The Development of an Internet-Based Treatment for Problem Gamblers and Concerned Significant Others: A Pilot Randomized Controlled Trial

Problem gambling creates significant harm for the gambler and for concerned significant others (CSOs). While several studies have investigated the effects of individual cognitive behavioral therapy (CBT) for problem gambling, less is known about the effects of involving CSOs in treatment. Behavioral couples therapy (BCT) has shown promising results when working with substance use disorders by involving both the user and a CSO. This pilot study investigated BCT for problem gambling, as well as the feasibility of performing a larger scale randomized controlled trial. 36 participants, 18 gamblers and 18 CSOs, were randomized to either BCT or individual CBT for the gambler. Both interventions were Internet-delivered self-help interventions with therapist support. Both groups of gamblers improved on all outcome measures, but there were no differences between the groups. The CSOs in the BCT group lowered their scores on anxiety and depression more than the CSOs of those randomized to the individual CBT group did. The implications of the results and the feasibility of the trial are discussed.     

Internet-Based Delivery of Cognitive Behaviour Therapy Compared to Monitoring,Feedback and Support for Problem Gambling: A Randomised Controlled Trial

The aim of this study was to investigate the efficacy of an Internet-based cognitive behavioural therapy program (I-CBT) for the treatment of problem gambling, when compared to a waitlist control and an active comparison condition consisting of monitoring, feedback, and support (I-MFS). Participants (N = 174) were randomly allocated to the three conditions. Variables of interest were gambling outcome and related mental health measures. Participants in the active conditions (I-CBT and I-MFS) completed six online modules. Both I-CBT and I-MFS conditions resulted in significant treatment gains on gambling severity. However, I-CBT was also associated with reductions in a range of other gambling-related and mental health outcomes. Compared with I-MFS, I-CBT produced greater effects across seven outcomes measures, relating to gambling urges, cognitions, stress, and life satisfaction. I-CBT participants also rated the program as significantly more satisfactory. Treatment gains observed for both active conditions were found to be stable through to 12 month follow up. The results indicate that the benefits of I-CBT were more than simply the non-specific effects of engaging in online treatment or receiving motivation, feedback, and support. Online treatments for gambling may be a valuable tool in increasing help-seeking and treatment engagement in this population, and be integrated as part of stepped care approaches to treatment.     

Exposure Therapy for Problem Gambling via Videoconferencing: A Case Report

This case report of a 31 year old woman who described her main problem as an uncontrollable urge to gamble on electronic gaming machines describes the application of exposure therapy (ET) by videoconferencing and the use of a clinical therapy assistant in the treatment of pathological gambling. The case study is used to demonstrate the effectiveness of this treatment with six sessions of therapy and 4 year follow up. The use of videoconferencing is discussed in relation to treatment effectiveness, ongoing follow up for the client and education and support for a community mental health nurse, therapy assistant, in a rural setting in South Australia. The implications of using this modality for the treatment of rural patients with problem gambling is discussed.     

The Involvement of a Concerned Significant Other in Gambling Disorder Treatment Outcome

Interpersonal distress is a common feature in gambling disorder and adding a concerned significant other (CSO) to the recovery process could be an effective tool for improving treatment outcome. However, little empirical evidence is available regarding the effectiveness of including a CSO to interventions. We aimed to compare treatment outcomes (i.e. compliance with therapy guidelines, dropout from treatment, and relapse during treatment) in a CBT program involving a CSO to CBT treatment as usual (TAU) without a CSO. The sample comprised male gambling disorder patients (N = 675). The manualized CBT intervention consisted of 16 weekly outpatient group sessions and a 3-month follow-up period. Patient CSOs attended a predetermined number of sessions with the patient and were provided with resources to acquire a better understanding of the disorder, to manage risk situations, and to aid patients in adhering to treatment guidelines. Patients with a CSO had significant higher treatment attendance and reduced dropout compared to patients receiving TAU. Moreover, patients whose spouse was involved in the treatment program were less likely to relapse and adhered to the treatment guidelines more than those with a non-spousal CSO. Our results suggest that incorporating interpersonal support to gambling disorder interventions could potentially improve treatment outcomes.     

