New Advances in the Treatment of Problem and Pathological GamblingNew Advances in the Treatment of New Advances in the Treatment of

Problem and Pathological GamblingProblem and Pathological Gambling

Nancy Petry, Ph.D. Nancy Petry, Ph.D. University of Connecticut Health CenterUniversity of Connecticut Health Center

Farmington, CTFarmington, CT

Supported by NIH grants: Supported by NIH grants: RO1RO1--MH60417MH60417, R01, R01--MH60471MH60471--suppl, R01suppl, R01--DA13444, DA13444, RO1RO1--DA016855, RO1DA016855, RO1--DA14618, R01DA14618, R01--DA018883DA018883, , RO1RO1--MH60417MH60417, , P60AG13631P60AG13631, P50, P50--DA09241, DA09241,

P50P50--AA03510 AA03510 and the and the DonaghueDonaghue Medical Investigator ProgramMedical Investigator Program

States with legalized gambling in 1963States with legalized gambling in 1963

Casino gamblingCasino gamblingOther gamblingOther gamblingNo legal gamblingNo legal gambling

States with legalized gambling in 1964States with legalized gambling in 1964

Casino gamblingCasino gamblingOther gamblingOther gamblingNo legal gamblingNo legal gambling

States with legalized gambling in 2000States with legalized gambling in 2000

Casino gamblingCasino gamblingOther gamblingOther gamblingNo legal gamblingNo legal gambling

OverviewOverview

A.A. Definitions and prevalence ratesDefinitions and prevalence ratesB.B. Consequences and Consequences and comorbiditiescomorbiditiesC.C. Treatments for gamblingTreatments for gambling

CognitiveCognitive--behavioral therapybehavioral therapyBrief interventionsBrief interventions

A.) DefinitionsA.) Definitions

Gambling is defined asGambling is defined as

“placing money on some event that has a “placing money on some event that has a possibility of resulting in some advantage.”possibility of resulting in some advantage.”

Types of gamblingTypes of gambling

Cards, dice, animal races, jai alia, slot Cards, dice, animal races, jai alia, slot machines, roulette, bingo, video poker, machines, roulette, bingo, video poker, sporting events, playing sports, lottery sporting events, playing sports, lottery tickets, scratch tickets, high risk stocks or tickets, scratch tickets, high risk stocks or commodities, internet gambling.commodities, internet gambling.

Types of gamblersTypes of gamblers

Level 1Level 1–– social or recreational gamblingsocial or recreational gambling

Level 2Level 2–– problem, at risk, in transition gamblingproblem, at risk, in transition gambling

Level 3Level 3–– DSMDSM--IV diagnosis of pathological IV diagnosis of pathological gambling (compulsive gambling)gambling (compulsive gambling)

DSM-IV Criteria for Pathological GamblingDSM-IV Criteria for Pathological Gambling

1. Preoccupied with gambling 6. “Chases” lost money. Returnsto gambling to get even.

2. Need to gamble withincreasing amounts ofmoney.

7. Lies to others to conceal extentof gambling.

3. Repeated unsuccessfulefforts to cut down or stopgambling.

8. Commits illegal acts to financegambling.

4. Restless or irritable whenattempting to cut down.

9. Jeopardizes or loses importantrelationship or job due togambling.

5. Gambles to escapeproblems or relievenegative mood.

10. Relies on others to relievedesperate financial situationscaused by gambling.

Prevalence rates in general population surveys

Prevalence rates in general population surveys

Prevalence rates in general population studiesPrevalence rates in general population studies

US studies

0

2

4

6

8

10K

alic

k,19

76

Ger

stei

n,19

99

Wel

te,

2001

Petry

et

al 2

005

%

Problem Pathological

N=1,749 2,417 2,638 43,093

International studiesInternational studies

0

2

4

6

8

10A

ustra

liaH

ong

Kon

gK

orea

New

Zeal

and

Nor

way

Swed

en

Switz UK

Problem Pathological

Gambling in South East Asian refugees (n=96) in CTGambling in South East Asian refugees (n=96) in CT

Over half reported Over half reported gambling in past 2 gambling in past 2 weeks.weeks.42% reported 42% reported wagering more than wagering more than $500 in past 2 months.$500 in past 2 months.

