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--> 6 Treatment of Pathological Gamblers The treatments and interventions for pathological gambling that have been developed and reported in the literature are quite similar to methods of treating other disorders or addictions. Substantial progress has not been made in understanding the treatment of this disorder or the characteristics of those seeking help for it, nor is there research basis for matching clients to treatments. Most published investigations are case studies or studies with small samples of clients whose circumstances may not be generalizable to larger populations (Knapp and Lech, 1987; Murray, 1993). Moreover, treatment approaches have not been subjected to rigorous and detailed empirical research (Blaszczynski and Silove, 1995). Given the lack of national attention to the treatment of pathological gambling, it is difficult to estimate the scope of intervention services available in the United States. We begin with a discussion of the definition of treatment and challenges in treating such disorders as pathological gambling. We then discuss what is known about the characteristics of those who seek treatment for pathological gambling. We then turn to treatment models that have been applied for helping pathological gamblers, what is known about treatment effectiveness, whether treatment is warranted, and issues related to treatment availability, utilization, funding, and treatment providers in the United
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--> States. We also identify priorities for further research, including treatment effectiveness, cost-effectiveness, how patients should be matched to treatments, and prevention strategies. Defining Treatment and Challenges to Treatment In the committee's view, the definition of treatment needs to be a broad one. We define treatment as: (1) activities directed at individuals for the purpose of reducing problems associated with problem or pathological gambling and (2) activities aimed at groups of individuals (e.g., communities) to prevent gambling problems from arising in the first place. Comprehensive treatments move through three stages: acute intervention, followed by rehabilitation, and ending with maintenance. These three stages can vary according to the philosophy of the providers, the settings in which treatment takes place, and the specific approaches employed. No systematic compilation of treatment services for pathological gambling has been made in the United States. Treatment is provided in many ways and in many settings, although outpatient treatment is probably the most common; no single treatment approach dominates the field. In fact, it appears to be common for approaches to be combined in most clinical settings. It is important, as well, to recognize that recovery from pathological gambling can take place without formal treatment. Such individuals have been classified by various descriptors, for example, so-called spontaneous recovery and natural recovery (Wynne, personal communication, 1998). Although the subject of natural recovery from psychoactive substances, such as alcohol and opiates, has received some attention in the professional literature (McCartney, 1996), no such attention has been given to gambling. Functionality of Addictive Behaviors All addictions, by their nature, pose special problems to treatment providers. Like other purposive human behavior, addictive behaviors have adaptive or functional value, with the result that efforts to change these behaviors often fail.
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--> Ambivalence is at the core of addiction (Shaffer, 1997). Those who are addicted and thinking about change want to free themselves from their addiction. At the same time, they crave the satisfactions that their addiction provides. As they become aware of the harm their addiction is doing, they begin to say that they want to quit. Of course, wishing or expressing a desire to quit a behavior is not the same as doing it. Despite the obvious harmful consequences, people in the throes of addiction cling to the part of the experience that they like: the part that was adaptive originally and may have even produced positive consequences, such as relief from painful emotions (Khantzian et al., 1990). The key to change comes when those addicted begin to realize that the costs of their addiction exceed the benefits, as when pathological gamblers identify gambling as a destructive agent in their life. It is at this point that addicted people often ask those who they trust to help them stop, and they take the first steps to seek professional help. This turning point is but the first step of a complex dynamic process, including the possibility that bouts of abstinence and relapse may occur for some time (Marlatt and Gordon, 1985). Preventing Relapse A challenge in the treatment of pathological gambling is preventing relapse. For example, few people who stop using drugs remain abstinent thereafter. Marlatt and Gordon examined how slips, that is, single episodes of drug use, can lead to a full-blown relapse (Marlatt and Gordon, 1985). Many personal and environmental factors interact to influence the risk of relapse for any individual trying to recover from an addiction. Successful recovery also involves the development of new skills and lifestyle patterns that promote positive patterns of behavior. The integration of these behaviors into day-to-day activities is the essence of relapse prevention (Brownell et al., 1986). Successful quitters substitute a variety of behavior patterns for their old drug-using lifestyle. For example, many take up some form of exercise. Spiritual conversions sustain others. In some patients, new behavior can become excessive, almost another addiction. We do not know whether the same substitute behaviors occur in pathological gamblers determined to quit.
