Disordered Gambling and Its Treatment

Pathological gambling is an increasing concern with the growth of legalized gambling opportunities, and clinicians who provide general psychotherapy, as well as those specializing in some disorders, are likely to encounter patients with gambling problems. This review article describes the diagnostic criteria for pathological gambling and screening methods for identifying individuals with gambling problems. Problem and pathological gambling are more likely to occur in certain populations, such as among individuals with substance use, mood and anxiety disorders, and medical problems. However, few pathological gamblers seek specialized gambling treatment. This paper reviews different forms of treatments that have been applied to gamblers, along with evidence of their efficacy. Clinical guidelines for identifying and treating gambling problems are outlined as well.     

Psychobiology of the near-miss in fruit machine gambling

Explanations involving the etiology of pathological gambling have tended to emphasize psychosocial factors. However, the possibility that psychobiological factors may be important in the development of pathological gambling behavior should not be ruled out. Psychobiological approaches are becoming ever more prominent with the three main lines of research being (a) a search for a physiological disposition and/or underlying biological substrate in pathological gamblers, (b) an examination of the role of arousal in gambling, and (c) speculation about endorphin-related explanations. The data from questionnaires and interviews with fruit machine gamblers suggest that both physiological and cognitive factors (e.g., the psychology of the near-miss) may be important in the explanation of excessive fruit machine gambling. Thus, if a gambler becomes physiologically aroused when he or she wins or nearly wins, it will stimulate further play, here termed the psychobiology of the near-miss.     

Glücksspielsucht in der Rechtsprechung des Bundesgerichtshofs

Among the non-substance-related addictions, pathological gambling is the only one that has gained noteworthy forensic relevance. There are numerous parallels to substance-related addictions and not only in the symptomatology. A high proportion of pathological gamblers commit criminal offences to enable them to continue gambling or to pay gambling debts. According to the jurisdiction of the Federal Court of Justice (BGH) pathological gambling in itself cannot be considered as a pathological mental disorder or other serious mental abnormality that substantially diminishes the responsibility of the offender (German Penal Code § 21 StGB); however, the BGH recognizes that in serious cases of pathological gambling mental changes and personality defects can evolve that show similar structure and severity to substance-related addictions and severe withdrawal symptoms might also develop. As with substance-related addictions a substantial diminution of the offender’s responsibility can be assumed, therefore, also with pathological gambling if it has led to most severe personality changes or if the offender suffered from severe withdrawal symptoms while committing an addiction-related crime. According to these criteria a substantial diminution of the offender’s responsibility can be stated only in very rare cases. A custodial addiction treatment order (§ 64 StGB), which is also possible for fully responsible delinquents, is not applicable to cases of mere pathological gambling because the order requires an addiction to alcohol or other drugs. A mental hospital commitment order (§ 63 StGB) can be issued by the court under the same strict conditions that are applied to cases of substance-related addictions. Based on these principles this can only be issued if the defendant is addicted to gambling due to a mental defect that can be distinguished from the addiction itself or if the dependence has already been manifested in very severe personality changes. Pathological gambling can cause a propensity to commit serious offences and therefore, under the further conditions of §§ 66, 66a StGB justify detention for the purpose of incapacitation or a deferred incapacitation order. Even during imprisonment, detainees must be offered a suitable therapy (§ 66c para 2 StGB); however, penitentiaries do not offer the best environment for the treatment of pathological gamblers. The treatment in an addiction therapeutic setting appears to be more promising. Criminal political demands to make custodial addiction treatment orders also applicable to pathological gamblers have, however, very little chance of success.     

Psychobiology of the Near-Miss in Fruit Machine Gambling

Explanations involving the etiology of pathological gambling have tended to emphasize psychosocial factors. However, the possibility that psychobiological factors may be important in the development of pathological gambling behavior should not be ruled out. Psychobiological approaches are becoming ever more prominent with the three main lines of research being (a) a search for a physiological disposition and/or underlying biological substrate in pathological gamblers, (b) an examination of the role of arousal in gambling, and (c) speculation about endorphin-related explanations. The data from questionnaires and interviews with fruit machine gamblers suggest that both physiological and cognitive factors (e.g., the psychology of the near-miss) may be important in the explanation of excessive fruit machine gambling. Thus, if a gambler becomes physiologically aroused when he or she wins or nearly wins, it will stimulate further play, here termed the psychobiology of the near-miss.     

