conceptualizing and treating pathological gambling · community have a history of alcohol abuse or...

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Conceptualizing and Treating Pathological Gambling: A Motivationally Enhanced Cognitive Behavioral Approach

Edelgard Wulfert and Edward B. Blanchard, Universi ty at Albany, State Universi ty o f N e w York Rebecca Martell, Center f o r Problem Gambling, Albany, N Y

The field of pathological gambling is in its infancy. In this pap~ we describe cognitive and behavioral models and treatment approaches to pathological gambling. We conclude that, based on controlled outcome research, cognitive behavioral therapies are among the more promising interventions. Howev~ these interventions seem to pay insufficient attention to motivational factors and are marred by high attrition rates. As a possible remedy, we propose a motivationally enhanced cognitive behavioral intervention to increase pathological gamblers' engagement in, and commitment to, the treatment process. We present a case report to illustrate this intervention.

T HE UNITED STATES is in an era of widespread legal- ized gambling, which has resulted in a burgeoning

industry. With the proliferation of lotteries, casinos, off- track-betting (OTB) locations and other gaming opportunities, Americans wager increasing sums of money every year. To illustrate, in 1974 people spent an estimated $17 billion on gambling (Kallick, Suits, Dielman, & Hybels, 1979). By 1992, this amount had increased nine- teenfold to roughly $330 billion (Christiansen, 1993), and within the following decade it rose to $551 billion a year (National Research Council, 1999). Although most people gamble for social or recreational purposes and wager only small amounts, an association has been noted between the increased gambling opportunities and a rise in pathological gambling (Ladouceur & Walker, 1996; Volberg, 1994, 1996). Available meta-analytic data suggest that roughly 1% of adults in the U.S. and Canada currently meet criteria for pathological gambling and an additional 3% are problem gamblers (Shaffer, Hall, & Bilt, 1997). Concerns have therefore been expressed that pathological gambling may be developing into a serious public health problem.

Clinical Features That D e f i n e Pa tho log i ca l Gambl ing

Pathological gambling was first recognized as a sepa- rate diagnostic entity in 1980. In the current version of the Diagnostic and Statistical Manua l of Mental Disorders (DSM-IE, American Psychiatric Association, 1994), it is classified under the rubric of impulse control disorders.

Cognitive and Behavioral Practice 10, 61-72, 2003 1077-7229/03/61-7251.00/0 Copyright © 2003 by Association for Advancement of Behavior Therapy. All fights of reproduction in any form reserved.

However, judged by the 10 criteria that define pathological gambling (5 of which must be met to warrant a diag- nosis), the problem appears conceptually more similar to an addictive disorder such as alcoholism or drug dependence. Specifically, pathological gamblers are preoccu- pied with gambling (studying the paper, following a system) and use it as a means to escape from problems. Their excessive involvement with gambling leads to di- minished role performance (neglecting family or work obligations) and results in loss of control ("chasing" losses with increasingly risky bets to combat dysphoria), tolerance (wagering increasing amounts of money or taking greater risks to achieve the desired excitement), withdrawal-like symptoms (restlessness and irritability when attempting to cut down or stop), and repeated, unsuccessful attempts to quit (National Research Council, 1999; Winters, Bengston, Door, & Stinchfield, 1998).

Pathological gambling differs from social or recreational gambling not only quantitatively but also qualita- tively. The vast majority of people gamble for entertain- ment and do not risk more than they can afford (Shaffer et al., 1997). In contrast, pathological gamblers engage in self-destructive and reckless actions that generate adverse consequences for themselves and those around them. They manipulate others, deplete family resources, and sometimes steal or embezzle money to generate the resources needed to satisfy their addiction. Many harbor suicidal thoughts or make attempts to take their own lives (Blaszczynski & Farrell, 1998; Frank, Lester, & Wexler, 1991; Ladouceur, Dube, & Bujold, 1994). At the same time, most pathological gamblers are intrinsically ambivalent and resist giving up gambling in spite of the adverse consequences that result from their behavior.

Another characteristic of pathological gambling is its high psychiatric comorbidity, especially with substance use disorders and mood disorders (Black & Moyer, 1998;

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Crockford & el-Guebaly, 1998; Feigelman, Wallisch, & Lesieur, 1988; Linden, Pope, & Jonas, 1986; Specker, Carlson, E d m o n d s o n , J o h n s o n , & Marcotte, 1996). To illustrate, research has shown that between 19% and 50% of persons in t r ea tment for pathological gambl ing and 45% to 63% of pathological gamblers residing in the communi ty have a history of alcohol abuse or dependence (Slutske et al., 2000). Psychiatric comorbidity among pathological gamblers may be associated with greater severity of gambl ing (Ibanez et al., 2001), which may have impor tan t implicat ions for t reatment .

W h y Do Patho log ica l Gamblers Gamble?

We do not have a good under s t and ing of the etiological factors involved in pathological gambling. The litera- ture is reple te with compet ing etiological models that include spiritual, medical , and biological accounts, psy- chodynamic models, and behavioral or cognitive behavioral conceptual izat ions (for a review, see Nat ional Re- search Council , 1999; also Taber, 1987). In their majority, these models are variants of those developed to explain o the r addictions.

While potent ia l genetic or biological contr ibut ions to addictive behaviors have been receiving increased attention, it is important to understand that epigenetic events are probabilistic (Gottlieb, 1992). In other words, some individuals may have inheri ted a set of behavioral potentials for pathological gambling; but whether these potentials become actual ized depends on the effects of specific life exper iences (Kuo, 1967). To u nde r s t and pa thologica l gambl ing it is therefore essential to look beyond biology and examine crucial environmental , in terpersonal , and in t rapersona l factors. For the pu rpose of the p resen t paper, we will l imit our presenta t ion to behavioral and cognit ive behaviora l conceptua l iza t ions that are backed by research and enjoy some empir ical suppor t (Lopez Viets & Miller, 1997).

Behavioral Models One of the leading con tempora ry psychological ap-

proaches, behavior theory, explains how gambl ing behavior is shaped and ma in ta ined by winnings del ivered on variable ratio (VR) schedules of r e in fo rcement (Knapp, 1998; Schwartz, 1992). As the probabi l iw of reinforce- men t on VR schedules remains identical across trials, it is impossible to predic t when a bet will pay off. For this reason, VR s c h e d u l e s - - m o r e than o t h e r schedules of r e i n f o r c e m e n t - - p r o d u c e behavior that is very persistent and difficult to change (Knapp). The behavior becomes even more resistant if, by mere chance, a gamble r wins large sums of money early in his or he r gambl ing career because large re inforcements fur ther increase persistence (Rachlin, 1990).

Given that pun i shmen t should suppress ra ther than sustain behavior, how can a re inforcement-based mode l explain that gamblers persevere in the face of heavy losses? Three reasons have been cited to account for this appa ren t paradox. One is the br ief thrill of "coming close" to winning the j a c kpo t when seeing two 7s on a slot machine , even though hope quickly vanishes when the third 7 fails to appear. (Parenthetically, some slot machines are p r o g r a m m e d to yield "near misses" more often than chance to keep gamblers playing at no extra cost to the casino; National Research Council, 1999). A second reinforcement effect comes from autonomic arousal ("excite- m e n t ' ) associated with gambl ing (Blanchard, Wulfert, Fre idenberg , & Malta, 2000; Brown, 1987; Hart ley & Wulfert, 2001; Sharpe, Tarrier, Schotte, & Spence, 1995; Walker, 1992). Winnings elicit exc i tement that general- izes to contextual stimuli; the arousal associated with the expecta t ion of winning reinforces behavior on losing trials. Finally, pathological gambl ing may also be fueled by negative re in forcement contingencies. A subset of individuals with addictive disorders engage in the behavior p redominan t ly to seek rel ief from stressful or painful experiences (Wulfert, Greenway, & Dougher, 1996). There- fore, some forms of pathological gambling may be shaped and main ta ined by the exc i tement associated with gambl ing if it becomes a means for the individual to cope with, or escape from, aversive i n t e rpe r sona l or intrapersonal events.