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--> Characteristics of Treatment Seekers1 Understanding the characteristics of those who seek help for a given disorder can assist in developing effective treatments. As already noted, most clinical investigations in this field are case studies or studies with small samples of clients whose data may not be generalizable to larger populations. Thus, establishing an accurate profile of those seeking treatment is difficult. We can say a few things, however. Demographics Treatment seekers tend to be white middle-aged men (Blackman et al., 1989; Ciarrocchi and Richardson, 1989; Volberg, 1994; Volberg and Steadman, 1988), although more recent investigations suggest that admissions of women are increasing (Moore, 1998; Stinchfield and Winters, 1996). The majority tend to be in their 30s and 40s and have graduated from high school and attended some college (Blackman et al., 1989; Moore, 1998; Yaffee et al., 1993; Stinchfield and Winters, 1996). Gambling Severity Most clinical studies indicate that, before pathological gamblers come in for treatment, they gamble either every day or every week (Moore, 1998; Stinchfield and Winters, 1996). Little is known at this time about their preferences for types of gambling. One factor that may influence preference is proximity of certain games to gamblers; for example, one study showed that the preferred game of gamblers in Maryland was horse racing at Maryland tracks (Yaffee et al., 1993), and for Oregon clients, it was the video poker that is widely available there (Moore, 1998). Game availability does not simply translate to preference. Minnesota gamblers have been shown to prefer to gamble in casinos, which may be far from their homes, over purchasing lottery tickets, 1 The committee thanks Randy Stinchfield for his written summary and presentation of the literature in this section.
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--> which can be bought almost everywhere in the state (Stinchfield and Winters, 1996). Legal and Financial Consequences Although clients may be reluctant to fully disclose their legal entanglements, most clinical studies indicate that a sizable percentage reports having criminal charges pending as a result of engaging in illegal activity to fund their gambling or pay off their debts (Yaffee et al., 1993; Stinchfield and Winters, 1996; Taber et al., 1987). Some reports indicate that from half to two-thirds of pathological gamblers have committed an illegal act to get money to gamble (Dickerson, 1989; Dickerson et al., 1990; Lesieur et al., 1986). Large debts, most often in the tens of thousands of dollars, are also part of the picture (Blackman et al., 1989; Moore, 1998; Stinchfield and Winters, 1996). One study reported that 10 percent of 128 gamblers ages 20 to 68 treated as outpatients at a gamblers' treatment clinic had debts in excess of $100,000 (Blackman et al., 1989). Other Characteristics Additional personal and social consequences reported by those seeking treatment include work absenteeism and lost productivity on the job, presumably because they either skip work in order to gamble or are involved in gambling-related activities while at work; and marital discord and family estrangement, due to the deception, lying, and stealing associated with their gambling (Ciarrocchi and Richardson, 1989; Ladouceur et al., 1994; Lorenz and Yaffee, 1988; Stinchfield and Winters, 1996). Comorbidity As discussed in Chapter 4, a number of studies have found significant rates of cooccurring mental disorders and psychiatric symptoms among pathological gamblers. Studies have indicated evidence of pathological gambling cooccurring with substance use disorders, depression, suicidal thoughts and attempts, and various personality disorders.
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--> Treatment Approaches and Effectiveness Methods for treating pathological gambling include approaches that are psychoanalytic, psychodynamic, behavioral, cognitive, pharmacological, addiction-based and multimodal, and self-help. Often these approaches are combined to varying degrees in most treatment programs or counseling settings. The discussion below briefly describes each method and summarizes what is known from the empirical research about its effectiveness. In doing so, the discussion expands on the other literature reviews of treatment outcome (e.g., Blaszczynski and Silove, 1995; DeCaria et al., 1996; Lesieur, 1998; Murray, 1993; Walker, 1993; Lopez Viets and Miller, 1997; R.W. Wildman, personal communication to the committee, 1998). A table summarizing the literature on treatment outcome studies reviewed by the committee appears in Appendix D. Psychoanalytic/Psychodynamic Psychoanalysts seek to understand the basis of all human behaviors by considering the motivational forces that derive from unconscious mental processes (Wong, 1989). Psychodynamics refers to the ''science of the mind, its mental processes, and affective components that influence human behavior and motivations (Freedman et al., 1975:2601) and how these potentially opposing forces of cognition and emotion are translated into behavior. During the first half of the twentieth century, psychoanalysts provided the first systematic attempts to understand and treat gamblers (Rabow et al., 1984; Rosenthal, 1987). Psychoanalytic and psychodynamic treatment approaches have not been proven effective through evaluation research. They are briefly described here because they are the most common forms of treatment for pathological gambling at this time. These approaches are based on the principle that all human behavior has meaning and is functional. Even the most self-destructive behaviors can serve a defensive or adaptive purpose. This perspective suggests that pathological gambling is a symptom or expression of an underlying psychological condition. This approach takes the view that, although some individuals don't need to un-
