitive behavioral therapy was helpful for people above and beyond traditional treatment.”
The goal is “to generate a computer-based version that people can access when they need it and access it across distances. It could be used in rural areas, reaching more people.”
But first they need to develop the model and test it in a clinical trial, said Potenza. “So we are going to be testing how this would be used. Traditionally it has been computer-based on a desktop where people learn with a clinician. But now that people use smartphones more frequently it will be app-based. Our hope is we will test it and people will use it as the need arises to combat some of the factors that lead them to gamble.”
The modules for the app involve “different scenarios based on focus groups to gather information on people who have lived experience with gambling problems. That can generate scenarios that are helpful,” said Potenza. “I have been treating people for about twenty-five years in clinical settings for our state’s Better Choice Program. I’ve seen many people and heard a variety of different lived experiences that they have shared with me—but the gambling environment changes and evolves. For instance, PAPSA [Professional and Amateur Sports Protection Act of 1992] being overturned has led to more and more socially-accepted sports gambling. To understand the people who have problems with that it would be good to get the information from those people.”
Kiluk’s work is in substance use disorder treatment. One mode of treatment for that is CBT.
“It was initially developed in the ‘70s to treat depression and substance use and has been useful in treating gambling disorders,” he said. “One challenge is it requires a lot of resources to train therapists to apply CBT with a high degree of competence. To have expert supervisors is an impediment in getting it out more broadly. In the early 2000’s my mentor Kathleen Carroll had done a lot of work and wrote the manual for cognitive behavioral therapy. In 2005 she decided that one strategy to get it out there was to put it on a computer. It was put on a DVD-ROM format as a learning tool. CBT does a lot of teaching of skills to cope with thoughts, emotions and stress and what we did was put these teaching tools in a computer system. A patient could self-learn these skills.”
Now, 15 years later, computers don’t use DVDs anymore. “We created a web-based program that is adapted to mobile apps,” said Kiluk.”It teaches coping skills with patients directly. The idea is to do the same thing with a mobile app, to teach the same skills and put it on as a mobile app. They could learn and interact. They could do it when they have a few minutes alone.”
They plan to adapt CBT4CBT, which was created for substance use disorders, to problem gambling. “We designed it to mimic a therapy session of like 35 minutes, in a web-based program that makes sense,”he said. “It makes less sense in a mobile environment. We have used some later versions to make it more mobile. People would be able to do it in smaller chunks, more frequently and at their convenience, without having to make an appointment.”
The Mohegan Tribe became interested in broadening the treatments available to treat gambling addiction and thought Yale’s product could be an approach to treatment.
“It’s not just for development of the app,” said Kiluk. “We will go through evaluation to make sure the program is both safe and effective before letting it out. We aren’t just a bunch of app scientists. This is something we spent years putting together. We will want to do a clinical trial to make sure it is both safe for individuals seeking treatment and effective.”