Tele-counselling for Problem Gambling: A Case Study

Innovative approaches to the treatment of pathological gambling are required since the number of individuals who seek treatment tend to be fewer than the prevalence studies would indicate. In this study, an innovative approach to the treatment of pathological gambling was used in order to address the common hindrances to treatment-seeking these patients face. One such approach is to offer the option of manual-guided tele-counselling. This case study reports on the progress of one individual who was treated using this modality. For reasons of privacy and anonymity, the individual in this case report preferred to address her problem gambling with the assistance of a therapist whom she never met. The client was provided with 10 weeks of tele-counselling treatment during which six treatment modules were delivered. Problems of access, privacy and anonymity were overcome with this method and the client was able to reduce their gambling behavior significantly with the therapeutic gains being maintained at the 6-month follow-up. The implications for the treatment of problem gambling using a non-traditional approach are discussed.     

Group therapy for pathological gamblers: a cognitive approach

This study evaluated the efficacy of a group cognitive treatment for pathological gambling. Gamblers, meeting DSM-IV criteria for pathological gambling, were randomly assigned to treatment (N=34) or wait-list control (N=24) conditions. Cognitive correction techniques were used first to target gamblers' erroneous perceptions about randomness, and then to address issues of relapse prevention. The dependent measures used were the DSM-IV criteria for pathological gambling, perceived self-efficacy, gamblers' perception of control, desire to gamble, and frequency of gambling. Post-treatment results indicated that 88% of the treated gamblers no longer met the DSM-IV criteria for pathological gambling compared to only 20% in the control group. Similar changes were observed on all outcome measures. Analysis of data from 6-, 12- and 24-month follow-ups revealed maintenance of therapeutic gains. Recommendations for group interventions are discussed, focusing on the cognitive correction of erroneous perceptions toward the notion of randomness.     

Towards a relational framework for pathological gambling (Part I): Five circuits

Relationship patterns before and after pathological gambling were investigated qualitatively using eight in‐depth clinical case studies in which one partner met Diagnostic and Statistical Manual of Mental Disorders‐IV pathological gambling criteria. Five circuits of couple interactions are described: (i) fault‐lines; (ii) pressure points; (iii) escalation; (iv) relapse and (v) congruence. The exploration of these circuits is developed in two complementary articles. This first article delineates the first four circuits as recursive self‐perpetuating cycles of couple distress in systemic interaction with pathological gambling development and relapse. The second article delineates how a couple can be helped to extricate themselves from these recursive circuits through ‘congruence’. Implications of this relational formulation of pathological gambling for conceptualization, assessment and treatment are discussed.     

Discounting of probabilistic rewards is associated with gambling abstinence in treatment-seeking pathological gamblers

Individuals with addictive disorders, including substance abusers and pathological gamblers, discount or devalue rewards delayed in time more than controls. Theoretically, preference for probabilistic rewards is directly related to gambling, but limited empirical research has examined probabilistic discounting in individuals with pathological gambling. This study evaluated probability and delay discounting in treatment-seeking pathological gamblers and their association with gambling treatment outcomes during and after treatment. At time of treatment entry, 226 pathological gamblers completed probability and delay discounting tasks. They were then randomized to one of three treatment conditions, and gambling behavior was measured throughout treatment and at a 1-year follow-up assessment. After controlling for possibly confounding variables and treatment condition, more shallow probability discounting was associated with greater reductions in amounts wagered during treatment and likelihood of gambling abstinence at the end of treatment and throughout the follow-up period. No associations were noted between delay discounting and gambling treatment outcomes. These data suggest that probability discounting may be an important construct in understanding pathological gambling and its treatment.     

