Advancing Treatment Strategies for Pathological Gambling

Experiences from treatment trials are described. The use of structured instruments for subject characterization and symptom change assessment is discussed and the challenges of treating specific groups (e.g., those with co-occurring alcohol use disorders) explored. Treatment for pathological gambling might be advanced most rapidly through collaborative multi-center efforts.     

The Proxy Effect: Gender and Gambling Problem Trajectories of Iowa Gambling Treatment Program Participants

Recent research has found that men and women who end up in gambling treatment tend to follow different trajectories to that endpoint: women generally begin gambling later in life, but progress to problems and seek treatment more quickly. With women’s prevalence rates of gambling and disordered gambling increasing, it has become important to identify the causes and consequences of these trajectory differences. The current study used a sample of 2,256 gamblers enrolled in the Iowa Gambling Treatment Program to examine the relationship of gender and other demographic, economic and health-related (i.e., psychosocial) factors to empirically-identified gambling problem trajectories. The results indicated that gender made a statistically significant contribution to the prediction of trajectory, but increased predictive accuracy by only 1–2% beyond a model with psychosocial predictors. Gender’s contribution was limited to its relationship to age of initiation; men and women’s problem progression did not differ meaningfully once age of gambling initiation was taken into account. Gender is a unique contributor to the development of gambling problems among treatment seekers, but it is only one small part of the myriad psychosocial characteristics that influence gambling problem development.

Controlled Gambling for Pathological Gamblers

Despite its high prevalence, pathological gambling often remains untreated. It is estimated that only 10% of the pathological gamblers identified in prevalence studies will enter treatment. Within this small proportion, a high percentage will drop out. Despite the facts that some researchers argue against abstinence as the unique treatment goal and that regaining control appears to be possible for some pathological gamblers, abstinence has been the only treatment goal in most problem gambling interventions thus far. This paper examines the avenue of controlled gambling embedded in a harm reduction context as a viable solution for some pathological gamblers.     

Evaluation and Treatment of Pathological Gambling

The aim of this article was to describe a model for evaluating and implementing cognitive-behavioral treatment for pathological gambling. The model takes into account the fact that pathological gamblers form a heterogeneous group with varied biopsychosocial characteristics.     

Outcome of Minnesota's Gambling Treatment Programs

This study measured the outcome of four state-supported outpatient gambling treatment programs in Minnesota. The programs were developed specifically for the treatment of pathological gamblers and offered multiple modalities of treatment including individual, group, education, twelve-step work, family groups, and financial counseling. The therapeutic orientation was eclectic with an emphasis on the twelve steps of Gamblers Anonymous (GA) and a treatment goal of abstinence. The sample included 348 men and 220 women treated between January 1992 and January 1995. A pretest-posttest design was utilized with multidimensional assessments obtained at intake, discharge, six-months, and twelve-months post-discharge. Variables assessed included a range of clinical and outcome variables. At six month follow-up, 28% reported that they had abstained from gambling during the six months following discharge and an additional 20% had gambled less than once per month. Almost half of the sample (48%) showed clinically significant improvement in gambling frequency at six monthfollow-up. Outcome variables of gambling frequency, SOGS scores, amount of money gambled, number of friends who gamble, psychosocial problems, and number of financial problems, all showed statistically significant improvements from pretreatment to follow-up. The treatment programs yielded outcome results similar to those reported for alcohol and drug abuse treatment programs.     

Psychological Treatment of Slot-Machine Pathological Gambling: New Perspectives

In this paper the most relevant findings of our research team on pathological gambling in the last decade are presented. There is no conclusive empirical evidence of a specific profile of the pathological gamblers. The choice treatment appears to be stimulus control and in vivo exposure with response prevention, followed by a cognitive-behavioral intervention in relapse prevention. Predictive variables for the therapeutic failure were the dissatisfaction with the treatment, the alcohol abuse and the neuroticism as a personality variable. Unanswered questions for future research in this field are commented upon.     