Effects of Affective and Anxiety Disorders on Outcome in Problem Gamblers Attending Routine Cognitive–Behavioural Treatment in South Australia

This study evaluated the influence of 12-month affective and anxiety disorders on treatment outcomes for adult problem gamblers in routine cognitive–behavioural therapy. A cohort study at a state-wide gambling therapy service in South Australia. Primary outcome measure was rated by participants using victorian gambling screen (VGS) ‘harm to self’ sub-scale with validated cut score 21+ (score range 0–60) indicative of problem gambling behaviour. Secondary outcome measure was Work and Social Adjustment Scale (WSAS). Independent variable was severity of affective and anxiety disorders based on Kessler 10 scale. We used propensity score adjusted random-effects models to estimate treatment outcomes for sub-populations of individuals from baseline to 12 month follow-up. Between July, 2010 and December, 2012, 380 participants were eligible for inclusion in the final analysis. Mean age was 44.1 (SD = 13.6) years and 211 (56 %) were males. At baseline, 353 (92.9 %) were diagnosed with a gambling disorder using VGS. For exposure, 175 (46 %) had a very high probability of a 12-month affective or anxiety disorder, 103 (27 %) in the high range and 102 (27 %) in the low to moderate range. For the main analysis, individuals experienced similar clinically significant reductions (improvement) in gambling related outcomes across time (p < 0.001). Individuals with co-varying patterns of problem gambling and 12 month affective and anxiety disorders who present to a gambling help service for treatment in metropolitan South Australia gain similar significant reductions in gambling behaviours from routine cognitive–behavioural therapy in the mid-term.     

Treatment of Female Pathological Gambling: The Efficacy of a Cognitive-Behavioural Approach

Given that a substantial proportion of current pathological gamblers are female, it is evident that women are underrepresented in the treatment outcome literature. The current study was designed to redress the limited information on the treatment of female pathological gambling. Although the use of cognitive-behavioural therapy is the most highly recommended approach as ‘best practice’ for the treatment of pathological gambling, no attempt to date has been made to evaluate the efficacy of this approach for female pathological gambling. Nineteen female pathological gamblers with electronic gaming machine problems were treated with a cognitive-behavioural program. While pathological gamblers placed on a waiting list did not show significant improvement on gambling behaviour and psychological functioning measures, the female pathological gamblers showed significant improvement on these measures over the treatment period, and maintained this improvement at the 6-month follow-up evaluation. By the completion of the follow-up period, 89% of participants no longer met diagnostic criteria for pathological gambling. Although further scientific demonstration and replication are required, the outcomes of this study indicate that the therapy that is considered ‘best practice’ in the treatment of pathological gambling is effective for female pathological gambling.     

Who Really Wins? Efficacy of a Croatian Youth Gambling Prevention Program

This paper reports on the development and pilot evaluation of a Croatian school-based youth gambling prevention program “Who really wins?”. The program is aimed at minimizing risk and enhancing protective factors related to youth gambling. A short-term evaluation of the program was conducted with a sample of 190 first and second year high-school students (67.6% boys, aged 14–17 years; average age 15.61). An experimental design with two groups (Training vs. No Training) and two measurement sessions (pre-test and post-test sessions) was used to evaluate change in problem gambling awareness, cognitive distortions, knowledge of the nature of random events as well as in social skills. Results showed significant changes in the post-test sessions, which can be attributed to changes in the Training group. We observed a decrease in risk factors, namely better knowledge about gambling and less gambling related cognitive distortions. Immediate effects on protective factors such as problem solving skills, refusal skills, and general self-efficacy were not observed. Findings also show program effects to be the same for both boys and girls, students from different types of schools, for those with different learning aptitudes, as well as for those at different risk levels with regard to their gambling, which speaks in favour of the program’s universality. The program had no iatrogenic effects on behaviour change and shows promise as an effective tool for youth gambling prevention. Future research and a long-term evaluation are needed to determine whether the observed changes are also linked to behavioural change.     