Drinking patterns of pathological gamblers before, during, and after gambling treatment

Despite the high co-occurrence of alcohol consumption and gambling, few studies have investigated alcohol use changes during gambling treatment. Using latent growth modeling, we examined weekly alcohol use trajectories of treatment-seeking pathological gamblers across 36 weeks, allowing rates of change to differ across the 12-week pretreatment, during-treatment and posttreatment periods. For these secondary data analyses, we retained drinking gamblers (N = 163) from a combined sample of two randomized clinical trials for the treatment of pathological gambling. Results indicated a decrease in alcohol use corresponding with treatment entry and maintenance of less drinking during treatment and posttreatment. Despite these decreases in alcohol use overall, 31% (50 of 163) of participants exhibited risky drinking during the treatment or posttreatment periods. Gender, age, at-risk drinking (at any point in the 36-week interval), baseline gambling severity, treatment condition, and gambling during treatment predicted latent alcohol use growth factors. Although entry into gambling treatment was temporally associated with reductions in alcohol use in this retrospective analysis, a substantial portion of the sample exhibited at-risk drinking after treatment entry, suggesting that interventions targeting reductions in alcohol use may be useful for this population.     

The impact of comorbidity on the management of pathological gambling

A 30-year-old woman with severe pathological gambling and cyclothymia presented to our program with no previous history of pharmacologic or psychotherapeutic treatment. Pathological gambling is an impulse -control disorder not otherwise specified (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) in which comorbidity is common, particularly with substance abuse, obsessive-compulsive disorder and mood disorders. As described in this case, pathological gamblers with bipolar comorbidity may be effectively treated with mood stabilizers such as lithium. After receiving 10 weeks of lithium treatment, the patient showed improvement in both gambling behavior and affective instability. The identification of specific subtypes among patients with pathological gambling may be relevant to the choice of pharmacologic treatment.     

Does the Treatment of Cognitive Distortions Improve Clinical Outcomes for Problem Gambling?

Although dysfunctional beliefs about gambling outcomes among problem gamblers have been well-established, there is less known about whether specifically treating such beliefs is necessarily more effective than other therapeutic approaches. In the present study, brief, homogenous treatments for problem gambling (i.e., cognitive, behavioral, motivational, minimal intervention) were compared to each other. Each intervention was based on approaches empirically demonstrated to be clinically effective. The treatment sample consisted primarily of middle-aged, non-partnered, underemployed men recruited from the community via newspaper advertisements. The results showed that a cognitive approach did not yield superior outcomes than did treatments that did not explicitly address cognitive distortions. It is likely that there are several pathways to therapeutic change that may not necessarily require the modification of gambling-related psychopathology.     

Spielsucht – Alkoholabhängigkeit: „Zwei Süchte,eine Behandlung?“

While alcoholism has been undisputedly classified for decades as an addiction in diagnostic manuals like ICD -10 and DSM -IV, the classification of pathological gambling has not been definitively resolved, although alcohol dependence and pathological gambling have many addiction criteria in common. The course of gambling addiction is typically characterized by an initial phase, a critical habituation phase, and a phase of despair. While a gambling addiction may rapidly progress to chronic dependence within a year, the development of chronic alcohol dependence requires many years of misuse. For gambling addicts, external influence plays a considerable role (trigger situation) on the entry into gambling. For the majority of players, the initial contact comes from third parties, while for problem gamblers the social character of an invitation as a maintaining factor has less influence than for alcoholics. There are differences especially in the expression of comorbidities and the consequences of the addiction. For problem gamblers, these are more psychological than social, while secondary disorders are significant for alcoholics.     

Association of pathological gambling with depression in Scotland

Is most research concerning gambling and depression has been conducted on clinical populations, the present study examined the relationship between gambling and depression across a large sample in Scotland in higher education and the community. A questionnaire-based cluster design involved the distribution of the South Oaks Gambling Screen and the Centre for Epidemiologic Studies Depression Scale mainly to students and staff of higher educational establishments, with small community and gambling samples also included. Thirty-seven colleges and universities across Scotland participated in the research, with a sample of 2259 people aged sixteen years of age or over (M = 28.9 yr., SD = 13.4) being obtained. It was found that past-year probable pathological gamblers had significantly higher depression than problem gamblers, nonproblem gamblers, and nongamblers. However, when probable pathological gamblers who had sought treatment were omitted from the analysis, the nontreatment-seeking probable pathological gambling group no longer had significantly higher depression than the problem gambling group. Female problem and probable pathological gamblers had particularly high depressive symptomatology, suggesting co-morbid depression may be a prominent feature of problematic female gambling.     

