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Section 17
Psychological Treatment for Pathological Gambling

Question 17 | Test | Table of Contents

Helping problem gamblers
The treatment of compulsive gambling also resembles substance abuse treatment.Widely used methods include psychodynamic therapy, 12-step groups, motivational interviewing, and cognitive-behavioral therapies, often in combination. Psychodynamic therapists regard the gambling compulsion as a symptom or expression of an underlying psychological condition, often one with roots in childhood. The therapist tries to help the patient understand and confront this problem. One psychodynamic theory is that gamblers want to lose in order to punish themselves for guilty feelings. Other analysts have treated compulsive gambling as an attempt to ward off depression or as the result of narcissistic feelings of omnipotence.

Gamblers Anonymous, a 12-step group modeled on Alcoholics Anonymous, provides the most widely used treatment in the United States. Costing practically nothing and available everywhere (there are more than 1,000 chapters), it’s routinely recommended by professional therapists. Members acknowledge that they are powerless over the habit and try to heal themselves with the help of other group members and trust in a higher power. In confessional meetings,members tell stories of their addiction and confront the consequences of their behavior. They are asked to admit their failures, make amends to persons they have harmed, and carry the message to others. Sponsors (experienced members serving as mentors) offer advice and support.

Motivational interviewing is aimed at promoting readiness to change— and a commitment to treatment— by exploring and resolving mixed feelings. Avoiding aggressive confrontation, argument, labeling, blaming, and direct persuasion, the interviewer supplies empathy and advice, while helping compulsive gamblers define their goals. The emphasis is on promoting freedom of choice and encouraging confidence in the ability to change.

Behavioral therapists concentrate on eliminating the incentives for gambling and the external conditions and internal states that stimulate the urge to gamble. The incentives—reinforcements or rewards—include the thrill of the game, the exhilaration of winning, escape or distraction from everyday problems, and avoiding the shame of losing. Payoffs in gambling come occasionally and largely at random.

Psychological experiments show that behavior sporadically rewarded is particularly difficult to eliminate even when the rewards are withdrawn — one reason for the development of addiction.At the same time, the sights, sounds, and physical sensations and even moods and feelings associated with gambling begin to provoke an almost automatic response that leads to more gambling.

To unlearn this conditioned learning, patients identify, record, and try to avoid situations and feelings that provoke the urge to gamble. They may be taught to distance themselves from gambling spots, specialize in a particular kind of betting, set aside money not to be gambled, or do something practical with winnings, such as making mortgage payments. Some gamblers have themselves put on a list to be banned from casinos. In imaginal desensitization, gamblers contemplate betting scenarios while remaining physically relaxed instead of submitting to the craving. In covert sensitization, they are guided through scenarios in which, say, they are discovered embezzling by an employer or threatened by a loan shark.

Meanwhile, cognitive therapy may change their thinking. The aim is to clarify and alter underlying ideas about the world, the self, and the future—delusions of control, superstitions about chance and fate, selective recall of winnings, belief in special skill. Cognitive therapists teach compulsive gamblers to regard gambling as an expensive form of entertainment rather than a moneymaking venture.

In the family of a compulsive gambler, unpaid bills, constant argument, and chronic lying create anxiety, distrust, and conflict. Couples or family therapy may help, and family members can also get help for themselves through the mutual aid group Gam-Anon, which is modeled on Al-Anon.

Medication is not used much in the treatment of problem gambling, and there are few controlled or long-term studies of its effectiveness. In a couple of studies, the opiate antagonist naltrexone has been found to reduce gambling urges. Because of parallels between gambling and compulsive behavior, some have suggested the use of selective serotonin reuptake inhibitors (Prozac and related drugs). But antidepressants and other drugs are prescribed to gamblers mainly for associated mood disorders.

Effectiveness of treatment
Although some treatment is almost certainly better than none, little is known about which treatments work best for which gamblers. There are few randomized controlled trials. Behavioral and cognitive therapies, which have been studied most carefully, seem to be effective for some, at least in the short run. One study found that motivational interviewing plus a mailed self-help workbook was more effective than the workbook alone or assignment to a waiting list. The advantage persisted for six months, but no longer.