Twelve-Step Facilitated Versus Mapping-Enhanced Cognitive-Behavioral Therapy for Pathological Gambling: A Controlled Study

This study examined the efficacy of two group treatments for pathological gambling, a node-link mapping-enhanced cognitive-behavioral group therapy (CBGT-mapping) and twelve-step facilitated (TSF) group treatment. Forty-nine participants meeting criteria for pathological gambling were recruited from local newspaper advertisements. These participants were randomly assigned to one of three conditions: TSF (n = 11), CBGT-mapping (n = 18), and Wait-List control (n = 9); 11 refused treatment prior to randomization. Outcome measures included number of DSM-IV criteria met, perception of control/self-efficacy, desire to gamble, and frequency of gambling episodes. Analyses revealed a significant treatment group × time interaction (η2_partial = .39). Specifically, the group treatments resulted in significant improvements in the dependent measures, while the Wait-List group remained relatively stable. Overall, CBGT-mapping and TSF had no significant differences on any outcome measure at follow-up assessments. Analysis of post-treatment and 6-month follow-up reveal a significant improvement in gambling outcomes (i.e., fewer DSM-IV criteria met, greater self-efficacy, and fewer gambling episodes (η2_partial = .35), with treatment gains maintained at 6 months. These results are consistent with previous research for group treatment for pathological gambling and provide support for the utility of TSF and a mapping-based CBT therapy as viable intervention for pathological gambling.     

A Preliminary, Qualitative Exploration of the Influences Associated with Drop-Out from Cognitive-Behavioural Therapy for Problem Gambling: An Australian Perspective

It has been estimated that 80% of Australians engage in some form of gambling, with approximately 115,000 Australians experiencing severe problems (Productivity Commission 2010). Very few people with problem gambling seek help and, of those who do, large numbers drop-out of therapy before completing their program. To gain insights into these problems, participants who had either completed or withdrawn prematurely from an individual CBT-based problem gambling treatment program were interviewed to examine factors predictive of premature withdrawal from therapy as well as people??s ??readiness?? for change. The results indicated that there might be some early indicators of risk for early withdrawal. These included: gambling for pleasure or social interaction; non-compliance with homework tasks; gambling as a strategy to avoid personal issues or dysphoric mood; high levels of guilt and shame; and a lack of readiness for change. The study further showed that application of the term ??drop-out?? to some clients may be an unnecessarily negative label in that a number appear to have been able to reduce their gambling urges even after a short exposure to therapy.     

Predictors of Relapse in Problem Gambling: A Prospective Cohort Study

To explore the variation of predictors of relapse in treatment and support seeking gamblers. A prospective cohort study with 158 treatment and support seeking problem gamblers in South Australia. Key measures were selected using a consensus process with international experts in problem gambling and related addictions. The outcome measures were Victorian Gambling Screen (VGS) and behaviours related to gambling. Potential predictors were gambling related cognitions and urge, emotional disturbance, social support, sensation seeking traits, and levels of work and social functioning. Mean age of participants was 44 years (SD = 12.92 years) and 85 (54 %) were male. Median time for participants enrolment in the study was 8.38 months (IQR = 2.57 months). Patterns of completed measures for points in time included 116 (73.4 %) with at least a 3 month follow-up. Using generalised mixed-effects regression models we found gambling related urge was significantly associated with relapse in problem gambling as measured by VGS (OR 1.29; 95 % CI 1.12–1.49) and gambling behaviours (OR 1.16; 95 % CI 1.06–1.27). Gambling related cognitions were also significantly associated with VGS (OR 1.06; 95 % CI 1.01–1.12). There is consistent association between urge to gamble and relapse in problem gambling but estimates for other potential predictors may have been attenuated because of methodological limitations. This study also highlighted the challenges presented from a cohort study of treatment and support seeking problem gamblers.     

Effectiveness of a Self Help Cognitive Behavioural Treatment Program for Problem Gamblers: A Randomised Controlled Trial

The study aimed to strengthen the scarce literature on self-help treatments for Problem Gambling (PG) by comparing the effectiveness of a Self-Help Cognitive Behavioral Treatment (SHCBT) program (n = 23) with a 6-week Waitlist condition (n = 32) in problem gamblers. Participants were community volunteers with gambling problems and were randomly allocated to the Waitlist and treatment conditions. Results showed significant improvements at post-treatment in gambling behaviors including frequency of gambling, average amount gambled per day and PG symptoms as well as a number of gambling correlates including psychological states (e.g., depression, anxiety and stress), gambling cognitions, gambling urges, gambling related self-efficacy, satisfaction with life, and quality of life among those who completed the SHCBT program, when compared with the waitlist condition. The effect size (partial η ²) ranged from .25 to .57 for all assessed outcomes that showed significant improvement from pre- to post-treatment. It was concluded that a self-help CBT program can be beneficial for treating community problem gamblers.     