12

58

28

Pathological

Problem

Recreational

Petry, Petry, ArmentanoArmentano, , KouchKouch, , MovaMova, , NorinthNorinth, & Smith, 2003, & Smith, 2003

Prevalence rates in adolescentsPrevalence rates in adolescents

0

5

10

15

20

Adalf, 2

000

Carlso

n, 199

8Gers

tein, 1

999

Gupta, 19

98Lad

ouceu

r, 19

99W

estphal,

2000

%

PathologicalProblem

N=2,371N=2,371 997 534 817 3,426 12,066997 534 817 3,426 12,066

Ontario OR National Montreal Quebec LouisianaOntario OR National Montreal Quebec Louisiana

College students at UCONNCollege students at UCONN

05

10152025

Shaffer

et al.

1999

Lesieu

r et a

l. 199

1

Winter

s et a

l. 199

8

Oster &

Knap

p 2001

Neighbor

s et a

l. 200

2Petr

y et a

l, 200

7

%

PathologicalProblem

N=1356N=1356

Internet gambling in CT college students (n=1356) and its association with pathological gambling statusInternet gambling in CT college students (n=1356)

and its association with pathological gambling status

% Gambled on Internet

23

61.7

6.3 Never

Some

Weekly+

% Pathological Gamblers

0

20

40

60

80

Never Some Weeklyor more

%

Petry & Weinstock (2007). Am J on Addictions

B.) Consequences and ComorbiditiesB.) Consequences and Comorbidities

Medical problemsMedical problems

insomniainsomniahigh blood pressurehigh blood pressurecardiac disorderscardiac disordersintestinal disordersintestinal disorderspoorer general health than nonpoorer general health than non--problem problem gamblersgamblers

Pasternak & Fleming (1999)Pasternak & Fleming (1999)

SocialProblemPathological

74.0%74.0%

10.5%10.5%

15.4%15.4%

Patients treated at UCONN and inner city medical clinicsPatients treated at UCONN and inner city medical clinics

Ladd & Petry, 2002Ladd & Petry, 2002

Physical and medical problems in adults recruited from general medical clinics (n=1,405)Physical and medical problems in adults recruited from general medical clinics (n=1,405)

Short Form 12(lower scores indicate poorer functioning)

0

25

50

75

100

Physical Fx Role Phys. Bodily Pain General Health

Non Problem GamblerProblem GamblerPath Gambler

****** ******

Mea

nM

ean

*** p<.001*** p<.001

****** ******

Morasco, von Morasco, von EigemEigem, & Petry, 2006, & Petry, 2006

Financial and legal consequencesFinancial and legal consequences

FinancialFinancial$38,000$38,000--$113,000 average debt$113,000 average debt30% file for bankruptcy30% file for bankruptcy

LegalLegal60% commit illegal acts60% commit illegal acts

0

250500

90 92 94

Violent Crimes

0

5000

10000

90 91 92 93 94 95

Property Crimes

Substance abuse and gamblingSubstance abuse and gambling

Prevalence of pathological gambling in treatment-seeking substance abusersPrevalence of pathological gambling in treatment-seeking substance abusers

0

5

10

15

20

Cho 02

Elia 93

Lejoye

ux 99

Lesieu

r 86

McCorm

ick 93

Sellmam

02Ton

eatto

02Hall

00Lesi

eur 8

6Stei

nberg

92Ton

eatto

02

Fiegelm

an 95

Ledger

wood 0

2Lesi

eur 8

6Spu

nt 95

Toneat

to 02

Alcohol Cocaine

%

N=5176 85 79 243 581 124 ns

313 113 298 ns

Opioid220 62 34 117 ns

Prevalence of alcohol abuse/dependencein treatment-seeking gamblersPrevalence of alcohol abuse/dependencein treatment-seeking gamblers

0

20

40

60

Ibane

z, 20

01Lad

d&Pe

try, 2

003

Lesieu

r&Blum

e, 19

91Lind

en, 1

986

Maccal

lum, 2

002

McCorm

ick, 1

984

Spec

ker, 1

996

N=69 341 26 25 75 50 40

%

Psychiatric comorbidityPsychiatric comorbidity

Substance use disorders Substance use disorders Attention deficit disorderAttention deficit disorderAnxiety Anxiety DepressionDepressionSuicideSuicide

contemplation 48contemplation 48--70%70%attempt 13attempt 13--20%20%

Almost all data derived from treatmentAlmost all data derived from treatment--seeking seeking gamblers rather than community samples.gamblers rather than community samples.