Alcohol Use and Prior Substance Abuse Treatment in Relation to Gambling Problem Severity and Gambling Treatment Outcome

Recent research has made it clear that problematic gambling is often accompanied by problematic alcohol use. Unfortunately, little is known about the nature of this association, especially as it relates to gambling treatment outcome. The purpose of this study is to explore the effect of current alcohol use level and previous substance abuse treatment on the symptoms of a large cohort of pathological gamblers as well as on their response to treatment for pathological gambling. The sample included 464 men and 301 women recruited at six gambling treatment programs in Minnesota. Gambling treatment patients were assessed on a number of gambling problem severity and related clinical variables using the Gambling Treatment Outcome Monitoring System (GAMTOMS). Patients with frequent alcohol use had greater gambling involvement at baseline than infrequent alcohol users. Patients with a previous history of substance abuse treatment had more severe psychosocial problems, ostensibly resulting from their gambling behavior, than patients without past substance abuse treatment. A MANOVA with repeated measures showed that neither pretreatment alcohol use, nor past substance abuse treatment exerted significant effects on gambling treatment outcome. While the level of pretreatment alcohol use and a history of substance abuse treatment are markers for greater gambling problem severity, treatment outcome for pathological gambling was not adversely impacted by these variables.     

Problems in Measuring the Effectiveness of Cognitive Therapy for Pathological Gambling

Cognitive therapy is a relatively new approach to the treatment of pathological gambling. Theoretically, there are strong grounds for believing that cognitive treatments will be effective in helping individuals cut back and stop excessive levels of gambling. However, there is evidence that cognitive therapy for pathological gambling is being confused with cognitive-behaviour therapy. In this paper, the distinction between treatments that are cognitive and those that are cognitive-behavioural is highlighted. Such a distinction has strong implications for the manualisation of therapy. Additionally, a range of problems that confront the evaluation of all therapies for pathological gambling is considered. Spontaneous recovery without therapeutic intervention has been documented in both field studies of both problem and non-problem players and controlled trials of cognitive therapy compared to a waiting list control group. The implications of the phenomenon of spontaneous recovery for the evaluation of cognitive therapy are described. Other problems common to all evaluations of psychotherapies are considered in relation to gambling and recommendations made for outcome study designs.     

Clinical Care of Gambling Disorders: Training, Experience, and Competence Among VHA Psychologists

Problem gambling is a common, highly destructive disorder which is often overlooked by clinicians. Levels of clinical training, clinical experience, and professional competence for providing clinical services for problem gambling were examined in a survey of 181 clinical psychologists working in the Veterans Healthcare Administration (VHA). The results suggest that the majority of clinical psychologists have little or no formal training and little or no past or current clinical experience in the treatment of disordered gambling, nor do they see themselves as competent to evaluate or treat patients with disordered gambling. Most have not referred patients for treatment of problem gambling and do not know of a competent provider to whom they can refer. There is an identifiable subgroup, representing 9% of respondents, who do have more training, provide services, and see themselves as competent to provide care for patients with problem gambling. The amount of formal training is positively correlated with care provided and self-ratings of competence. Despite the lack of training and experience, most respondents expressed interest in receiving additional training. These data suggest that to improve rates of diagnosis and treatment of patients with problem gambling in mental health settings, additional training needs to be made available for mental health providers as a group, with specialized training for clinicians interested in specializing in this area.     

Significant Others and Gambling Treatment Outcomes

Aims This study investigates the effect of significant others on treatment outcomes among treated pathological gamblers. Design This is a cohort study of individuals who received gambling treatment. Setting Oregon Problem Gambling Services (OPGS) for gamblers and their family members. Participants 4,410 adult gamblers who were discharged from treatment between August, 2001 and April, 2007. Measurements OPGS enrollment forms provided gambler gender, age, ethnicity, education level, employment status, gambling-related debt, and whether the gambler had a significant other at the time of enrollment. Termination forms provided information on the type of discharge (successful/unsuccessful) and treatment length (in days). Participation of the gambler’s significant other in the family treatment program was identified. Findings Results showed that age, ethnicity, gambling debt, and having a significant other are associated with the odds of successful treatment. Education level moderates the effect of having a significant other on treatment success. Age, ethnicity, education, employment, and having a significant other participate in treatment significantly impacted gamblers’ length in treatment. Conclusions These findings indicate that there may be a benefit to integrating significant others in gambling treatment methods. Significant others may act as social supports for gamblers seeking treatment, and involving loved ones in gambling treatment models may positively affect gambler treatment outcomes.     