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--> derstand why they gamble in order to stop, there are many others whose lives do not improve with abstinence, which is experienced as futile and hopeless (Rosenthal and Rugle, 1994). They then develop a major depression, turn back to gambling, or seek out some other addictive or self-destructive behavior with which to distract themselves. Psychoanalytic and psychodynamic therapy attempts to help pathological gamblers to understand the underlying source of their distress and confront it. Clinicians have considered psychodynamically oriented psychotherapy useful in treating some of the comorbid disorders and character pathology observed among pathological gamblers, perhaps especially the narcissistic and masochistic subtypes. Although several others have noted the value of psychodynamic treatment for addictive behaviors (Boyd and Bolen, 1970; Kaufman, 1994; Khantzian, 1981; Shaffer, 1995; Wurmser, 1978), there have been no controlled or randomized studies exploring the effectiveness of this approach for treating pathological gamblers. The psychoanalytic understanding of gambling problems rests on the foundation formulated by Freud (1928), who thought that it was not for money that the gambler gambled, but for the excitement. In fact, Freud speculated that some people gamble to lose. He thought this tendency was rooted in a need for self-punishment, to expiate guilt, and, for the male gambler, because of ambivalence toward the father. Bergler (1936, 1943, 1958) expanded on this concept of masochism, emphasizing the pathological gambler's rebellion against the authority of the parents and specifically the reality principle they represent. A number of early psychoanalysts, dating back to Simmel in 1920, emphasized narcissistic fantasies and a sense of entitlement, pseudo-independence, and the need to deny feelings of smallness and helplessness. Other analysts (Greenson, 1947; Galdston, 1960) described early parental deprivation, with the gambler then turning to Fate or to Lady Luck for the love, acceptance, and approval he or she had been denied. Several analysts (Greenson, 1947; Comess, 1960; Niederland, 1967) saw compulsive gambling as an attempt to ward off an impending depression. Boyd and Bolen (1970) viewed it as a manic defense against helplessness and depression secondary to loss. Still others have emphasized
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--> the eroticization of tension and fear (Von Hattingberg, 1914), the central role of omnipotence (Simmel, 1920; Bergler, 1936; Greenson, 1947; Lindner, 1950), and problems identifying with parents (Weissman, 1963). More recently, analysts have been investigating deficiencies in self-regulation as they pertain to gambling and other addictive disorders (Krystal and Raskin, 1970; Wurmser, 1974; Khantzian, 1981; Schore, 1994; Ulman and Paul, 1998). The psychoanalytic literature provides individual case histories of gamblers treated successfully (Lindner, 1950; Harkavy, 1954; Reider, 1960; Comess, 1960; Harris, 1964; Laufer, 1966). The only analyst to present information about a series of treated gamblers was Bergler (1958). In his account of 200 referrals, 80 appeared to be severe cases and, of those, 60 remained in treatment. A critique of his treatment appears in Rosenthal (1986). According to Bergler, 45 were cured and 15 experienced symptom removal. By a cure, he meant not only that they stopped gambling, but also that they addressed core conflicts and gave up their pattern of self-destructiveness. There is no information on whether "cured" patients were followed-up after treatment. There is a significant need, not only for randomized treatment outcome studies, but also for clinical vignettes and case histories that discuss what it is that clinicians who use these treatments actually do. It is necessary to deconstruct psychoanalytically and psychodynamically oriented interventions and techniques to see what specific components contribute to favorable treatment outcomes. And of course there are differences between one therapist and another with regard to their capacities for empathy, timing, tact, role-modeling, and support—which can complicate research on treatment effectiveness in general and psychodynamic treatment in particular. Behavioral Behavioral treatment methods actively seek to modify pathological gambling behavior on the basis of principles of classical conditioning or operant theory. Several variations of behavioral treatment methods are used today, often in combination. Aversion treatment consists of applying an unpleasant stimulus, such
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--> as a small electric shock, while the patient reads phrases that describe gambling behavior. During the procedure's final phrase, the patient reads about an alternative activity to gambling, such as returning home, but receives no shock (McConaghy et al., 1991). Imaginal desensitization consists of two steps. Patients first engage in a procedure to relax. Then they are asked to imagine a series of scenes related to gambling that they find arousing. They learn from this procedure to relax when they encounter opportunities to gamble, rather than to submit to their cravings. An extension of imaginal desensitization is in vivo exposure, in which relaxation techniques are applied while the patient is actually experiencing a gambling situation. Behavioral counseling has been used in both individual and group treatment settings. Subjects receive reinforcement for desired gambling behaviors, such as gambling at a reduced level, betting less money, and so on. Specific treatment goals can be more formalized in the form of contingency contracting, in which specific aspects of behavior are rewarded or punished. Other behavioral techniques have been reported in the gambling treatment literature. Two of them, behavioral counseling, in which the