National Epidemiological Survey on Alcohol and Related Conditions (NESARC)National Epidemiological Survey on Alcohol and Related Conditions (NESARC)

FaceFace--toto--face personal interviews with 43,093 respondents face personal interviews with 43,093 respondents 18 years and older in the civilian 18 years and older in the civilian noninstitutionalnoninstitutionalpopulation residing in households and group quarterspopulation residing in households and group quarters81% response rate81% response rateAfrican Americans, Hispanics, and young adults (ages 18African Americans, Hispanics, and young adults (ages 18--toto--24) were 24) were oversampledoversampled..Conducted in 2001Conducted in 2001--20022002Supported by NIAAASupported by NIAAAIncluded a module on pathological gambling Included a module on pathological gambling (Petry, Stinson, (Petry, Stinson, & Grant, 2005).& Grant, 2005).

Comorbidity of psychiatric disorders with pathological gamblingComorbidity of psychiatric disorders with pathological gambling

OR (95% CI) PGs with disorder (%)Alcohol* 6.0 (3.8-9.7) 73.22Drug* 4.4 (2.9-6.6) 38.10Nicotine* 6.7 (4.6-9.9) 60.37Major depression* 3.3 (2.3-4.9) 36.99Dysthymia* 3.3 (1.9-5.6) 13.20Mania* 8.0 (4.7-13.7) 22.80Panic disorder w/ agoraphobia* 5.2 (2.6-10.5) 5.09Social phobia* 2.2 (1.2-4.1) 10.55Specific phobia* 3.5 (2.2-5.5) 23.54Generalized anxiety* 3.1 (1.8-5.3) 11.15Any personality disorder* 8.3 (5.6-12.3) 60.82

Petry et al. (2005) J Clin Psychiatry

C.) Treatments for gamblingC.) Treatments for gambling

Treatments appliedTreatments applied

1.) Pharmacotherapy1.) Pharmacotherapy2.) Self2.) Self--help help 3.) Inpatient3.) Inpatient4.) Marital/family 4.) Marital/family 5.) Psychoanalytic 5.) Psychoanalytic 6.) Cognitive6.) Cognitive--behavioral behavioral 7.) Brief treatments7.) Brief treatments

Gamblers AnonymousGamblers Anonymous

Over 1000 chapters in USOver 1000 chapters in USSocial supportSocial supportFinancial advice, pressure reliefFinancial advice, pressure relief

Overall attrition rates are high, abstinence is low Overall attrition rates are high, abstinence is low (Stewart & Brown, 1988).(Stewart & Brown, 1988).

Cognitive-behavioral therapyCognitive-behavioral therapy

1.) Triggers1.) Triggers2.) Functional analysis2.) Functional analysis3.) Pleasant activities3.) Pleasant activities4.) Self4.) Self--managementmanagement5.) Coping with urges5.) Coping with urges6.) Assertiveness training/refusal skills6.) Assertiveness training/refusal skills7.) Correcting irrational thinking7.) Correcting irrational thinking8.) Preparing for emergencies8.) Preparing for emergencies

Treatment studyTreatment study

Pathological gamblers randomly assigned to:Pathological gamblers randomly assigned to:

1.) Referral to GA1.) Referral to GA

2.) Referral to GA plus 2.) Referral to GA plus CBT selfCBT self--help manualhelp manual

3.) Referral to GA plus 3.) Referral to GA plus professionallyprofessionally--delivered CBTdelivered CBT

DemographicsDemographics

GA Ref Manual Therapy n 63 84 84 Male 50.0% 57.6% 58.8% Caucasian 81.3% 84.7% 84.7% Age 44.5 44.2 46.0 Married 39.1% 36.5% 42.4% Income $42,500 $43,000 $46,000 Prev. Subs Abuse TX

31.7% 29.8% 21.2%

GA Attendance

0

25

50

75

100

GA ref

Manual

Therap

y

% S

ubje

cts

Addiction Severity Index Gambling score

0.2

0.4

0.6

0.8

PreTX

Wk 4 Wk 8

GA refManualTherapy

ResultsResults

Days Gambled

0

5

10

15

PreTX

Wk 4 Wk 8

Day

s

GA ref

Manual

Therapy

Median $ Gambled

0500

1000150020002500

PreTX

Wk4

Wk8

$

Results Results (cont.)(cont.)