Gambling Participation and Problems Among Employees at a University Health Center

This study evaluated the frequency and intensity of gambling behaviors among employees at an academic health center. Employees were sent an anonymous questionnaire assessing demographic characteristics, participation in gambling activities, and gambling-related problems. Of the 904 respondents, 96% reported gambling in their lifetimes, with 69% gambling in the past year, 40% in the past two months, and 21% in the past week. The most common forms of gambling were lottery and scratch tickets, slot machines, card playing, sports betting, bingo, and track. Only 1.2% of the sample reported gambling on the internet. Using scores on the South Oaks Gambling Screen, 3.0% of the respondents were classified as Level 2 (or problem) gamblers, and an additional 1.8% were Level 3 (or pathological) gamblers. Compared to Level 1 (non-problem) gamblers, Level 2 and Level 3 gamblers were more likely to be male, single, and employed full-time, and to have lower income and education. About half of the Level 2 and Level 3 gamblers reported interest in an evaluation of their gambling behaviors and treatment interventions. These data suggest the need to screen for gambling problems in health care professionals and to provide gambling-specific treatments.     

Conceptual and Methodological Issues in Treatment Outcome Research

Few studies have evaluated the comparative efficacy, effectiveness and mode of action of specific treatment interventions, or developed evidence-based best-practice management guidelines for the treatment of problem gambling. While individual and multi-modal programmes demonstrate positive results, systematic well-designed randomised controlled studies incorporating follow-up blind assessments and standardised diagnostic and outcome measures are needed to establish long-term outcomes.     

The effect of compliance-improving interventions on the cognitive-behavioural treatment of pathological gambling

This exploratory study investigated the effect of interventions designed to improve compliance and reduce dropout rates during the outpatient treatment of pathological gambling at a University-based gambling treatment clinic. Forty subjects (29 males, 11 females, mean age = 37.6) meeting DSM-IV criteria (APA, 1994) for pathological gambling were randomly assigned to either a cognitive-behavioural treatment or a cognitive-behavioural treatment combined with interventions designed to improve treatment compliance. Compliance was indicated by the completion of all treatment sessions. Outcome measures were DSM-IV criteria assessed by structured clinical interview, South Oaks Gambling Screen scores, and percentage of income gambled. Logistic regression analyses identified pretreatment characteristics predicting compliance and outcome. Compliance-improving interventions significantly reduced dropout rates, resulting in superior outcomes at posttreatment compared to the cognitive behavioural treatment alone. At 9-month follow-up, there was no difference in outcome between treatments, although both produced clinically significant change. Comorbid problem drinking, drug use, and problem gambling duration predicted poor compliance. Poor outcome was predicted by comorbid problem drinking. The clinical implications of these results are discussed in light of the exploratory nature of the study and the need for future research to address compliance, outcome, and comorbidity issues.     

Problem Gambling in Non-English Speaking Background Communities in Queensland,Australia: A Qualitative Exploration

This paper provides an overview of qualitative research into problem gambling among non-English speaking background (NESB) communities in Queensland, Australia. The focus for this pilot study was the Chinese, Greek and Vietnamese communities. Using qualitative methodologies, this community-based research explored the motivations for gambling, and the impacts of problem gambling upon individuals and communities. Findings indicate that problem gambling is evident in each of the communities of study, but the issue is characterised by a pervasive sense of denial. Gambling is an issue of enormous shame and stigma, not only for the problem gambler but their entire family. As a result, most problem gamblers do not seek professional help but try to resolve the problem themselves or within the family unit. Research findings indicate that service access could be increased through a range of strategies including the provision of culturally appropriate community education and gambling help services, partnerships between NESB communities, gambling help services and community workers, and the development and implementation of preventative strategies.     

