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Almost all treatment approaches for pathological gambling have been modelled after preexisting substance addiction models (1). Recent studies have provided initial evidence for the validity of gambling as “a dependence without drugs” (2–4). Nonetheless, the overlap of etiologic and clinical aspects with substance dependence is not a complete one, calling for the investigation of treatment techniques specific to gambling psychopathology. In the 1960s, the first behavioural approaches in gambling treatment were based mostly on aversion therapy; however, subsequent case reports and small, uncontrolled studies failed to provide consistent evidence of its usefulness (5). Since the late 1980s, case reports described the treatment of pathological gamblers based on cognitive therapy (6,7), which also brought a renewed interest in behavioural interventions (8,9). This paper reviews the new generation of cognitive-behavioural models in a search for original insights that are specific to gambling treatment. MethodWe conducted a computerized search of the literature on Medline and PsycINFO databases from 1965, using the following key words: gambling, treatment, cognitive, cognition, and behaviour therapy. The abstracts of the articles identified on this search were examined, and articles addressing cognitive and behavioural techniques that were empirically tested for pathological gambling were selected. Further, to enhance the search, other relevant articles were drawn from the reference lists. Behavioural Approaches to GamblingBased on the principles of classical and operant conditioning theory (10), the first behavioural treatments for gambling tried coupling aversive stimuli, usually small electrical shocks, to the memory of gambling. Two studies comparing aversion therapy with other treatment modalities (11,12) failed to confirm an initial enthusiasm prompted by case reports (13–19). Dickerson first emphasized the role of intermittent reinforcement schedules in the persistence of gambling (20). Petry and Roll highlighted 4 other factors that related to operant learning principles found in gambling (21). First, low response cost relates to the effort required to place a single bet and to the possibility that winning is usually low, from both physical and economic points of view. Second, magnitude of reinforcement indicates that, to guarantee the business profitability, gambling odds have to be in favour of the gambler losing money rather than winning. Nevertheless, occasional big wins are expected, providing the illusion of a pro-player activity. Priming, the third, signifies that gambling machines will also offer small wins, which aside from lowering the cost of continuous playing and enhancing variability of the reinforcement schedule, may also suggest that a bigger win is just around the corner. Other priming strategies include casinos’ sending invitations for a free meal to regular customers who have been away for longer than usual. Fourth, immediacy in deliverance of the reinforcement is crucial; recent evidence has demonstrated that fast-paced gambling machines are more likely to develop problem gambling than are lotteries and other games that allow longer intervals between the bet and the outcome (22). Indeed, gambling reinforcement schedules seem like a real-life compendium of Skinnerian principles. The operant conditioning approach, however, does not explain the recurrence of gambling behaviour after a gambling session is terminated, including relapses after long-term abstinence (23). Brown postulated that the arousing properties of gambling enabled the association of the behaviour to circumstantial stimuli (24). Such stimuli would become triggers for gambling behaviour. For this reason, Brown proposed a return to the classical conditioning model—but this time, with emphasis on cue exposure rather than on aversion therapy (25). Two therapeutic processes of exposure and desensitization have been described: imaginal and in vivo. The imaginal exposure has the patient seated or lying down and relaxed. Next, the therapist asks the patient to mentally picture the typical circumstance that leads to gambling. The therapist conducts the client through a script, whereby the patient ends up with a mental picture of facing a gambling opportunity. At this point, the therapist actively suggests a response other than gambling (that is, to leave the place and to engage in another activity). The session ends with breathing and other relaxation techniques (26). In vivo exposure follows the same process: it leads the patient to face a gambling opportunity and then prevents the response. Yet, it differs in that the client is asked to actually stand for a while in front of the gambling machine, table, or game device. To reduce the potential for relapsing, the client is gradually exposed by manipulating other elements; specifically, distance, money availability, and external aide from a cotherapist (27–29). Data on the efficacy of both methods are scarce. Imaginal desensitization compared positively over aversion therapy in 1 study (11). In vivo exposure has been compared with cognitive restructuring, using a combination of both techniques and with a waiting list control group (9). In vivo exposure had the best outcome. Surprisingly, the combined treatment did not show a better outcome than did the waiting list. Only 1 study compared both exposure methods (12). In this study, we compared imaginal desensitization with in vivo exposure, aversion therapy, and relaxation technique. Imaginal desensitization had the best outcome, and aversion therapy had the worst outcome. Yet, brief descriptions preclude appraising whether the in vivo exposure was properly conducted. In fact, Echeburua has stressed the importance of carefully coaching the patients to observe gambling machines, as well as to watch players, but to restrain from actively following the outcomes on the screen, which could be equivalent to a mental relapse that would invalidate the exposure (9). Further, behavioural approaches have been criticized for not taking into account individual differences and internal processes, such as personality, cognitions, and emotions (23,25,30).
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