Cognitive Accounts From a cognitive perspective, excessive gambl ing is

thought to be med ia ted by cognitive biases (Ladouceur, Boisvert, & Dumont , 1994; Sylvain, Ladoucem, & Bois- vert, 1997). Biases in the form of i r rat ional or supersti- tious beliefs result when cont ingencies not only reinforce gambl ing behavior but also temporal ly cont iguous cognitions. O the r cognitive biases stem from the h u m a n ten- dency to ignore basic statistical concepts (base rates, re- gression to the mean, the conjunct ion pr inciple) while relying on j u d g m e n t a l heuristics (salience, availability, representat iveness) , as social cognitive psychologists have aptly demons t ra ted (e.g., Nisbett & Ross, 1980; Tversky & Kahneman, 1982). Regardless of their origin, cognitive biases can functionally be viewed as self-rules (Zettle & Hayes, 1982) and as such they may come to media te decisions. For example , gamblers temporal ly d iscount losses and cognitively frame their bet t ing activities in strings, with each string end ing after a win. Thus, in their subjec- tive exper ience, "persistence leads to winning," a l though the game objectively has a negative rate of re turn (Rach- lin, 1990).

The h u m a n mind also tends to impose pat terns and sequences on unrelated events (Wagenaar, 1988). This bias has come to be known as the gambler 's fallacy (Yackulic &

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Pathological Gambling 63

Kelly, 1984). In roulette, for example, most people believe that after several black numbers a red number is more likely to come, although each trial is independent and the probabilities for red and black remain constant across trials. Another bias, termed the illusion of control (Langer, 1975), refers to the belief that random events can be influenced to achieve a desired outcome. The gaming industry capitalizes on this bias by giving games of chance the trappings of skill-based events. Examples are presenting lotto players with a choice between random picks versus selecting their own numbers; equip- ping slot machines with levers to give the illusion that the wheel can be influenced by lever pulls; or offering casino games with complex features (roulette, craps, blackjack) to give the impression that outcomes depend on strategic decisions.

Summary Scholars agree that no currently available model suf-

fices to fully describe why some individuals turn into pathological gamblers (Shaffer & Gambino, 1989), but few would deny that experience and learning factors play a significant role. Viewed from a cognitive behavioral perspective, pathological gambling emerges from a complex history of reinforcement. Contingencies not only shape behavior but also psychological reactions and gambling- specific cognitions including expectations, cognitive biases, and irrational beliefs about the outcomes of chance events. These cognitions may come to function as "rules" or "self-rules" that mediate environmental inputs and make behavior insensitive to the actual contingencies (for a synopsis of rule-governed behavior, see Catania, 1998; also Wulfert, 1993, and Zettle & Hayes, 1982). In other words, pathological gamblers follow their beliefs and expectancies more than the actual outcomes of their wagers. As rule following is intermittently reinforced by payoffs, such rules are difficult to disconfirm and therefore tend to be followed for long periods of time.

Cognitive and Behavioral Treatments of Pathological Gambling

A useful explanatory model in psychopathology not only increases the theoretical understanding of a disorder but also guides treatment development by identifying relevant maintaining factors of the problem behavior. Cognitive and behavioral accounts of pathological gambling have served this function well (for a comprehensive cognitive behavior theory of pathological gambling, see Sharpe & Tarrier, 1993). Empirical and theoretical efforts carried out in these traditions have led to the identification of various factors presumably involved in pathological gambling, including environmental triggers (receiving a pay check, money pressures, gambling advertisements),

interpersonal problems (conflict, family pressures), and intrapersonal variables (cognitive biases, negative mood states, heightened arousal and excitement). A number of these presumed causative factors have been successfully targeted in intervention studies (e.g., Echeburua, Baez, & Fernandez-Montalvo, 1994, 1996; McConaghy, Armstrong, Blaszczynski, & Allock, 1983; McConaghy, Blaszczynski, & Frankova, 1991; Sylvain & Ladouceur, 1992; Sylvain et al., 1997). Significant decreases in pathological gambling have been reported as a function of correcting gambling- specific erroneous cognitions (e.g., Sylvain et al.), expos- ing gamblers in vivo or in imagination to eliciting and dis- criminative stimuli while preventing gambling (e.g., Brent & Nicki, 1997; Echeburua et al., 1996), decreasing arousal to gambling cues through cognitive behavior therapy (Freidenberg, Blanchard, Wulfert, & Malta, 2002), or less- ening the appetitive quality of gambling through procedures such as relaxation training or aversive conditioning (e.g., McConaghy et al., 1991). Although much more research is needed, these studies lend some preliminary support to the effectiveness of cognitive and behavioral interventions for the treatment of pathological gambling.

Unfortunately, the usefulness of cognitive behavioral interventions seems somewhat compromised by high attrition and recidivism rates. In most studies cited above, the refusal and dropout rates ranged from 25% to 50%. To illustrate, Echeburua and colleagues (1996) randomly assigned 64 compulsive slot machine players either to behavior therapy, group cognitive restructuring, a com- bined treatment, or a wait list. Fourteen (22%) of the research participants dropped out and 15 (23%) relapsed during follow-up. In a study by McConaghy and colleagues (1991), only 63 (53%) of 120 gamblers treated with desensitization, relaxation, aversion, or exposure could still be contacted at 12-month follow-up. In a ran- domized controlled trial by Sylvain et al. (1997), only 29 (52%) of 56 gamblers--mostly video poker players-- who were assessed and found to be eligible for the study decided to enter treatment. Fourteen of those were ran- domized to cognitive behavior therapy and 15 were placed on wait list. Twelve months later, only 9 gamblers from the treatment group (64%) could still be contacted, 8 of whom were abstinent or improved.

These data, discouraging as they might seem, should not be construed as an indictment of cognitive or behavioral interventions because the studies uniformly show that a significant number of gamblers who complete treatment do benefit. However, the high dropout rates suggest that many pathological gamblers are ambivalent about treatment and apparently waver in their commitment to change. It is therefore reasonable to conclude that insufficient attention may be paid to these motivational fluctuations, which may then translate itself into higher attrition rates and treatment failures.

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The Role of Motivation in the Treatment of Addictive Behaviors

Behavioral scientists have long acknowledged that ambivalence about change is the no rm ra ther than the ex- cept ion for persons struggling with an addict ion. Addic- tive behaviors inc luding pathological gambl ing are, by their very nature , at once intensely rewarding and enor- mously costly (Shaffer, 1997). The ensuing a p p r o a c h - avoidance conflict makes it difficult for individuals to extr icate themselves from the addic t ion because their motivat ion to change waxes and wanes.

To be t te r unde r s t and the motivat ional dynamics of the recovery process, inc luding the ambivalence that is typical for persons with an addictive disorder, Prochaska and DiClemente have s tudied smokers, a lcohol abusers, and drug users. Gu ided by these empir ical observations, they fo rmula ted a transtheoretical model of change (Prochaska & DiClemente , 1982; Prochaska, DiClemente, & Norcross, 1992; Prochaska et al., 1994). Accord ing to this model , the add ic ted individual cycles back and forth th rough dif- ferent stages of readiness to change that range from pre- con templa t ion (I don't have a problem) to con templa t ion (Maybe I do have a problem), prepara t ion (I am going to cha~ge), act ion (quitting), and main tenance or relapse. As it is difficult for pathological gamblers to reconci le the ra- t ionally derived need to change with their s t rong desire tbr the exc i tement associated with gambling, it is easy to see how thei r readiness to change fluctuates.

A second line of evidence for motivat ional ambivalence is that addic ted persons rarely seek t rea tment vol- untari ly (Donovan & Rosengren, 1999). This is also the case with pathological gamblers as it often takes external pressures (e.g., from a spouse, an employer, or the law) to he igh ten their initial awareness that their behavior is problemat ic . When such clients first en te r counseling, they tend to resist change. However, research has shown that it is possible to engage resistant clients in the treat- men t process th rough an approach that has been t e rmed motivational interviewing (Miller & Rollnick, 1991). This app roach is conceptual ly derived from Prochaska and DiClemente ' s (1982) stages-of-change model . Its central tenet is that the therapis t must engage clients in treat- men t by mee t ing them at their cur ren t stage of readiness. This can be accompl ished by providing clients with personal ized feedback about the effects of their addictive behavior on their life in an empathic , nonconf ron ta t iona l therapeut ic style. In a nonjudginental therapeutic environ- ment, clients can evaluate their si tuation realistically and nondefensively, which often tips the motivat ional balance toward act ion and enhances their co m mi tmen t to change (Miller & Rollnick, 1991; Miller & Sovereign, 1989; Miller, Zweben, DiClemente , & Rychtarik, 1992).