0

2

4

6

8

10

12

0 100 200 300

Days

Mea

n

GA referralWorkbookTherapy

0

1

2

3

0 100 200 300Days

Days Gambled Dollars Gambled (logged)

Long-term follow-upsLong-term follow-ups

Petry et al., 2006Petry et al., 2006

Other symptom reductionOther symptom reduction

Brief symptom inventory scores

0

0.5

1

1.5

PreTX

Wk8

Wk24

GA refManualTherapy

Compliance with treatmentCompliance with treatment

Treatment compliance

0

25

50

75

100

None

Some

>75%

%

Manual

Therapy

Treatment Satisfaction

0255075

100GA re

ferral

Manual

Therap

y

% V

ery

satis

fied

Predictors of abstinence in those assigned to a CB conditionPredictors of abstinence in those assigned to a CB condition

WaldWald, p value, p value OR (95% CI)OR (95% CI)GenderGender n.s.n.s.AgeAge n.s.n.s.EthnicityEthnicity n.s.n.s.Psych severityPsych severity n.s.n.s.GA meetings attendedGA meetings attended n.s.n.s.TxTx condcond. (Workbook . (Workbook vsvsindividual therapy)individual therapy)

n.s.n.s.

CB sessions/chapters CB sessions/chapters completedcompleted

5.36, p<.025.36, p<.02 1.16 (1.021.16 (1.02--1.31)1.31)

How does the CBT work?How does the CBT work?

1.) Identify triggers1.) Identify triggers

Places where you are likely to gamble:Places where you are likely to gamble:

People with whom you are likely to gamble:People with whom you are likely to gamble:

Times or days when you are likely to gamble:Times or days when you are likely to gamble:

Activities that make it likely you’ll gamble:Activities that make it likely you’ll gamble:

Emotions or feelings that make it likely you’ll gamble:Emotions or feelings that make it likely you’ll gamble:

Identify when you don’t gamble.Identify when you don’t gamble.

Places where you don’t gamble:Places where you don’t gamble:

People with whom you don’t gamble:People with whom you don’t gamble:

Times or days when you don’t gamble:Times or days when you don’t gamble:

Activities that you do when you aren’t gambling: Activities that you do when you aren’t gambling:

Emotions or feelings that don’t make you feel like gambling:Emotions or feelings that don’t make you feel like gambling:

2.) Consequences2.) Consequences

What are the positive effects from gambling?What are the positive effects from gambling?get away get away relaxingrelaxingexciting exciting win $win $

What are the negative effects from gambling?What are the negative effects from gambling?lose $ lose $ more arguingmore arguingdepresseddepressed lose self respectlose self respect

TriggerTrigger

GamblingGambling

+ Effects+ Effects

-- EffectsEffects

Functional analysisFunctional analysis

TriggerTrigger Thoughts &Thoughts & Behavior +EffectsBehavior +Effects --EffectsEffectsFeelings Feelings

1. 1. creditor worried/angry casino felt lucky lost more $creditor worried/angry casino felt lucky lost more $gambling only Nov 8gambling only Nov 8

optionoption

2. 2. weekend felt bored races excited angry , deprweekend felt bored races excited angry , depressed essed

Oct 30Oct 30

3.) Increase other activities3.) Increase other activities

Pleasant events checklist.Pleasant events checklist.List favorite activities: spontaneous and planned.List favorite activities: spontaneous and planned.Identify people and times to try at least one activity in the Identify people and times to try at least one activity in the upcoming week.upcoming week.SubstituteSubstitute

HighHigh--risk timerisk time1.)1.)2.)2.)3.)3.)

Other activityOther activity1.)1.)2.)2.)3.)3.)

7.) Changing irrational thinking7.) Changing irrational thinking

What are the odds of winning a million dollars?What are the odds of winning a million dollars?