Increased Urge to Gamble Following Near-Miss Outcomes May Drive Purchasing Behaviour in Scratch Card Gambling

Previous research into scratch card gambling has highlighted the effects of these games on players’ arousal and affective states. Specifically, near-miss outcomes in scratch cards (uncovering 2 of 3 needed jackpot symbols) have been associated with high levels of physiological and subjective arousal and negative emotional evaluations, including increased frustration. We sought to extend this research by examining whether near-misses prompted increases in gambling urge, and the subsequent purchasing of additional scratch cards. Participants played two scratch cards with varying outcomes with half of the sample experiencing a near-miss for the jackpot prize, and the other half experiencing a regular loss. Players rated their urge to continue gambling after each game outcome, and following the initial playing phase, were then able to use their winnings to purchase additional cards. Our results indicated that near-misses increased the urge to gamble significantly more than regular losses, and urge to gamble in the near-miss group was significantly correlated with purchasing at least one additional card. Although some players in the loss group purchased another card, there was no correlation between urge to gamble and purchasing in this group. Additionally, participants in the near-miss group who purchased additional cards reported higher levels of urge than those who did not purchase more cards. This was not true for the loss group: participants who experienced solely losing outcomes reported similar levels of urge regardless of whether or not they purchased more scratch cards. Despite near-misses’ objective status as monetary losses, the increased urge that follows near-miss outcomes may translate into further scratch card gambling for a subset of individuals .     

Self-Exclusion Program: A Longitudinal Evaluation Study

Few self-exclusion programs have been evaluated and their long-term impact remains unknown. This study has two main goals: (1) to assess changes in gambling behaviour and gambling problems for self-excluded patrons, and (2) to follow self-excluded gamblers for a two-year period (during and after the self-exclusion period). Individuals who excluded themselves (N = 161 at the initial stage) participated in telephone interviews after signing the self-exclusion agreement and were followed at 6, 12, 18 and 24-months. Results show that according to the DSM-IV, 73.1% of the participants were pathological gamblers. The self-exclusion program has many positive effects. During the follow-ups, the urge to gamble was significantly reduced while the perception of control increased significantly for all participants. The intensity of negative consequences for gambling was significantly reduced for daily activities, social life, work, and mood. The DSM score was significantly reduced over time. This reduction also took place between the baseline and the 6-month follow-up. The clinical implications of the results are discussed in relation to the effectiveness of the program. Suggestions are provided in order to increase compliance of self-excluded patrons.     

On Doing Research in a Clinical Setting

Abstract

Objective: To evaluate the efficacy of a stand-alone personalized normative feedback (PNF) intervention targeting misperceptions of gambling among college students. Participants: Undergraduates (N = 136; 55% male) who reported gambling in the past 30 days were recruited between September 2011 and March 2012. Methods: Using a randomized clinical trial design, participants were assigned to receive either PNF or an attention control task. In addition to self-report, this study used 2 computer-based risk tasks framed as “gambling opportunities” to assess cognitive and behavioral change at 1 week post intervention. Results: After 1 week, participants receiving PNF showed a marked decrease in perception of other students’ gambling, and evinced lower risk-taking performance on 2 analog measures of gambling. Conclusions: Changes in both self-reported perceived norms and analog gambling behavior suggest that a single, stand-alone PNF intervention may modify gambling among college students. Whether it can impact gambling outside of the laboratory remains untested.     