Brief motivat ional in tervent ions have led to positive results with substance abusers in residential settings (Brown

& Miller, 1993) and outpat ient t rea tment (Project MATCH Research Group , 1997), with a lcohol-us ing p r e g n a n t women (Handmaker , Miller, & Manicke, 1999), and with cigarette smoking (Colby et al., 1998) and alcohol-using adolescents (Monti et al., 1999).

A Case for Motlvationally Enhanced Cognitive Behavior Therapy for Pathological Gambling

By conceptual iz ing pathological gambl ing as an addictive disorder, it becomes appa ren t that cognitive and behavioral intervent ions pe r se are likely no t sufficient without paying special a t tent ion to motivat ional factors. Most pathological gamblers are unders tandab ly ambivalent about re l inquishing an activity that has been their main source of satisfaction, even though it is also a source of great distress. Many hope they can scale back their gambl ing activities and exper ience the pleasure without the pain. Eventually they will come to the realization that they need to quit, bu t therapists who fail to unde r s t and the gambler ' s ambivalence and t ime their t r ea tment strategies incorrect ly will probably lose the cl ient in the process. Motivational interviewing may therefore be the "miss- ing link" to engage pathological gamblers in the t rea tment process and p repare them for cognitive behavior therapy.

Only one publ i shed study to date has examined the efficacy of a br ie f motivat ional e n h a n c e m e n t intervention in t reat ing p rob lem gamblers. Hodgins, Currie, and el-Guebaly (2001) assigned 102 self-identified p rob l em gamblers to one of three condit ions: a workbook-based self-help t rea tment e i ther with or without a br ie f motiva- t ional t e lephone interview and a wait-list control . The motivat ional e n h a n c e m e n t had an immedia te positive effect as after 1 mon th gamblers in the motivat ional condi t ion repor ted greater improvements than those in the o ther two groups. However, the initial effect dissipated over the 12-month follow-up per iod.

The Hodgins et al. (2001) study suggests that motiva- t ional interviewing a lone may be insufficient to sustain a lasting change in excessive gambling. We surmise that motivat ional interviewing as a therapist style ra ther than a t rea tment pe r se (Miller et al., 1992) might be the ideal supp lemen t to cognitive behavior therapy. As some research evidence suggests that cognitive behavior therapy is efficacious for gamblers who complete t r ea tment (e.g., Sylvain et al., 1997), adding motivat ional interviewing might significantly enhance t rea tment ou tcome by. en- gaging ambivalent clients in the t rea tment process and counterac t ing p rema tu re attrit ion.

Cognitive Motivational Behavior Therapy Based on this reasoning , we are in the process o f

deve lop ing and p i lo t test ing an in te rven t ion that com- bines critical e lements of Miller and Rollnick's (1991)

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motivat ional interviewing app roach with Ladouceur and col leagues ' (Sylvain et al., 1997) cognitive behavior therapy and Marlat t and Gordon ' s (1985) relapse prevent ion. A synopsis of this t r ea tment and a case example to illustrate the in tervent ion is p resen ted below.

Assessment. M1 clients are scheduled for an initial assessment with a t ra ined intake worker who conducts a s t ructured clinical interview and adminis ters several stan- dard ized quest ionnaires. We inform clients that the goal of this assessment is to obtain a t ho rough under s t and ing of their gambl ing habi t and genera l life si tuation and that the results of this assessment will be reviewed with them so that cl ient and therapis t toge ther can develop an effective t rea tment p rogram ta i lored to the client 's needs. The intake worker obtains extensive informat ion about the client 's background and gambl ing history (e.g., deve lopmen t of the problem, p re fe r r ed modes of gambling, dura t ion and intensity of gambl ing episodes, winnings and losses, family income and debt, means of fi- nanc ing the gambl ing habi t inc luding borrowing or ob ta in ing money illegally, consequences and impact of gambl ing on diverse life areas). If qualified, the intake worker can adminis te r the St ructured Clinical Interview for DSM-IV (SCID-I; First, Gibbon, Spitzer, & Williams, 1996) to assess comorb id Axis I disorders, part icularly substance abuse. A ques t ionnai re f rom the National Op in ion Research Council (NORC; 1999) known as the NORC DSM-1V Screen (NODS) may be used to diagnose gambl ing problems. O the r quest ionnaires are adminis- te red to obta in a quantitative index of gambl ing (South Oaks Gambl ing Screen, SOGS; Lesieur & Blume, 1987), and to assess depress ion (Beck Depression Inventory-II, BDI-II; Beck, Steer, & Brown, 1996) and anxiety (Depres- sion Anxiety Stress Scales, DASS, Lovibond & Lovibond, 1995; Antony, Bieling, Cox, Enns, & Swinson, 1998). The client 's motivat ion can be assessed with available ques- t ionnaires such as the University of Rhode Island Change Assessment (Prochaska et al., 1992) or a Likert-type readiness scale. The therapis t discusses the findings of the assessment with the cl ient and provides a written summary.

A second, abbreviated assessment is scheduled after the client completes three therapy sessions. The client completes the readiness scale. The Working Alliance Inventory by Horvath and Greenberg (1989) can also be useful. These measures assess the degree to which the client is motivated and engaged in t rea tment . Taking these measures early in t r ea tment has been shown to be more predict ive of outcome than la ter ratings (Horvath & Symonds, 1991; Sam- stag, Batchelder, Muran, Safran, & Winston, 1998).

Finally, at the end of t rea tment , BDI-II, NODS, SOGS, and STAI are readmin is te red to obta in t r ea tment outcome data. These are also used for follow-up assessments.

Motivational enhancementphase. The initial phase of our t rea tment is spread over the first two to three sessions

with the in tent to achieve two goals: bu i ld ing motivat ion for and s t rengthening c o m m i t m e n t to change by using the five basic pr inciples of motivat ional interviewing (ex- pressing empathy, developing discrepancy, avoiding argu- menta t ion , rol l ing with resistance, and suppor t ing self- efficacy). (The r eade r unfamil iar with motivat ional interviewing is re fer red to Miller & Rollnick, 1991, or Miller et al., 1992.)

The therapis t provides the cl ient with a summary of the results of the assessment that serve as feedback. Fol- lowing Miller and Rollnick's (1991) r ecommenda t ions , the therapis t uses empath ic and reflective s tatements and presents the informat ion in an objective, non judgmen ta l way ("Your assessment results suggest that only about 1% to 2% of adults obta in scores equal to or h igher than you. What do you think about this? .... The informat ion you provided indicates that you have spent 38% of your ne t income on gambl ing dur ing the past year. Does this surprise you?"). The goal is to prevent defensiveness and to he igh ten the discrepancy between what is and the client 's narrative that may be co lored by denia l and minimizat ion. Together therapis t and client explore the satisfaction the cl ient has derived f rom gambl ing and the impact gambl ing has had on various areas of the client 's life ("Tell me a little more about your gambling. What do you like about it? What 's positive for you?" "Tell me what's the o ther side? What don ' t you like so much about your gambling?") .

By apprais ing and weighing the positive and negative consequences of the excessive behavior, the therapis t makes the cl ient aware of the ambivalent feelings associated with giving up gambl ing ("So you really want to make some changes, and at the same t ime it's ha rd for you to th ink that you would never go to the races again"). By developing greater awareness, the client usually begins to emi t self -motivat ional s ta tements and expresses a desire to change. The therapis t uses the concerns el ici ted from the cl ient as the basis for negot ia t ing a change plan ("Where does this leave you now? Wha t would you like to do?").

Developing a t rea tment plan with realistic change goals is a collaborative effort between cl ient and therapist. When formula t ing the plan, the therapis t consis- tently communica tes an impor t an t message that it is the client 's responsibil i ty and choice to change or cont inue as before ("It's up to you what you want to do"; "I canno t change your gambl ing for you"; "Only you can do it"). To- gether, therapis t and cl ient ga ther informat ion on the changes the cl ient wants to make, the reasons for these changes, the steps n e e d e d to accomplish change goals and ways to recognize when the goals are or are no t being met. The therapist writes this informat ion down on a Change Plan Worksheet (Miller et al., 1992) and the cli- en t then makes a formal commi tmen t to follow the treat- men t plan.