gambler is given verbal reinforcement for desired outcome behaviors, and in vivo exposure, in which the gambler is exposed to gambling behaviors but is not allowed to gamble, are mentioned in the literature but have not been empirically tested. Although behavioral treatment methods have been used and evaluated, such studies typically have had small sample sizes and no control groups. Case studies using various combinations of behavior treatments are common (e.g., Dickerson and Weeks, 1979; Cotler, 1971; McConaghy, 1991; Rankin, 1982; Greenberg and Marks, 1982; Greenberg and Rankin, 1982). However, findings from these limited studies are not consistent enough to reach conclusions about treatment effectiveness. Early studies of effectiveness on behavioral forms of treatment for pathological gamblers focused on aversion treatment. The studies involved single patients and provided minimal evidence of treatment success (e.g., Barker and Miller, 1966; Goorney, 1968). Subsequent research on aversion treatment using electric shock for pathological gamblers had only slightly larger samples (e.g., Seager, 1970; Koller, 1972;
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--> Seager et al., 1966; Salzman, 1982) and produced equally questionable findings. Larger outcome studies have been undertaken and provide more evidence for treatment effectiveness. In a study of 110 German pathological gamblers, Iver Hand (1998) described a behavioral treatment that begins with an extensive assessment of the client's motivation for treatment, symptoms, the consequences of his or her gambling, and social competence. This assessment is followed by client training in emotional awareness, coping with negative emotions, and social and problem-solving skills. An uncontrolled evaluation of this approach revealed favorable treatment results (Hand, 1998). The most rigorous work on behavior treatments with pathological gamblers has been published in a series of study reports by McConaghy, Blaszczynski, and colleagues (McConaghy et al., 1983, 1991; Blaszczynski et al., 1991). The earlier studies by this group compared imaginal desensitization with either aversion treatment or behavioral approaches. In a 1988 study (McConaghy et al., 1988), the effectiveness of imaginal desensitization was compared with imaginal relaxation (teaching the client general relaxation techniques). Although the early studies by this group had relatively small sample sizes, otherwise strong methodologies revealed that treatment techniques were successful at one month and also at one year following treatment. Using a large sample and expanding the comparisons of behavioral approaches, McConaghy et al. (1991) randomly allocated 120 participants to one of four techniques: aversion treatment, imaginal desensitization, imaginal relaxation, or in vivo exposure. A total of 63 clients were recontacted two to nine years later (a 53 percent follow-up response rate). The group that received imaginal desensitization benefited more than those receiving the other three behavioral approaches when abstinence and controlled gambling were combined as the outcome variable. (The authors defined controlled gambling as gambling in the absence of the subjective sense of impaired control and adverse financial consequences, based on self-rating and confirmation from a spouse or significant other). If just abstinence was considered, imaginal desensitization was equivalent to the other treatments' combined rate of abstinence (30 percent and 27 percent, respectively).
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--> In a further investigation of this sample, Blaszczynski and colleagues (1991) found that the abstainers and controlled gamblers showed a significant reduction in arousal levels, anxiety, and depression during the follow-up period compared with those who could not control their gambling. Also of significance are the study's findings pertaining to the controlled gamblers. The pattern of gambling suggested that controlled gambling is not necessary a temporary response followed by a relapse to heavier gambling (Blaszczynski et al., 1991:299). Because the sample sizes of the McConaghy and Blaszczynski studies are relatively small and because only about half of the original sample was contacted for follow-up (although the long follow-up periods used were laudable), these results should be interpreted with caution. Cognitive and Cognitive-Behavioral Several clinicians and researchers have convincingly argued (see Blaszczynski and Silove, 1995; Walker, 1992; Gaboury and Ladouceur, 1989) that pathological and problem gamblers share irrational core beliefs about gambling risks, an illusion of control, biased evaluations of gambling outcomes, and a belief that gambling is a solution to their financial problems (Ladouceur et al., 1994; Toneatto, personal communication to the committee, 1998). Cognitive treatment aims to counteract underlying irrational beliefs and attitudes about gambling that are believed to initiate and maintain the undesirable behavior (Gaboury and Ladouceur, 1989). Treatment typically involves teaching clients strategies to correct their erroneous thinking. Many, for example, do not understand the concepts of probability and randomness, believing that they can exert some control over whether they win or lose. The effectiveness of cognitive treatments has received limited attention by researchers and, as for other studies of treatment success, most have small sample sizes and no control groups (e.g., Gaboury and Ladouceur, 1989; Sylvain and Ladouceur, 1992), from which little can therefore be concluded. However, a push for more comprehensive models to explain the origins of problem gambling (Sharpe and Tarrier, 1993) has elicited investigations of the efficacy of combining cognitive and behavioral approaches. Investigations combining these treatments include case studies
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