Pathological Women Gamblers: Gender-Related Aspects of Control

This study examines the control exhibited by pathological women gamblers over their lives and their surroundings, and how this is governed by their perception of their gender role and socio-cultural expectations of them as women. Seventeen pathological women gamblers (13 of whom were mothers) were recruited from three addiction treatment centers in Israel, and participated in semi-structured interviews. Three central themes emerged during analysis: maintaining control over the gender roles—putting child raising and housekeeping duties first despite their gambling habits; control over the choice of gambling venue—gambling far from their home, or where they knew the owners; and moral control—steering clear of immoral behaviors in spite of their addiction to gambling. Further analysis reveals how pathological women gamblers who are also mothers make rational choices that help them juggle between their gender roles and gambling, to minimize the social costs that might be incurred by their gambling habit. Moreover, presenting the gambling behavior as more moral than theft or prostitution enabled them to normalize their behavior. The study’s findings show how the decisions and choices made by the women in this study are shaped by the socio-cultural context in which they are made.     

BEHAVIORAL TREATMENT FOR PATHOLOGICAL GAMBLING IN PERSONS WITH ACQUIRED BRAIN INJURY

The present investigation examined a behavior‐analytic clinical treatment package designed to reduce the pathological gambling of 3 individuals with acquired brain injury. A prior history of pathological gambling of each patient was assessed via caregiver report, psychological testing, and direct observation of gambling behavior. Using an 8‐week one‐on‐one client—patient format, a treatment program was developed in which the patient learned about the antecedents, consequences, and motivating operations that controlled the emission of gambling behavior. Data were collected on both self‐report of gambling urges and behavior following therapy and during in situ gambling opportunities. The therapy program reduced urges to gamble and actual gambling for all patients. The potential of behavior‐analytic therapy for reducing the pathological gambling of patients with and without brain injury is discussed.     

Psychological Factors that Promote and Inhibit Pathological Gambling

This paper describes qualitative data regarding psychological factors that may affect gambling behavior among treatment-seeking pathological gamblers. Participants (n = 84) diagnosed with pathological gambling were treated in a clinical trial examining the efficacy of cognitive behavioral therapy (CBT). Qualitative data were collected from participants during each of 8 structured CBT sessions. Specific gambling-related psychological factors that were assessed include triggers, consequences, high-risk situations, craving experiences, assertiveness skills, cognitive distortions, and coping strategies. The most commonly reported triggers for gambling were lack of structured time and negative emotional state, which were similar to the high-risk times for gambling. The most frequently listed positive consequences of gambling were enjoyment associated with winning and use of gambling as an escape. Negative consequences of gambling included depressed mood, financial problems, and conflict with family. Coping strategies changed during treatment, as participants reported relying less upon avoidance and distraction, and became better able to utilize support networks and cognitive coping skills. These data are important to better understand the factors associated with the development, maintenance, and cessation of pathological gambling.     

A comparison of individual and group cognitive-behavioural treatment for female pathological gambling

The current study aimed to determine the differential efficacy of a cognitive-behavioural treatment program for female pathological gamblers delivered in individual and group format. Fifty-six female pathological gamblers with electronic gaming machine gambling problems were randomly assigned to the control (waiting list) group or one of the treatment groups (individual or group treatment). Treatment comprised a 12-session program including financial limit setting, alternative activity planning, cognitive correction, problem solving, communication training, relapse prevention, and imaginal desensitisation. Treatment outcome was evaluated with conceptually related measures within the areas of gambling behaviour and psychological functioning. While individual and group treatment formats generally produced comparable outcomes in terms of gambling behaviour and psychological functioning, group treatment failed to produce superior outcomes to the control group in relation to several measures of psychological functioning. Moreover, by the completion of the six-month follow-up, 92% of the gamblers allocated to individual treatment compared with 60% allocated to group treatment no longer satisfied the diagnostic criteria for pathological gambling. These findings suggest that some caution should be employed when delivering cognitive-behavioural treatment in a group format until further research is conducted to establish its efficacy.     