Overestimate odds of winningOverestimate odds of winning

Winning $1 millionWinning $1 millionKilled in car accidentKilled in car accidentChoking to deathChoking to deathStruck by lightningStruck by lightning

1 in 13,000,0001 in 13,000,0001 in 53,0001 in 53,0001 in 68,0001 in 68,0001 in 2,000,0001 in 2,000,000

The odds of:The odds of:

New studyNew study

Everyone meets with a therapist once weekly for 8 Everyone meets with a therapist once weekly for 8 weeksweeksPsychoeducationPsychoeducation plus case managementplus case managementCognitiveCognitive--behavioral therapybehavioral therapyCognitiveCognitive--behavioral therapy plus contingency behavioral therapy plus contingency managementmanagement

Longer term (2 year) followLonger term (2 year) follow--ups included.ups included.

Preliminary adherence measuresPreliminary adherence measures

Therapy attendance

0

2

4

6

8

CBT CBT-CM

Mea

n se

ssio

ns

GA Attendance

0

1

2

3

4

5

CBT CBT-CM

Mea

n m

eetin

gsHomework exercises

0

20

40

60

80

CBT CBT-CM%

Com

plet

ed

Brief interventions Brief interventions

RationaleRationale

Despite the large numbers and adverse consequences Despite the large numbers and adverse consequences of disordered gambling, fewer than 8% of of disordered gambling, fewer than 8% of pathological gamblers ever seek or receive services pathological gamblers ever seek or receive services (National Research Council, 1999).(National Research Council, 1999).

Virtually no problem gamblers seek or receive Virtually no problem gamblers seek or receive services (NGISC, 1999).services (NGISC, 1999).

What can we do?What can we do?

Expand treatment services.Expand treatment services.Expand outreach.Expand outreach.Determine reasons why people don’t seek Determine reasons why people don’t seek services.services.Tailor interventions to fit the needs of the Tailor interventions to fit the needs of the patients who would be most likely to benefit patients who would be most likely to benefit from them.from them.

Brief interventions for reducing heavy alcohol use.Brief interventions for reducing heavy alcohol use.

Simple advice Simple advice Motivational enhancement therapy Motivational enhancement therapy 11--4 sessions 4 sessions

Brief treatments for problem gamblersBrief treatments for problem gamblersBrief treatments for problem gamblers

Screening effortsScreening effortsSubstance abusersSubstance abusersMedical/dental patients Medical/dental patients Older adults (senior centers)Older adults (senior centers)Gambling establishment patronsGambling establishment patrons

Random assignmentRandom assignment

1. Evaluation plus no1. Evaluation plus no--treatment controltreatment control2. Evaluation plus 5 minutes of brief advice2. Evaluation plus 5 minutes of brief advice3. Evaluation plus 1 session of Motivational 3. Evaluation plus 1 session of Motivational

Enhancement TherapyEnhancement Therapy4. Evaluation plus 4 sessions of therapy 4. Evaluation plus 4 sessions of therapy

(MET+CBT)(MET+CBT)

DemographicsDemographics

No tx 10 min Brief Advice

1 session of MET

4 sessions MET+CBT

n 48 37 55 40

Female 31% 51% 36% 45%

Caucasian 61% 66% 65% 60%

Age 41 44 45 44

Income $25,871 $23,583 $27,277 $31,552

Education 12.5 13.5 13.8 13.2

Addiction Severity Index Gambling scores

0

0.2

0.4

0.6

0 1 2

Day

s

No tx10 min1 session4 session

ShortShort--term resultsterm results

Dollars Gambled

0

250

500

750

1000

0 1 2

$ *p<.05,*p<.05,10 min 10 min vsvs no no txtx

Petry et al. (2008). J Petry et al. (2008). J ClinClin Consult PsychologyConsult Psychology

*p<.05,*p<.05,10 min 10 min vsvs no no txtx

Addiction Severity IndexGambling scores

00.10.20.30.40.5

0 1 2 3 4 5 6 7 8 9

Months

Day

s

No tx10 min1 session4 session

ResultsResults

Dollars Gambled

0

250

500

750

0 1 2 3 4 5 6 7 8 9

Months

$

*p<.05,*p<.05,10 min 10 min vsvs no no txtx

* p<.05 10 min vs. no * p<.05 10 min vs. no txtx BLBL--m1m1p<.05 4 session p<.05 4 session vsvs no no txtx, to m9, to m9

Proportions improved by month 9Proportions improved by month 9

0

10

20

30

40

50

60

%

No change Substantiallyimproved

Recovered

No txBrief AdviceMETMET+CBT*p<.05,

BA v. no tx

Predicting recovered/substantially improved at month 9Predicting recovered/substantially improved at month 9