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It should be no ted that not all gamblers choose abstinence as a goal. Some clients do not want to quit but simply learn to control their gambling. Al though our philos- ophy is that total abs t inence is the safest choice, we do not impose this goal on clients. Instead, we suggest that the cl ient make a t ime-l imited c ommi t men t and try. a pe- r iod of abst inence to f ind out what it is like to break an old habi t and live without gambling. ("The goal is totally up to you. However, it has been our exper ience that a pe r iod of comple te abst inence works really well for most people . It 's a safe choice and gives the person t ime to ex- pe r i ence what life is like without gambling. Would you be willing to give it a try?") If the cl ient is adama n t about not giving up gambl ing entirely, we ask him or he r to develop a change plan with specific limits and parame- ters (e.g., l imit ing the f requency of gambl ing and the amounts wagered, and openly discussing this p lan with the cl ient 's spouse or significant o ther ) . We also agree on emergency p rocedures the cl ient follows when the plan fails (e.g., cal l ing the therapist , agree ing to abstinence as a goal if the cl ient cannot mainta in the self- imposed limits).

Cognitive behavioral treatment phase. Once the gamble r has commi t t ed him- or herself to a specific t rea tment plan, the behavior change phase is initiated. It is mode led after Sylvain et al.'s (1997) cognitive behavioral treat- men t and lasts anywhere from 8 to 15 sessions, depend- ing on the client 's needs and the severity of his or he r gambl ing prob lem. It should be no ted that, a l though this t r ea tment phase is devoted to cognitive res t ructur ing and behavioral p rob lem solving, the therapis t retains a motivational inteiMewing style. The therapis t refrains from lectur ing or forceful persuasion and provides information in an objective, compassionate , and non judgmenta l way that allows clients to realize the extent of their gambl ing p rob lem for themselves.

Therapis t and client begin to review situations in which the cl ient tends to gamble. The therapist then helps the cl ient to unde r s t and the difference between risk situations and triggers for the gambl ing behavior by having the cl ient descr ibe in detail a typical gambl ing sit- uat ion, inc luding the envi ronment , people involved, and any thoughts and feelings present before, during, and after the gambl ing episode. Risk situations are circumstances that provide the oppor tun i ty and motivation for gambl ing (e.g., an u p c o m i n g big race, feel ing bo red or lonely, having a conflict with one 's spouse, having a pay- check in one 's pocket) . 7kiggers are problemat ic beliefs and cognitive biases occurr ing in these high-risk situations. They fuel the desire and directly lead to the gambl ing behavior:

I can feel it: This is my lucky day. It's a D. Wayne Lucas horse; it's gotta win.

This machine hash 't paid off all day long; it's bound to

pay off any minute now. I'll stop at OTB for jus t one race. It's a sure bet.

To illustrate how thoughts ra ther than situations get gamblers into trouble, the therapis t uses examples such as the following:

"hnagine that you and a f r iend are read ing in the pape r that a horse t ra ined by D. Wayne Lukas will run at Behnont today. You think, Surfside won twice in Saratoga and once at Belmont this year. He's got to win

this race. In contrast, your f r iend thinks, Surfside looks awfully good, but I wouldn "t bet my money, on him! The track is too sloppy and too many things can go wrong, t

So who do you think is more likely to place a b e t ? - Do you th ink the situation de te rmines whether a person will gamble; or might it be his beliefs and what he tells himself about the situation? What are your thoughts on this?"

According to Ladouceur (1999), one of the most crucial steps in the cognitive behavioral t r ea tment of pathological gambl ing is to help gamblers c o m p r e h e n d the difference between luck and chance. What clients view as "luck" are in fact the odds of a game de t e rmined by prob- ability. Using mul t ip le examples and in-session "experi- ments" (e.g., tossing a coin 100 times, having the cl ient predic t heads or tail, and writ ing down and analyzing the sequence of predic t ions) , the therapis t guides the cl ient toward an under s t and ing that games of chance, as op- posed to games of skill, are unpredictable (if you toss a fair coin, there is no way of knowing whether it's going to be heads or tails; the chance is 50:50) and uncontrollable

(noth ing that you th ink or do can influence the outcome) , and that each trial is independent (the coin has no memory; five tails in a row does not make it more likely that the next toss will result in heads) . In a game of skill (e.g., chess), the ou tcome can be inf luenced by knowl- edge, effort, and perseverance whereas in games of chance (e.g., slot machine) no th ing the gamble r thinks or does can affect the outcome. The only sure th ing is that the house always wins.

Often gamblers who be t on horses or o ther games with a skills c o m p o n e n t are not readily convinced that they can ' t "beat the odds." In these cases, the skilled therapist pat iently provides informat ion, using a Socratic dia- logue to educate the client. The idea here is to convey that, over all gamblers who be t on a given race, the rate of re turn is negative because roughly 18% of the money wagered goes to the racing association. Hence the individual horse race be t tor should expect to lose money in the long run. Even skilled hand icappers cannot p red ic t a race with reasonable certainty because chance factors p redomina te (e.g., the relative condi t ions of the horses

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and jockeys at the t ime of a race, the track condit ions, and sometimes even p rea r r anged outcomes) . Moreover, the bet t ing public is not privy to a host of relevant informat ion (e.g., the horses ' heal th on the day of the race, the shoes they are wearing, the jockey 's mood) . It is also impor t an t to unde r s t and that in a par i -mutuel system one can only attain substantial financial gains by bet t ing on horses with the best yield, not on favorites (irrespective of the fact that favorites only win one th i rd of the t ime). As pathological gamblers tend to minimize these facts, the therapis t persistently works to make clients aware of their e r roneous cognit ions until they begin to see their bet t ing activities in a more realistic light.

Ano the r impor t an t t r ea tment c o m p o n e n t is teaching pathological gamblers the behavior chain involved in excessive gambl ing (Ladouceur, 1999). Using the gambler ' s own experiences , the therapis t illustrates that excessive gambl ing is like a behavior chain: One link leads to the next and results in a vicious cycle of winnings and losses. Dur ing a winning streak, pathological gamblers do not stop gambling. Believing that "today's my lucky day!" they cont inue bet t ing until they eventually lose everything they have won and more. Dur ing a losing streak they chase their losses, p lac ing larger and riskier bets in an at- t empt to recupera te the money they have lost, and in the process they lose even more. To in te r rup t this vicious cycle, the therapis t encourages the cl ient to try a pe r iod of total abst inence to exper ience what it is like to live without gambling. The client makes a t ime-l imited commi tmen t to abst inence that can be ex t ended for ano the r pe r iod when the l imit has been reached. (If a cl ient is complete ly resistant to the idea of abst inence, the therapist proceeds as descr ibed above and assists the cl ient in the deve lopmen t of a change plan with realistic parame- ters and limits.)

Homework assignments are an impor t an t c o m p o n e n t of t rea tment . Between sessions, the cl ient keeps track of urges to gamble or actual gambl ing episodes and any thoughts that occur red before, dur ing, and after the gambling. In session, the therapis t encourages the cl ient to identify cognitive errors and biases expressed in these thoughts and to replace them with rat ional statements. As the gambler ' s way of th inking and behaving is deeply ingrained, this cor rec t ion p rocedure may have to be car- r ied out many times, but repe t i t ion will eventually cast doub t on the gambler ' s convictions. Once the gamble r fully comprehends the futility of wagering money on chance events, not only intel lectually but also exper ien- tially, often his or he r desire for gambl ing diminishes (Ladouceur, 1999).

Pathological gamblers, like o thers who suffer from addiction, t end to exper ience difficulties in a variety of life areas. Therefore , problem-solving skills t ra ining is par t of the cognitive behavioral t reatment . The therapis t helps

clients to conceptual ize their pa thologica l gambl ing as a l ea rned maladapt ive coping response in react ion to situ- ational, in terpersonal , or in t rapersonal pressures. Clients can choose to un lea rn this habi t and replace it with more adaptive p rob l em solving (e.g., how to solve conflicts; how to deal with d i sappoin tment , anger, or re ject ion more constructively) and assertiveness skills (e.g., how to refuse pressures to gamble) .