Gamblers Anonymous, like Alcoholics Anonymous, has undoubtedly transformed some lives, but the dropout rate is high, and it’s not clear how much the confessional meetings help the general run of people with gambling problems. In one study, only 8% of members had achieved abstinence for a year or more. Besides, many gamblers want to return to controlled betting instead of the abstinence required by Gamblers Anonymous principles.

The future: Needs and proposals
The 1999 National Gambling Impact Study Commission report recommends more research on how to encourage compulsive gamblers to seek treatment and how to help their families. The Commission also calls for more study of the connections between gambling, mood disorders, and alcoholism; the effects of gambling on bankruptcy, suicide, divorce, and crime rates; and the new problems created by electronic and Internet gambling.

Like alcoholism and drug addiction, pathological gambling is a social problem that demands more than individual therapeutic solutions.  Most states have councils on compulsive gambling and set aside some gambling revenues for treatment, prevention, and education. Many authorities now believe stricter regulations are needed, especially on marketing, promotion, credit availability, and access by adolescents.

Some high schools have introduced programs in which adolescents are warned about manipulation by the gaming industry and educated about legal issues, myths of chance and probability, and ways to recognize when gambling is out of control.

The National Gambling Impact Study Commission’s report recommended more public awareness, education, and prevention programs for both adolescents and adults. The Commission suggested that legal gambling facilities be required to state a policy on the problem of pathological gambling and train their management and staff to recognize and discourage it.

Specialized gambling counselors are certified through the National Gambling Counselor Certification Board and the American Academy of Health Care Providers in the Addictive Disorders, but payment is not always covered by insurers and health maintenance organizations. Pathological gambling was not officially listed as a psychiatric disorder until the 1980s, and some think that even 20 years later, it has not gained the public and professional recognition it deserves.

Pathological gambling involves five or more of the following:
• Preoccupation with past, present, and future gambling experiences and with
ways to obtain money for gambling.
• Need to increase the amount of wagers.
• Repeated unsuccessful efforts to cut back or stop.
• Becoming restless or irritable when trying to cut back or stop.
• Gambling to escape from everyday problems or to relieve feelings of helplessness,
anxiety, or depression.
• Trying to recoup immediately after losing money (chasing losses).
• Lying about gambling.
• Committing illegal acts to finance gambling.
• Losing or jeopardizing a personal relationship, job, or career opportunity
because of gambling.
• Requesting gifts or loans to pay gambling debts.

Harvard Mental Health Letter. (2004, March). Problem gambling. 20(9), 1-4.


Personal Reflection Exercise #10
The preceding section contained information effectiveness of treatment for pathological gambling.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Treatment for Problem Gambling
and Counselors' Perception
of their Clinical Competence:
A National Web Survey in Sweden

- Månsson, V., Samuelsson, E., Berman, A. H., & Nilsson, A. (2022). Treatment for problem gambling and counselors' perception of their clinical competence: a national web survey in Sweden. Addiction science & clinical practice, 17(1), 70. https://doi.org/10.1186/s13722-022-00347-w

Peer-Reviewed Journal Article References:
Green, K. E., Archey, M. L., & Barton, O. R. (2018). Evaluating biofeedback training in conjunction with a cognitive–behavioral intervention for adults with impulse control deficits: A pilot study. Practice Innovations, 3(2), 123–137.

Petry, N. M., Ginley, M. K., & Rash, C. J. (2017). A systematic review of treatments for problem gambling. Psychology of Addictive Behaviors, 31(8), 951–961.

Pfund, R. A., Peter, S. C., McAfee, N. W., Ginley, M. K., Whelan, J. P., & Meyers, A. W. (2021). Dropout from face-to-face, multi-session psychological treatments for problem and disordered gambling: A systematic review and meta-analysis. Psychology of Addictive Behaviors. Advance online publication.

Pfund, R. A., Peter, S. C., Whelan, J. P., Meyers, A. W., Ginley, M. K., & Relyea, G. (2020). Is more better? A meta-analysis of dose and efficacy in face-to-face psychological treatments for problem and disordered gambling. Psychology of Addictive Behaviors, 34(5), 557–568.

QUESTION 17
What factor may hinder the effectiveness of Gambler’s Anonymous? To select and enter your answer go to Test.

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