Assessing the Need for Higher Levels of Care Among Problem Gambling Outpatients

Most treatment for gambling disorder is provided on an outpatient basis. Only a small number of jurisdictions in North America provide higher levels of gambling treatment, such as residential or intensive outpatient (IOP) care, despite the potential need for these services. Further, there appear to be few guidelines for determining appropriate level of gambling treatment. The aim of the present study was to assess the appropriateness of higher levels of problem gambling care among clients receiving outpatient treatment. Problem gamblers and their therapists independently completed questionnaires that assessed the need and desire for residential and IOP treatment. About 42% of problem gambling outpatients noted that they would be “probably” or “definitely” willing to attend residential treatment, and about half indicated they would be equally likely to attend IOP. Therapists recommended about a third of their clients as appropriate for higher levels of care. For both client and therapist assessments, there was a significant association between desire or recommendation for level of treatment and severity of gambling and co-occurring problems. Further, therapist recommendations for level of care were significantly associated with client willingness to attend higher levels of treatment. Our data reveal the potential need for higher levels of care for problem gambling, as evaluated by clients and their therapists. Policy implications for the funding of residential and IOP treatment are discussed.     

Gambling Disorder Due to Brazilian Animal Game (“Jogo do bicho”): Gambling Behavior and Psychopathology

Gambling is currently widespread across the globe and despite legally restricted, it is significantly common in Brazil. A traditional and common form of gambling in Brazil is the Brazilian animal game (BAG)—“Jogo do bicho” in Portuguese. In 2013, BAG activities collected approximately 19 billion Brazilian reais—equivalent to more than 8 billon American dollars, a figure almost 60 % higher than legal lotteries. Although a common form of gambling, the gambling behavior and psychopathology of gambling disorder (GD) associated with BAG has never been systematically studied. The aim of this study is to conduct, the first research approaching GD due to BAG. We assessed 897 participants of whom 63 subjects (7.0 %) presented with GD due to BAG and 834 with GD associated with other forms of gambling. After comparing these two groups, major differences were found in demographics, gambling behavior elements and psychopathological variables. This research reinforces the need for further research on BAG and the need for specific approaches in GD. The particularities of BAG may affect treatment strategies as, for example, suggest some adaptations in social and psychotherapeutic approaches. We also highlight the need to acknowledge the “hidden” BAG as a potential addictive game.     

The Role of Social Workers in the Treatment of Addictions

Abstract

This article describes the history of social workers' involvement in the treatment of addictions in the United States. Beginning with Mary Richmond, the “mother of social casework,” social workers have played an increasingly important role in the treatment of individuals with alcohol and other drug problems and of their family members. Today, social workers are important players not only in program development, administration, and treatment of chemical addictions, but also in “process” addictions, such as eating disorders and gambling. Moreover, social workers are increasingly involved in addictions research and policy arenas.     

NIDA: Plethora of treatments for SUDs,regardless of substance

When people refer to “evidence‐based” treatment, they mean treatment that has been proven to be effective and has been incorporated into strict protocols via manuals, so they can be replicated. The National Institute on Drug Abuse (NIDA) has been tracking the many treatment models for general substance use disorders, as well as for specific substances. Motivational interviewing (MI), medication‐assisted treatment (MAT), contingency management (CM) and cognitive behavioral therapy (CBT) are all evidence‐based modalities, explained Ruben Baler, Ph.D., NIDA health scientist, in an email to ADAW.     

Withdrawal and Tolerance Phenomenon in Problem Gambling

The phenomenological similarities between gambling and substance dependence have led to the conceptualization of pathological gambling as an addictive disorder. Tolerance and withdrawal are important features of both disorders, suggesting commonalities in the neurobiological processes associated with neuroadaptational underpinnings. However, there are few empirical studies supporting the presence of tolerance and withdrawal reported in the gambling literature. Moreover, there are no studies comparing the equivalence of tolerance and withdrawal between gambling and alcohol dependence. This study compared tolerance and withdrawal features in samples of gamblers, alcoholics and gamblers who also met criteria for alcohol dependence. In contrast to the addiction model, findings indicate that, while a majority of participants increased bet size, the motivation to do so was not for excitement or to maintain arousal levels as indicated by the DSM-IV-TR but because of cognitive factors related to winning. Results supported the notion that pathological gamblers experienced similar levels of withdrawal symptom severity as alcohol-dependent participants. Further research is needed to evaluate whether those symptoms result from the inability to gamble or from the loss of an avoidant stress coping strategy.