Relapse prevention phase. As r e c o m m e n d e d by Ladou- ceur (1999), we never end t rea tment without p repa r ing the cl ient for the possibility of a slip or relapse. Termina- t ion and relapse prevent ion (Marlatt & Gordon , 1985) are addressed in the last two sessions. Gambling-specific relapse prevent ion (Ladouceur) consists of he lp ing the cl ient to recognize events and apparent ly i rrelevant decisions that may lead to gambling. This can be the decis ion to visit an old gambl ing buddy ( ' lus t to see how he's doing") , to buy a racing form for an impor t an t u p c o m i n g race ("I jus t want to see who's running") , to drive by OTB ("It's the shor ter way home") , or to keep credi t cards or larger amounts of cash in one 's wallet ("in case I need to buy something") . We teach the cl ient coping strategies that equip him or he r to deal with difficult si tuations and resist temptat ion. One such strategy is "stop, look, and lis- ten": If you feel t empted to gamble, pause, look inside yourself, and identify what you are saying to yourself. Rec- ognize tr igger thoughts, d ispute them, and walk away from the temptat ion. The cl ient also receives a h a n d o u t with emergency procedures , start ing f rom "remain calm and remove yourself from the situation" to "call a hot l ine or your therapis t for help." At the conclusion of treat- men t the client makes a commi tmen t to re turn for booster sessions should a lapse occur.

Preliminary tests of this treatment in an uncontrolled series of case studies. We are current ly testing the jus t descr ibed t rea tment in col labora t ion with a local t r ea tment facility that serves pathological gamblers and their families. In an uncon t ro l l ed explora tory study, to date we have com- p le ted t r ea tment with n ine male pathological gamblers, mostly horse-race bet tors (Wulfert, Blanchard, Fre idenberg, & Martell, 2002). All men who en te red our program met DSM-1Vcriteria for pathological gambling. Pre- and pos t t rea tment SOGS and NODS scores on each of these clients are p resen ted in Table 1. However, it is impor t an t to keep in mind that our main concern has been to coun te r the high d r o p o u t rates typically found in treat- m e n t ou tcome studies and to retain clients in treatment. To date we have fully accompl ished this goal. All n ine clients who en te red t rea tment have comple t ed the active phase and are now in various stages of follow-up. Al though it is p r ema tu re to discuss the long-term outcomes of this small sample, approximate ly 6 months after t r ea tment seven gamblers no longer met DSM-IV criteria, with six be ing comple te ly abstinent. Of the r ema in ing two clients,

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68 Wulfert et al.

Table 1 Descriptive Information on Nine Pathological Gamblers Treated

With Cognitive-Motivational Behavior Therapy

Subject SOGS SOGS DSM DSM # Pre Post* Pre Post* Comorbid Axis I Diagnoses

1 16 1 9 1 MDD, dysthymia, alcohol and cocaine abuse

2 8 0 7 0 MDD, dysthymia, social phobia

3 18 1 8 3 MDD, marijuana abuse 4 20 9 8 5 None 5 9 0 7 1 None 6 12 0 8 1 Dysthymia, GAD 7 19 0 10 1 None 8 19 0 8 2 PTSD. PD, MDD 9 16 0 8 0 None

Note. SOGS = South Oaks Gambling Screen; DSM = Number of DSM-/Vdiagnostic criteria met (scale 0-10); MDD - major depres- sive disorder; GAD = generalized anxiety disorder; PTSD = post- traumatic stress disorder; PD = panic disorder * During past 3 months.

one has i m p r o v e d - - f r o m playing the horses five times a

week to gambling once a month or l e s s - - and one is a t rea tment failure. (Parenthetically, the latter is the only client who refused abstinence as a t reatment goal.) Al- though it would be premature to draw firm conclusions from this work in progress, we are encouraged by these prel iminary results. Not all clients benefited to the same degree from the intervention, which should surprise no one familiar with treating addictive behaviors; however; all clients were retained in t reatment and are con t inu ing in follow-up.

In the following brief case example, we illustrate how our t reatment interlinks motivational, cognitive, and behavioral strategies. The case can be viewed as typical inso- far as the problems presented by this client (involving marital, vocational, and recreational issues) frequently occur in the t rea tment of pathological gamblers.

Case Example The client, Mr. J., was a middle-aged married Cauca-

sian lab technician, He went for help to the Employee As- sistance Program (EAP) because his "life was out of control." He compulsively bet on horses and, over moun t ing financial pressures and marital problems, he had also begun to use alcohol and other substances with increasing frequency dur ing the past 6 months. The precipitating event for his appo in tmen t was that his wife and stepson had left him because of his gambling and substance abuse. The EAP officer referred Mr. J. for counseling.

Mr. J. was admit ted to our program and underwent a comprehensive psychological assessment. On a structured psychiatric interview he scored in the clinical range for

alcohol and cocaine abuse and met criteria for double depression: major depression precipitated by the separation from wife and stepson, superimposed on dysthymic disorder of 4 years' duration. The client had noticeable

suicidal ideation, but no plans, and claimed he d idn ' t care if he died because "there would be less aggravation for [his] family."

On the gambling-specific assessment Mr. J. scored 16 of 20 possible points on the SOGS and met 9 of 10 D S M -

/Vcriteria for pathological gambling. He had started serious gambling, primarily OTB, a round age 26 after get- ting married. Just 5 days prior to the assessment he had "the worst week ever," losing approximately $10,000 at the races. He spent 2 to 4 hours a day reading newspapers and racing forms and daily followed races on radio and cable TV. Aside from horse-race betting, Mr. J. regularly played card games and golf with friends, bett ing up to several hund r e d dollars per occasion. Mr. J. had an annual salary of $40,000 but was $65,000 in debt as he had borrowed $25,000 against his re t i rement account and he and his spouse had taken out $40,000 in addit ional loans.

During his first session, Mr. J. told his therapist that he had started substance abuse counsel ing and had not used alcohol or cocaine in 3 weeks. He said he needed to quit gambling but was not sure he could stop. The therapist validated Mr: J.'s decision to come to treatment and began to explore with him what he liked and disliked about his

gambling and why he thought he needed to stop. Mr. J. said he wanted to get his wife and stepson back. He described himself as competitive: "Everything becomes more exciting when you have money on it." But he also recognized the damaging consequences of his gambling: "When reality sets in, you feel b a d . . , you feel lower and lower about yourself. It destroys your life." He blamed his alcohol and cocaine use on the fact that he had "nothing left inside to feel good about." The therapist responded with empathy, validated the client's decision to quit using substances, and asked what he wanted to do about his gambling. Mr. J. decided he would stay away from OTB, but he did not want to give up playing cards and golf because he was concerned about losing his friends. The therapist reflected Mr. J.'s concerns about social isolation ("Your wife has left you and it scares you to think you might lose your friends too if you decide to quit all gambling"). The therapist also told him it was up to him what he wanted to change about his gambling, but that at some time he might want to try a period of total abst inence ("to find out what it's like to live without gambling").

During the following session, the therapist and Mr. J. examined the assessment data, the effect that gambling had on the client's life, inc luding his family, job, friends, finances, and self-esteem, and how in the process he had lost self-respect and the respect of people he valued. Using double-sided reflections, the therapist showed Mr.J. the

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cont rad ic t ion between life goals he valued and his cur- ren t si tuation, inc luding his "friends" who encouraged his gambl ing habi t ("I can see that you really want to have a normal family life; you want your wife and stepson to be p r o u d o f you and you know this won ' t h a p p e n as long as you hang out with your friends. And at the same t ime it's fun to play cards with your fr iends and you believe they won ' t t empt you to gamble. What do you th ink your life will be like a year f rom now if you cont inue to hang out with your friends?"). After much soul searching, the cli- en t dec ided he would try to quit all gambling, a l though he was still no t sure he could succeed. The therapis t sug- gested that Mr.J. make a t ime-l imited commi tme n t ( 'Just for a m o n t h or two, to see what your life is like if you d o n ' t gamble at all"). The cl ient dec ided no t to gamble for 1 month , "even if it means that I can ' t play golf with my friends."

