Behavioral Treatment Approaches for Gambling Disorders1

Howard J. Shaffer, Ph.D., C.A.S.
Debi LaPlante, Ph.D.
Division on Addictions, Harvard Medical School

Behavioral strategies for the treatment of gambling disorders assume that patterns of excessive gambling – and the associated emotional feelings – are learned; therefore, clinicians can apply principles of learning to encourage the changes necessary that will ameliorate the problem. From this perspective treatment begins with a careful "behavioral analysis" that determines where, when and how frequently gambling behaviors occur. Behavioral treatment specialists help gamblers determine the precise emotional and social context for their gambling and then develop and/or substitute alternative behaviors. Once learned, the recovering gambler can practice these alternative behaviors in real life settings to reduce the likelihood of relapse.

In this article we will discuss recent research pertaining to three aspects of behavioral treatment: cognitive behavioral therapy (CBT), motivational enhancement, and relapse prevention.

COGNITIVE BEHAVIORAL THERAPY

CBT attempts to reduce individuals' maladaptive gambling by correcting erroneous perceptions about probability, skill, and luck that serve to maintain problem gambling behaviors. Consequently, the treatment techniques include cognitive correction, social skills training, problem solving training, and relapse prevention (Ladouceur, Sylvain, Boutin, & Doucet, 2002; Sylvain, Ladouceur, & Boisvert, 1997). Empirical assessment of CBT has compared waitlist control groups to treatment groups. Reliable reduction in gambling, urges to gamble and the number of DSM criteria met have been observed at 6- and 12-month evaluations (Sylvain et al., 1997). This research also has found that patients increased their perceptions of self-efficacy and perception of control. Similarly, Ladouceur, Sylvain, Letarte, Giroux, and Jacques (1998) found that when individuals were given education about randomness, they were able to maintain therapeutic gains (i.e., reduced problem gambling) for at least 6 months.

Other researchers have been more skeptical, however. For example, (Blaszczynski & Silove, 1995) suggested that conclusive statements about behavioral and cognitive treatment efficacy might be premature because of a lack of systematic empirical comparisons of these with other treatment approaches. They also suggest that serious methodological limitations prevent comparison of existing treatment outcome studies.

MOTIVATIONAL ENHANCEMENT STRATEGIES

Motivational enhancement strategies (e.g., motivational counseling, resistance reduction) are cognitive behavioral treatment approaches designed to lower resistance and enhance motivation for change. Motivational enhancement strategies augment pre-existing motivation by improving the therapeutic alliance. This is accomplished by recognizing that clients are, at best, ambivalent about experiencing personal change (Miller & Rollnick, 1991; Orford, 1985; Rollnick & Morgan, 1995; Shaffer, 1994, 1997). With improved therapeutic relationships, clients are more willing to consider and explore their ambivalence. Shaffer (1992; 1994; 1997; Shaffer & Robbins, 1995) has suggested that painful ambivalence is responsible for stimulating denial as a defense mechanism and the appearance of intractability among people struggling with addictive disorders.

Clinicians who utilize motivation enhancement techniques typically focus on two motivational concerns: (1) inadequate motivation to change and (2) resistance to change. Some have suggested that if motivation to change is inadequate, it has to be energized (charged), like a weak battery (Miller & Rollnick, 1991). One way of achieving this is through systematic interviewing. Motivational interviewing strategies presume that the level of motivation necessary for change is lacking and insufficient to stimulate and sustain change, but that it can be enhanced via appropriate questioning.

In contrast, others have suggested that individual's level of motivation is not necessarily the problem; rather, the client's resistance to change is a primary problem.² Resistance is often considered the core of what makes it difficult for people, even the most healthy, to achieve consistently ÒgoodÓ mental health (Ellis, 1987; Shaffer & Simoneau, 2001). Based upon psychodynamic principles, resistance reduction assumes that internal and external obstacles dilute or weaken existing levels of motivation for change that can already be sufficient to drive the change process; therapeutic approaches work to eliminate such obstacles. For example, resistance reduction strategies encourage therapists to validate self-destructive behavior as a legitimate choice by asking clients about the perceived benefits of these activities (e.g., gambling), rather than exclusively focusing on the costs (e.g., losses). Within this safe context, clients can more freely explore all of the costs and benefits associated with a pattern of addictive activity. Since a resistance reduction strategy does not ask clients to give up anything, patients also have less need to resist therapeutic interventions. With little need to resist treatment, previously inhibited motivation is released for clients to use in changing seemingly intractable behavior patterns.
Resistance reduction and other motivational enhancement strategies are not mutually exclusive. Clinicians should consider employing the full range of motivational enhancement approaches to advance the treatment objectives and the health of disordered gamblers.

A decision balance is the major technique used in motivational enhancement strategies. At every stage of treatment, motivational strategies ask patients to address the pros and cons of their current behavior and value of staying the same or changing.

RELAPSE PREVENTION AND RECOVERY TRAINING

Relapse prevention and recovery training are modalities designed to increase a person's ability to identify and cope with high-risk situations that commonly create problems and precipitate relapse. These strategies are most frequently associated with cognitive-behavioral treatments. The techniques have been well developed and widely used in the alcohol and drug treatment field (Annis, 1986; Annis & Davis, 1989; Marlatt & Gordon, 1985; McAulliffe & Ch'ien, 1986). More recently, these strategies have been applied to gambling treatment. The gambling risk situations identified include environmental settings (e.g., casinos, lottery outlets), intrapersonal discomfort (e.g., anger, depression, boredom, stress) and interpersonal difficulties (e.g., finances, work, family, etc.). The goal is to develop coping methods to deal effectively with these specific high-risk situations without relying on unhealthy and maladaptive gambling behavior. To date, other than its incorporation into the program outcome studies of Ladouceur and colleagues (e.g., Ladouceur et al., 1998), there has been a paucity of research addressing the effectiveness of relapse prevention in the gambling field.
 
Readers interested in this area have many resources. There are many seminal reviews of behavioral and cognitive behavioral treatment for addictive behaviors; some of these are now classic (e.g., Bandura, 1969; Ellis & Grieger, 1977; Ellis & Whiteley, 1979; Kendall & Hollon, 1979; Mahoney, 1974; Marlatt & Gordon, 1985; Meichenbaum, 1977). Recently, Kadden (2001)  summarized the value of these strategies for alcoholism treatment. Kadden's summary also applies to gambling and the range of addictive behaviors.

¹Portions of this article are from a new chapter, "The treatment of gambling related disorders," by Shaffer and LaPlante (in press) in Relapse Prevention. G. A. Marlatt and D. M. Donovan. New York, Guilford.
²Although this article primarily focuses on addictive behaviors, the discussion and its application are not limited exclusively to the addictions. Many of the treatment strategies and techniques described in this article also will apply to other clinical problems.

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