Treatment Goal Selection for Female Pathological Gambling: A Comparison of Abstinence and Controlled Gambling

The current study was an exploratory investigation of the selection of controlled gambling as a goal of treatment for female pathological gambling. Specifically, it aimed to explore: 1) the popularity of controlled gambling as a goal of treatment; 2) the reasons pathological gamblers select abstinence and controlled gambling as goals of treatment; and 3) the characteristics of pathological gamblers attracted to abstinence and controlled gambling. The sample comprised 85 female pathological gamblers attending a cognitive-behavioural treatment program for pathological gambling. The selection of controlled gambling by one-third (34%) of the sample suggests that, at least in the Australian context, controlled gambling is a relatively popular goal of treatment for female pathological gamblers. In this study, the only differences between treatment-seeking female pathological gamblers selecting abstinence and controlled gambling were that those selecting controlled gambling were older and were less likely to endorse the belief that problematic gambling is a disease or affliction that can only be overcome by lifelong abstinence. Further research investigating the characteristics of pathological gamblers associated with controlled gambling as both a goal and outcome of treatment is required in order to ensure that treatment-seeking pathological gamblers can make an informed decision regarding their goal selection.     

Frequent Card Playing and Pathological Gambling: The Utility of the Georgia Gambling Task and Iowa Gambling Task for Predicting Pathology

The current investigation examined performance on two laboratory-based gambling tasks, the Georgia Gambling Task (GGT; Goodie, 2003. The effects of control on betting: Paradoxical betting on items of high confidence with low value. Journal of Experimental Psychology: Learning, Memory, and Cognition, 29, 598–610) and the Iowa Gambling Task (IGT; Bechara, Damasio, Damasio, & Anderson, 1994. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition, 50, 7–15), as well as self-reported markers of gambling pathology using the Diagnostic Interview for Gambling Severity (DIGS; Winters, Specker, & Stinchfield, 2002. The downside: Problem and pathological gambling (pp. 143–148). Reno, NV: University of Nevada, Reno) among a sample of undergraduate students who are frequent card players. Two hundred twenty-one participants (55 female and 166 male; mean age 19.21 years) who self-classified as playing cards at least once per month completed these measures. Performance on GGT and IGT systematically related to gambling-related pathology in several ways. Overconfidence and bet acceptance on the GGT, and myopic focus on reward on the IGT, predicted gambling related pathology. GGT and IGT performance correlated with each other, but both contributed independently to predicting gambling pathology. Card playing frequency predicted gambling pathology but not GGT or IGT performance. Discussion focuses on the role of biases of judgment and risky decision making in pathological gambling.     

Methodological Problems in Research on Treatments for Pathological Gambling

These common methodological problems affect the usefulness of pathological gambling (PG) treatment research: (1) Most PG etiological models derive from substance abuse; (2) Most PGs recover on their own and few seek treatment, so PGs in treatment studies may not be representative; (3) Data on treatment-seeking PG women, older adults, and minority group members, or on group, marital, and psychodynamic approaches to PG, are sparse; (4) Little research has examined the impact of comorbidity on PG treatment response; (5) Design deficiencies burden many PG treatment studies.     

A Perspective on Problem Gambling Treatment: Issues and Challenges

Researchers face several challenges in conducting gambling treatment research. These include the impact of monetary incentives to participate, difficulty in subject recruitment, treatment ambivalence, heterogeneity of gambling behaviors among treatment samples, the role of natural recovery, the impact of intractable financial pressures, and the specification of adequate process and outcome measures. Each challenge is defined and potential resolutions suggested.     

A Comprehensive Policy Analysis of and Recommendations for Senior Center Gambling Trips

Abstract

Gambling is one of the fastest growing industries in America. Public support is high for legalized gambling among all age groups. Because gambling is growing in popularity as an activity among those 65 and over, many senior centers are beginning to offer group trips to casinos and other gambling attractions such as dog tracks. This paper analyzes senior center casino gambling trips, with particular attention to the number of trips offered, how trips are funded, the policy implications of offering trips, and policy alternatives for state and local policymakers. Data for the study come from personal interviews with activity directors of 16 senior centers across Massachusetts and a formal survey of 30 additional senior centers in Central Massachusetts. Benefits of a new policy option, a public education strategy, are also reviewed.