The client was now cons idered ready for Phase 2 and in the following session the therapis t ini t ia ted the cognitive intervention. The therapis t and Mr. J. made a list of all the situations that increased the l ike l ihood that the cl ient might gamble (e.g., be ing pressured by friends, read ing about an impor t an t race, l is tening to a gambl ing adver t i sement on the radio, need ing cash). Using the analogy of a gas station (a potent ia l high-risk environ- ment) and someone l ighting a match (the spark necessary to create an explosion) , the therapis t exp la ined the difference between high-risk situations (those that sup- po r t gambling) and triggers (i.e., thoughts that create the just i f icat ion for gambling) . In Mr.J. 's case, two typical high-risk situations were social pressures and money pressures. When one of his fr iends called him to play golf (high-risk si tuat ion), the tr igger for gambl ing was the thought , "Betting on golf with my fr iends isn't really gambling." Similarly, when Mr. J. n e e d e d money for a birth- day presen t for his son (high-risk si tuat ion), he just i f ied his trip to OTB with the thought (trigger), "Tiznow is a sure thing. I f I be t jus t $30, I ' l l have the money to buy Joe l the skateboard he wants." The therapist patiently led Mr. J. to under s t and why these thoughts were unproduct ive (e.g., It 's always possible you' l l win, but it's more likely you won't . Even favorites lose the race more often than not. There ' s no way you could have been sure Tiznow would win. And, unfor tunate ly for you, he d id indeed lose. Might there have been ano the r way you could have had a nice b i r thday surprise for Joe l wi thout risking your last $30?).

Over the next five sessions, Mr. J. gradually l ea rned to chal lenge his a t t i tude about gambling. The therapis t took care to mainta in a d ia logue ra ther than using a di- dactic approach. This gave Mr. J. the oppor tun i ty to ex- p lore long-held beliefs without get t ing defensive and to grasp that his th inking was f raught with cognitive errors and superst i t ious beliefs (e.g., "D. Wayne Lucas horses

always win," an assertion ta in ted by the client 's selective pe rcep t ion bu t factually wrong). He l ea rned to dispute his beliefs and replace them with more accurate apprais- als ("Surfside might win, bu t my own exper ience tells me that there is no sure way of knowing"; '~]ust because my gut feel ing is tel l ing me someth ing doesn ' t make it t r u e - - it's quite possible that I ' ll lose my money"). Between sessions, he kept track of risk situations and triggers, which were then examined and cha l lenged in session.

Mr. J. began to accept the idea that horse racing was inf luenced by so many chance factors that his handicap- p ing skills were simply no t good enough to justify risking money he could no t afford to lose. He had no t gambled in several weeks bu t c la imed that he really missed the ex- c i tement of going to OTB" "It's no t about money, it 's the adrenal ine! It's the exc i tement you feel when you watch a race!" Mr. J. 's claim led to an interes t ing exchange with the therapist , who t r ied to convince the cl ient that his exc i tement was the p roduc t of his expecta t ion to win money ("Hmm, so you th ink it's the exc i tement of the race that motivates you. Let 's look at that a bit more closely. How long do you th ink you would keep on playing the horses if they a n n o u n c e d at OTB that f rom now on all winnings will go to the Red Cross?"). When Mr. J. admi t ted that his exc i tement was largely genera ted by the hope of winning money, it was easy to br ing him back to the real izat ion that this hope was founde d on the er roneous assumption that he could make money on a venture with a negative rate of return.

Seven weeks into therapy, Mr.J. began to discuss marital issues more freely. Initially, he had indica ted he would do whatever it takes to get his wife and son back. Now he began to br ing up long-standing conflicts between the spouses and admi t ted to feelings of anger and low self- es teem in response to his wife's f requent criticism. As he had kept his 1-month c ommi tme n t to abst inence and ex- t ended it for ano the r month , par t of the session t ime was now al located to p rob lem solving. With the therapist ' s as- sistance, Mr. J. ident i f ied several p rob l em areas (he had difficulty asserting himself with his wife; he d id not deal effectively with stress at work and some colleagues who taunted him; and as he was now living alone and ne i the r gambled nor played cards, he often felt bored) . Using a bra ins torming approach, Mr. J. and the therapis t gener- a ted numerous possible solutions to the client 's lack of recreat ional activities. Mr. J. r e m e m b e r e d that a young cousin had repeatedly invited him to work out and he dec ided to contact him. The two men fell into a rou t ine of workouts and body bui ld ing several days a week. On weekends, Mr. J. occasionally played golf with an old f r iend who was no t involved in gambl ing or d rug use. These activities not only decreased the client 's b o r e d o m bu t improved his physical condi t ion and appea rance as he lost weight and began to feel be t te r abou t himself.

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70 Wulfert et al.

As therapy progressed, Mr. J. thought less and less about gambl ing and sessions were now scheduled on a bi- month ly basis. But his work situation con t inued to be a significant source of stress. He felt stuck, th inking he would never f ind an equivalent j o b elsewhere. However, the therapis t he lped him to identify a n u m b e r of irrational thoughts that kept him from explor ing alternatives (e.g., I am not qualified. I wouldn 't know what to say in an in-

terview. What i f anyone f o u n d out about m~ drug .use and the

gambling?). W h e n he finally dec ided to look into o ther opt ions and sent out applicat ions, he was very surpr ised when his efforts pa id off. Within a shor t t ime he found ano the r j o b and dur ing the last mon th of t rea tment he changed employment .

One addi t ional impor t an t deve lopmen t in Mr. J. 's recovery process was that he was no longer sure he wanted to repai r his marr iage, a goal that had been p a r a m o u n t at the beg inn ing of t rea tment . He had asked his wife to jo in him in mari ta l counseling, but she was unwilling because she felt that Mr. J. was "the one with the problem." Her lack of coopera t ion and con t inued put-downs increased their e s t rangement and Mr. J. accepted the possibility that they might be head ing toward a divorce.

After 2 initial sessions of motivat ional e n h a n c e m e n t and 12 sessions of cognitive motivat ional behavior therapy, Mr.J. was ready for Phase 3 ( terminat ion) . The final 2 sessions were ex t ended over 5 weeks. Mr. J. and the therapis t discussed relapse prevent ion and follow-up and reviewed the progress made dur ing t reatment . The therapist taught Mr. J. steps (detailed by Ladouceur, 1999) to take if he felt t empted to resume gambling or if he slipped:

• Remain calm: When a tempta t ion arises, give yourself time; the urge usually passes. Take the role of an observer and identify what thoughts and feelings come up. Recognize the fallacy in your reasoning. Try no t to give in to temptat ion.

• Remember your resolution: You have worked so hard. Look at all the effort you have invested. Is it worth throwing away what you have achieved so far? Re- m e m b e r all the reasons why you dec ided to stop gambling.

• When a slip occurs, remember that it doesn't have to become

a ful l-blown relapse. Carefully analyze the situations that led to the urge or slip. Don ' t b lame yourself; it only makes you feel worse. Identify the context in which the urge occurred. What was the high-risk sit- uat ion, what was the trigger? Was there a warning sign before the si tuation occurred? What could you do differently the next t ime around?

• Mentally rehearse alternatives: Picture yourself in the same situation, but now a t tend to your thoughts and dispute unrealist ic statements. Remember , you are in control.

• Ask for help'. If p rob lems persist or lapses occur more frequently, get help. Call a fr iend, j o in a suppor t group, call your therapist . Remember , if you had a flat tire and d idn ' t carry tools, you wouldn ' t hesitate to flag down ano the r motorist . So why not do the same when you have a p rob lem with gambling?

Mr. J. felt quite conf ident that he would no t resume gambl ing or become involved again with drugs. He received a h a n d o u t i n t ended to serve as a "memory aid" (Ladouceur, 1999) summariz ing the steps to take in situations that might compromise his resolve. Mr.J. agreed to contact the therapis t if necessary. He also was encouraged to a t tend weekly Gamblers Anonymous meet ings for aftercare, which he agreed to do.

Mr. J. 's total t r ea tment consisted of 16 sessions ex- t ended over 23 weeks. At the pos t t rea tment assessment, his SOGS scores had decreased f rom 16 to 1 and he no longer met D S M - I V criteria for pathological gambling. Dur ing his 3-, 6-, and 12-month follow-up appoin tments , Mr. J. r epo r t ed that he had complete ly abs ta ined from gambl ing and drug use. He r epor t ed no desire to re turn to his former lifestyle. He felt very positive about his new j o b and had made new friends at Gamblers Anonymous who shared his interest in golf. His wife had filed for a legal separation. He expected to be divorced within a year and recently had begun to date. In short, there were many hopeful signs that Mr.J. had tu rned his life around.