VariableVariable BetaBeta WaldWald p valuep value Odds ratio Odds ratio (95% CI)(95% CI)

FemaleFemale --.36.36 .80.80 .37.37AgeAge --.01.01 .36.36 .55.55SOGSSOGS --.17.17 10.510.5 p<.001p<.001 0.84 (.760.84 (.76--.93).93)ASIASI--medmed --1.281.28 5.115.11 p<.05p<.05 0.28 (.090.28 (.09--.84).84)ASIASI--alcalc 1.611.61 0.970.97 .33.33ASIASI--drugdrug --3.073.07 .83.83 .36.36BSIBSI --.02.02 0.000.00 .96.96Brief AdviceBrief Advice 1.811.81 8.428.42 p<.01p<.01 6.08 (1.86.08 (1.8--20.6)20.6)METMET .86.86 2.852.85 .09.09MET/CBTMET/CBT .78.78 1.961.96 .16.16

How does the brief advice work?How does the brief advice work?

Continuum of gamblingContinuum of gambling

Pathological/compulsiveHeavy/At riskRecreationalNon

Continuum of gamblingContinuum of gambling

Pathological/compulsiveHeavy/At riskRecreationalNon

Your level of gamblingYour level of gamblingputs you in this group. puts you in this group.

Point out their specific risk factors for problem gambling.Point out their specific risk Point out their specific risk factors for problem gambling.factors for problem gambling.

Substance abuseSubstance abuseFamily members Family members Psychiatric problemsPsychiatric problemsFrequency and quantity of gamblingFrequency and quantity of gamblingSuperstitious thinkingSuperstitious thinkingMajor life changesMajor life changes

Brief adviceBrief advice

Limit amount of money spent gambling.Limit amount of money spent gambling.Cash only, limited access, leave ATM/credit Cash only, limited access, leave ATM/credit cards at home.cards at home.

Limit amount of time and days gambling.Limit amount of time and days gambling.Not daily, commitments with othersNot daily, commitments with others

Don’t expect to win.Don’t expect to win.Spend time on other recreational activities.Spend time on other recreational activities.

SummarySummary

Problem and pathological gambling is fairly common and Problem and pathological gambling is fairly common and associated with adverse family, social, and medical associated with adverse family, social, and medical consequences. consequences. CognitiveCognitive--behavioral therapy is efficacious in reducing behavioral therapy is efficacious in reducing gambling problems in pathological gamblers.gambling problems in pathological gamblers.Problem gamblers are unlikely to seek treatment, so direct Problem gamblers are unlikely to seek treatment, so direct screening and intervention strategies seem useful.screening and intervention strategies seem useful.Very brief interventions appear effective in reducing Very brief interventions appear effective in reducing problem gambling. problem gambling.

Thanks to…..Thanks to…..

YolaYola AmmermanAmmerman, M.A., M.A.Scarlett Anicette, M.A.Scarlett Anicette, M.A.Anne Doersch, M.A.Anne Doersch, M.A.Heather Gay, M.S.W.Heather Gay, M.S.W.Ron Kadden, Ph.D.Ron Kadden, Ph.D.David Ledgerwood, Ph.D.David Ledgerwood, Ph.D.Suzanne McColl, M.A.Suzanne McColl, M.A.Cheryl Molina, M.A.Cheryl Molina, M.A.Ben Morasco, Ph.D.Ben Morasco, Ph.D.Betsy Parker, M.A.Betsy Parker, M.A.Robert Robert PietrzakPietrzak, M.P.H., M.P.H.Nicole Reilly, B.A.Nicole Reilly, B.A.Karen Steinberg, Ph.D.Karen Steinberg, Ph.D.Julie Julie UrosUros, B.A., B.A.Jeremiah Weinstock, Ph.D.Jeremiah Weinstock, Ph.D.

Gambling treatment manuals and Gambling treatment manuals and handouts are available in:handouts are available in:

Petry, N.M. Pathological Petry, N.M. Pathological Gambling: Etiology, Gambling: Etiology, ComorbidityComorbidity, and Treatment. , and Treatment. American Psychological American Psychological Association Press: Association Press: Washington, DC.Washington, DC.

http://http://books.apa.org/books.cfm?ibooks.apa.org/books.cfm?idd=4316046=4316046