Recovering from Disordered Gambling

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

Perhaps more than any other question, people ask about the treatments that are available for dealing with gambling disorders. Before getting to this specific question, it is very important to understand that treatment is just one of several pathways to recovery. Like many other addictive behavior patterns (e.g., Cunningham, Sobell, Sobell, & Kapur, 1995; Schachter, 1982; Shaffer & Jones, 1989; Sobell, Cunningham, & Sobell, 1996; Sobell, Ellingstad, & Sobell, 2000; Waldorf, 1983; Waldorf & Biernacki, 1979, 1981; Waldorf, Reinarman, & Murphy, 1991; Winick, 1962), there is evidence that people with gambling disorders have the ability to change without formal treatment (e.g., Hodgins, Wynne, & Makarchuk, 1999); those who recover from addictive disorders without treatment tend to have milder forms of the disorder and fewer co-existing problems that complicate the recovery process. Similarly, recovery need not always come from experience with clinicians, since self-help, like Gamblers Anonymous or self-directed recovery, is also an option.

UNASSISTED OR "NATURAL" RECOVERY

Conventional wisdom has assumed that there are only two ways out of any addiction: treatment or death.  However, almost every adult knows someone who has stopped smoking cigarettes without having participated in treatment (e.g., Schachter, 1982).  Since Winick (1962) first described "maturing out" of narcotics use, the idea of recovery from addiction without treatment has captivated many clinical investigators.  Recent research suggests that recovery from addiction without formal or informal treatment is more common than previously expected (Cunningham et al., 1995; Hodgins et al., 1999; Sobell et al., 1996). If gambling disorders are similar to substance use disorders, then it is likely that people without treatment recover from gambling disorders at rates similar to the rate of "natural" recovery from other addictive disorders. Naturally recovering gamblers are interesting and important groups to understand since they might provide important insights into both treatment seekers and important elements of treatment that are not currently part of formal treatment protocols.

ASSISTED RECOVERY

Not everyone can – or believes they can – effectively evoke natural recovery processes. Consequently, although many revise their behavior without treatment (e.g., Cunningham et al., 1995; Schachter, 1982; Shaffer & Jones, 1989; Sobell et al., 1996), a lot of people seek treatment and recovery via clinical pathways.

COMMON FACTORS AND TREATMENT OUTCOME

To date, clinicians and scientists have not accepted any particular treatment as the standard for gambling related problems. Consequently, like many other disorders, nonspecific or common factors account for a considerable amount of treatment outcome (e.g., Frank, 1961; Hubble, Duncan, & Miller, 1999).  Hubble et al. (1999) suggest that nonspecific treatment factors include (1) the extra-therapeutic attributes that clients bring with them to treatment (e.g., education, family support, etc.); (2) relationship factors displayed by the treatment provider (e.g., empathy, caring, warmth, etc.); and (3) the hope, expectancies and placebo effects that are often associated with the start of treatment. Thus, the unique effects of particular treatment programs might be easily mistaken for nonspecific effects that accompany all treatment programs. Estimates of specific effects for treatment programs are likely best identified via empirical research.

A full discussion of the nonspecific factors that influence treatment outcome is beyond the scope and intent of this article. However, there are many useful resources for readers interested in the factors common to successful treatment (e.g., Frank, 1961; Havens, 1989; Hubble et al., 1999; Imhof, Hirsch, & Terenzi, 1984; Maltsberger & Buie, 1974; Miller, 2000; Miller et al., 1995; Polanyi, 1967; Schon, 1983; Shaffer, 1994; Shaffer & Robbins, 1991; Shaffer & Robbins, 1995).  Recognizing nonspecific treatment effects within treatment episodes holds the potential to maximize treatment benefits.

TREATMENT STRATEGIES

Gambling disorders have a variety of characteristics that require treatment attention.  As a syndrome, gambling disorders have common and unique elements. The common attributes, like anxiety or depression, are shared with many other mental disorders. The unique elements, like increasing the size of wagers to get the same level of excitement as experienced with lesser bets, are exclusive to gambling problems. Like other syndromes (e.g., AIDS), gambling might respond best to a ÒcocktailÓ approach. This treatment strategy considers and combines many different resources for help-seeking patients. For example, pharmacotherapy and various forms of psychotherapy and counseling (e.g., individual, group, family, and financial) combine to address biological, cognitive, and behavioral problems. Each of these treatments are available in short- and longer-term configurationsÑsometimes limited only by insurers and managed care companies. New and exciting medications are available to people with gambling disorders, including opioid antagonists (e.g., naltrexone), selective serotonin reuptake inhibitors (SSRIs) and mood stabilizers; other drugs also are being tested.
  
There currently is insufficient information about the long-term effectiveness of the various treatment approaches. Treatment outcomes should be evaluated against standards similar to the criteria clinicians use to assess the effectiveness of cancer treatments, meaning they should be judged against five-year follow-up rates. Anything less than this time frame can be very misleading. Short-term gains should not provide a false sense that all risk of relapse is over.
In the next issue: the specific behavioral treatments available for gambling disorders.

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