Concluding Comments

We have sugges ted that the behavioral , emot iona l , and cognit ive manifes ta t ions subsumed u n d e r the label of pathological gambl ing or iginate from a mul t i tude of factors, some of which are complex cond i t ion ing pro- cesses and cognitive distortions. Al though to date con-

trolled t rea tment outcome research continues to be sparse, available studies suggest that pathological gamblers, like others who suffer f rom addictive disorders, r e spond well to cognitive behavioral interventions. Unfortunately, many gamblers leave therapy premature ly or relapse after com- plet ing t reatment . We suggest that this most likely is an indicat ion that gamblers ' motivat ion to quit gambl ing fluctuates.

Through a motivational enhancement approach, pathological gamblers may become more acutely aware of the toll their addictive behavior takes on their lives. We sub- mit that such awareness, when genera ted within an empathic and support ive therapeut ic context , can increase motivation for t r ea tment and thereby exer t a significantly positive effect on cl ient coopera t ion and therapeut ic outcomes. Being cognizant of pathological gamblers ' motiva- t ional ambivalence and address ing it r ight from the start is therefore paramount . Because motivational fluctuations

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P a t h o l o g i c a l G a m b l i n g 11

a r e t h e n o r m r a t h e r t h a n t h e e x c e p t i o n w i t h th i s d i sor -

de r , t h e r a p i s t s s h o u l d n o t b e d e c e i v e d by a g a m b l e r ' s p r o -

t e s t a t i o n s t h a t h e o r s h e is e n t e r i n g t r e a t m e n t r e a d y to

c h a n g e . A n y i n d i v i d u a l w h o d e r i v e s e n o r m o u s p l e a s u r e

f r o m a n act ivi ty t h a t n o t o n l y h a s p o s i t i v e b u t a l so h a r m -

fu l c o n s e q u e n c e s e x p e r i e n c e s a n i n t e r n a l c o n f l i c t t h a t

cal ls f o r d i s s o n a n c e r e d u c t i o n to a c h i e v e c o n s i s t e n c y . M o -

t i va t i ona l e n h a n c e m e n t s t r a t e g i e s m a y b e a m o n g t h e b e s t

t e c h n i q u e s ava i l ab l e to d a t e t h a t h e l p g a m b l e r s r e s o l v e

th i s c o n f l i c t in a c o n s t r u c t i v e way.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Antony, M. M., Bieling, EJ., Cox, B.J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item ver- sions of the Depression Anxiety Stress Scales (DASS) in clinical groups and a community sample. Psychological Assessment, 10, 176- 181.

Beck, A. T., Steer, R. A., & Brown, G. IC (1996). Beck Depression Inventory. manual (2nd ed.). San Antonio, TX: Psychological Corporation.

Black, D. W., & Moyer, T. (1998). Clinical features and psychiatric comorbidity of subjects with pathological gambling behavior. Psy- chiatric Services, 49, 1434-1439.

Blanchard, E. B., Wulfert, E., Freidenberg, B., & Malta, L. S. (2000). Physiological reactivity of pathological gamblers. Applied Psycho- physiology and Biofeedback, 25, 155-165.

Blaszczynski, A., & Farrell, E. (1998). A case series of 44 completed gambling-related suicides. Journal of Gambling Studies, 14, 93-109.

Brent, S., & Nicki, R. M. (1997). A preliminary consideration of cue- exposure, response-prevention treatment for pathological gambling behaviour: Two case studies. Journal of Gambling Studies, 13, 145-157.

Brown,J. M., & Miller, W. R. (1993). Impact of motivational interviewing on participation and outcome in residential alcoholism treatment. Psychology of Addictive Behaviors, 7, 211-218.

Brown, R. I. E (1987). Classical and operant paradigms in the manage- ment of gambling addiction. Behavioral Psychotherapy, 15, 111-122.

Catania, C. (1998). Learning. Englewood-Cliffs, NJ: Prentice-Hall. Christiansen, E. M. (1993). Income 1992 gross annual wager of the

U.S.: Part 1. Gaming and Wagering Business, 14, 7, 12- 35. Colby, S. M., Monti, E M., Barnett, N. E, Rohsenow, D.J., Weissman, IC,

Spirito, A., Woolard, R. H., & Lewander, W.J. (1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study. Journal of Consulting and Clinical Psychology, 66, 574-578.

Crockford, D. N., & el-Guebaly, N. (1998). Psychiatric comorbidity in pathological gambling: A critical review. Canadian Journal of Psy- chiatry, 43, 43-50.

Donovan, D. M., & Rosengren, D. B. (1999). Motivation for behavior change and treatment among substance abusers. In J. A. Tucker, D. M. Donovan, & G. A. Marlatt (Eds.), Changing addictive behavior Bridging clinical and public health strategies (pp. 127-159). New York: The Guilford Press.

Echeburua, E., Baez, C., & Fernandez-Montalvo,J. (1994). Effectividad diferencial de diversas modalidades terapeuticas en el trata- miento psicologico del juego patologico: Un estudio experimen- tal. Analisis y Modificacion de Conducta, 20, 617-643.

Echeburua, E., Baez, C., & Feruandez-Montalvo, J. (1996). Compara- tive effectiveness of three therapeutic modalities in the psychological treatment of pathological gambling: Long-term outcome. Behavioural and Cognitive Psychotherapy, 24, 51-72.

Feigelman, W., Wallisch, L. S., & Lesieur, H. R. (1988). Problem gamblers, problem substance users, and dual-problem individuals: An epidemiological study. American Journal of Public Health, 88, 467-470.

First, M. B., Gibbon, M., Spitzer, R. L., & Williams,J. B. W. (1996). User's guide for the Structured Clinical Interview for DSM-IV Axis I Disorder- Research version (SCID-I, Version 2.0, February. 1996final version). New York: Biometrics Research Department, New York State Psy- chiatric Institute.

Frank, M. L., Lester, D., & Wexler, A. (1991). Suicidal behavior among members of Gamblers Anonymous. Journal of Gambling Studies, 7, 249-254.

Freidenberg, B. M., Blanchard, E. B., Wulfert, E., & Malta, L. S. (2002). Changes in physiological arousal to gambling cues among participants in motivationally enhanced cognitive behavior therapy for pathological gambling. Applied Psychophysiology and Biofeedback, 27, 251-260.

Gottlieb, G. (1992). Individual development and evolution: The genesis of novel behavi~ New York: Oxford University Press.

Handmaker, N. S., Miller, W. R., & Manicke, M. (1999). Findings of a pilot study of motivational interviewing with pregnant drinkers. Journal of Studies on Alcohol, 60, 285-287.

Hartley, J., & Wulfert, E. (2001). Physiological arousal for high- and low- frequency horse race betters. Unpublished manuscript, University at Albany.

Hodgins, D. C., Currie, S.R., & el-Guebal~ N. (2001). Motivational enhancement and self-help treatments for problem gambling. Journal of Consulting and Clinical Ps'~chology, 69, 50-57.

Horvath, A. O., & Greenberg, L. S. (1989). Development and valida- tion of the Working Alliance Inventory. Journal of Counseling Psy- chology, 36, 223-233.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis.Journal of Counseling Psychology, 38, 139-149.

Ibanez, A., Blanco, C., Donahue, E., Lesieur, H. R., Perez de Castro, I., Fernandez-Piqueras, J., & Saiz-Ruiz, J. (2001). Psychiatric comorbidity in pathological gamblers seeking treatment. American Jour- nal of Psychiatry, 158, 1733-1735.

Kallick, M., Suits, D., Dielman, T., & Hybels,J. (1979). A survey of Amer- ican gambling attitude and behavi~ Ann Arbor, MI: University of Michigan Survey Center, Institute for Social Research.

galapp, T.J. (1998). Behaviorism and public policy: B. E Skinner's views on gambling. Behavior and Social Issues, 7, 129-139.

Kuo, Z.Y. (1967). The dynamics of behavior development. New York: Ran- dom House.

Ladouceur, R. (1999). La passi6n dujeux: Le traitement (The passion of gambling: Its treatment). Unpublished treatment manual, Uni- versit~ Laval.

Ladouceur, 1~, Boisvert, J. M., & Dumont,J. (1994). Cognitive-behavioral treatment for adolescent pathological gamblers. BehaviorModifica- tion, 18, 230-242.