Internet-Based Treatment of Pathological Gambling with a Three-Year Follow-Up

Effective therapies for pathological gambling exist, but their use is limited to about 10% of the target population. In an attempt to lower the barriers for help, Internet-based cognitive behavioural therapy (ICBT) has been shown to be effective when delivered to a non-depressed sample with pathological gambling. This study sought to extend this finding to a larger, more representative population, and also test a model to predict responder status. Following advertisement, a total of 284 participants started an 8-week ICBT programme with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. The average time spent on each participant, including telephone conversations, e-mail, and administration, was 4 h. In addition to a mixed effects model to evaluate the effectiveness of the treatment, two logistic regression analyses were performed with the following eight pre-defined response predictor variables: work-life satisfaction, primary gambling activity, debts due to gambling, social support, personal yearly salary, alcohol consumption, stage of change, and dissociative gambling. ICBT resulted in statistically significant reductions in the scores of pathological gambling, anxiety, and depression as well as an increase in quality of life compared to pre-treatment levels. Follow-ups carried out in the treatment group at 6, 18, and 36 months indicated that treatment effects were sustained. Using the eight predictor variable model rendered an acceptable predictive ability to identify responders both at post-test (AUC = .72, p < .01) and at 36-month follow-up (AUC = .70, p < .01). We conclude that ICBT for pathological gamblers, even if depressed, can be effective and that outcome can partly be predicted by pre-treatment characteristics.     

Cognitive treatment of pathological gamblers

This study evaluates the efficacy of a cognitive treatment for pathological gambling. Five pathological gamblers were treated in a multiple baseline across subjects design. Cognitive correction targeted the erroneous perceptions towards the notion of randomness. Four subjects reported a clinically significant decrease in the urge to gamble, an increase in their perception of control, and no longer met the DSM-IV criteria for pathological gambling. Therapeutic gains were maintained at the 6 month follow-up. Results suggest that cognitive therapy targeting the misconception of the notion of randomness is a promising treatment for pathological gambling, a refractory disorder to most therapeutic interventions.     

Is control a viable goal in the treatment of pathological gambling?

According to a report of National Gambling Impact Study Commission (National Gambling Impact Study Commission (1999). Final report. Washington, DC: Government Printing Office.), 97% of problem gamblers in the United States do not seek treatment. Within the small proportion of problem gamblers who enter into treatment, a high percentage drops out. Despite the fact that some researchers argue against abstinence as the only acceptable treatment goal and that regaining control over gambling behaviour appears to be possible for some pathological gamblers (PG), abstinence has been the only gambling intervention treatment goal. The primary goal of this study was to verify whether controlled gambling is a viable goal for pathological gamblers. The second goal was to identify the characteristics that predicted a successful outcome for treatment with a controlled gambling goal. Eighty-nine PGs were enrolled in cognitive-behavioural treatment aimed at controlled gambling. Six and twelve month follow-ups were conducted in order to evaluate the maintenance of therapeutic gains and to identify significant predictors of successful controlled gambling. Results showed that using the intent-to-treat procedure, 63% had a score of 4 or less on the DSM-IV at the end of treatment. That proportion was 56% and 51% at the 6- and 12-month follow-ups. If we retain only those who completed the treatment, these proportions increased to 92%, 80% and 71% at post-treatment, 6- and 12-month follow-ups, respectively. On the majority of the measures, significant improvements were found at post-treatment and the therapeutic gains were maintained at the 6- and 12-month follow-ups. However, few variables were identified to predict who would benefit from control rather than abstinence. The clinical and philosophical implications of these results are discussed in this paper.