Ladouceur, R., Dube, D., & Bujold, A. (1994). Prevalence of pathological gambling and related problems among college students in the Quebec metropolitan area. Canadian Journal of Psychiatry, 144, 1184-1188.

Ladouceur, R., & Walker, M. (1996). A cognitive perspective on gambling. In E M. Salkovskis (Ed.), Trends in cognitive and behavioural therapies (pp. 89-120). NewYork:John Wiley.

Langer, E.J. (1975). The illusion of control.Journal of Personality and Social Psychology, 32, 311-328.

Lesieul, H. R., & Blume, S. B. (1987). The South Oaks Gambling Screen (SOGS) : A new instrument for the identification of pathological gamblers. American Jourual of Psychiatry, 144, 1184-1188.

Linden, R. D., Pope, H. G., &Jonas, J. M. (1986). Pathological gambling and major affective disorder: Preliminary findings.Journal of Clinical Psychiatry, 47, 201-203.

Lopez Viets, V. C., & Miller, W. R. (1997). Treatment approaches for pathological gamblers. Clinical Psychology Review, 17, 689- 702.

Lovibond, S. H., & Lovibond, E E (1995). Manual for the Depression Anxiety Stress Scales. Sydney: The Psychology Foundation of Austra- lia Inc.

Marlatt, G. A., & Gordon.J .R. (Eds.). (1985). Relapse prevention: Main- tenauee strategies in the treatment of addictive behaviors. New York: The Guilford Press.

McConaghy. N., Amstrong, M. S., Blaszczynski, A., & Allock, C. (1983). Controlled comparison of aversive therapy and imaginal

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12 Wulfert et al.

desensitization in compulsive gambling. British Journal of Psychia- try, 142, 366-372.

McConaghy, N., Blaszczynski, A., & Frankova, A. (1991). Comparison of imaginal desensitization with other behavioral treatments of pathological gambling. British Journal of Psychiatry, 159, 390-393.

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing. NewYork: The Guilford Press.

Miller, W. R., & Sovereign, R. G. (1989). The check-up: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, E E. Nathan, & G. A. Marlatt (Eds.), Addictive behaviors: Prevention and early intervention (pp. 219-231 ). Amsterdam: Swits & Zeitlinger.

Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual (U.S. Department of Health and Human Services, DHHS Publication No. [ADM]92- 1894). Washington, DC: U.S. Government Printing Office.

Monti, E M., Colby, S. M., Barnett, N. E, Spirito, A., Rohsenow. D.J., Myers, M., Woolard, R., & Lewander, W. (1999). Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department.Journal of Consulting and Clini- cal Psychology, 67, 989-994.

National Opinion Research Council. (1999). Gambling impact and behavior study: NORC at the University of Chicago. Retrieved December 2, 2002, from http://www.norc.uchicago.edu/new/gamb-fin.htm.

National Research Council. (1999). Pathological gambling: A critical review. Washington, DC: National Academy Press.

Nisbett, R., & Ross, L. (1980). Human inference: Strategies and shortcom- ings of social judgment. Englewood Cliffs, NJ: Prentice Hall.

Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276-288.

Prochaska,J. O., DiClemente, C. C., & Norcross,J. C. (1992). In search of how people change: Applications to addictive behaviors. Amer- ican Psychologist, 47, 1102-1114.

Prochaska, J. O., Velicer, w. E, Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rokowski, W., Fiore, C., Harlow, L. L., Redding, C. A., Rosen- bloom, D., & Rossi, S. R. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39-46.

Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-28.

Rachlin, H. (1990). Why do people gamble and keep gambling despite heavy losses? Psychological Science, 1, 294-297.

Samstag, L. W., Batchelder, S. T., Muran,J. C., Safran,J. D., & Winston, A. (1998). Early identification of treatment failures in short-term psychotherapy: An assessment of therapeutic alliance and interpersonal behavior. Journal of Psychotherapy Practice and Research, 7, 126-143.

Schwartz, B. (1992). Psychology of learning and behavior. New York: Norton.

Shaffer, H.J. (1997). Psychology of stage change. In J. H. Lowinson, P Ruiz, R. B. Millman, andJ. G. Langrod (Eds.), Substance abuse: A comprehensive textbook (3rd ed., pp. 100-106). Baltimore: Williams and Wilkins.

Shaffer, H.J., & Gambino, B. (1989). The epistemology of "addictive disease": Gambling as a predicament.Journal of GamblingBehaviog, 5, 211-229.

Shaffer, H.J., Hall, M. N., & Bilt, J. V (1997). Estimating the prevalence of dis- ordered gambling behavior in the United States and Canada: A meta-analysis. Cambridge, MA: Harvard Medical School Division on Addictions.

Sharpe, L., & Tarrier, N. (1993). Towards a cognitive-behavioural theory of problem gambling. British Journal of Psychiatry, 162, 407-412.

Sharpe, L., Tarrier, N., Schotte, D., & Spence, S. H. (1995). The role of autonomic arousal in problem gambling. Addiction, 90, 1529-1540.

Slutske, W. S., Eisen, S., True, W. R., Lyons, M.J., Goldberg,J., & Tsuang, M. (2000). Common genetic vulnerability for pathological gambling and alcohol dependence in men. Archives of General Psychia- try, 57, 666-673.

Specker, S. M., Carlson, G. A., Edmondson, K. M., Johnson, P E., & Marcotte, M. (1996). Psychopathology in pathological gamblers seeking treatment. Journal of Gambling Studies, 12, 67-81.

Sylvain, C., & Ladouceur, R. (1992). Correction cognitive et habitues de j eu chez les joueurs de poker video. Revue Canadienne des Sci- ences du Comportement, 24, 479-489.

Sylvain, C., Ladouceur, R., & Boisvert, J. (1997). Cognitive and behavioral treatment of pathological gambling: A controlled study.Jour- nal of Consulting and Clinical Psychology, 65, 727-732.

Taber, J. I. (1987). Compulsive gambling: An examination of relevant models. Journal of Gambling Behavior, 3, 219 - 223.

Tversky, A., & Kahneman, D. (1982). Judgment under uncertainty: Heuristics and biases. In D. Kahneman, P. Slovic, & A. Tversky (Eds.) ,Judgment under uncertainty: Heuristics and biases (pp. 3-20). New York: Cambridge University Press.

Volberg, R. (1994). The prevalence and demographics of pathological gamblers: implications for public health. American Journal of Public Health, 84, 237-241.

Volberg, R. (1996). Prevalence studies of problem gambling in the United States. Journal of Gambling Studies, 12, 111-128.

Wagenaar, W. (1988). Paradoxes of gambling behavior. American Jour- nal of Psychology, 103, 290-297.

Walker, M. B. (1992). Irrational thinking among slot machine players. Journal of Gambling Studies, 8, 245-261.

Winters, K. C., Bengston, E, Door, D., & Stinchfield, R. (1998). Preva- lence and risk factors of problem gambling among college students. Psychology of Addictive Behaviors, 12, 127-135.

Wulfert, E. (1993). Rule-governed behavior. In E N. Magill (Ed.), Survey of socialscience:Psychology (pp. 2115-2121). Pasadena, CA: Salem Press.

Wulfert, E., Blanchard, B. B., Freidenberg, B., & Martell, R. (2002). Retaining pathological gamblers in treatment with cognitive-motivational behavior therapy: A pilot study. Manuscript submitted for publication.

Wulfert, E., Greenway, D. E., & Dougher, M.J. (1996). A logical func- tional analysis of reinforcement-based disorders: Alcoholism and pedophilia. Journal of Consulting and Clinical Psychology, 64, 1140- 1151.

Yackulic, R. A., & Kelly, I. W. (1984). The psychology of the "Gambler's Fallacy" in probabilistic reasoning. Psychology: A Journal of Human Behavim;, 21, 55-58.

Zetde, R. D., & Hayes, S. C. (1982). Rule-governed behavior: A poten- tial theoretical framework for cognitive-behavioral therapy. In P. C. Kendall (Ed.), Advances in cognitive-behavioral research (Vol. 1, pp. 73-118). New York: Academic Press.

Address correspondence to Edelgard Wulfert, Ph.D., Department of Psychology, University at Albany, State University of New York, 1400 Washington Ave., Albany, NY 12222; e-mail: [email protected].

Received: September 20, 2001 Accepted: February 26, 2002

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conceptualizing and treating pathological gambling · community have a history of alcohol abuse or...

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