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Are There Cognitive and Behavioural Approaches Specific to the Treatment of Pathological Gambling?
Cognitive Approaches to Gambling
The behaviourists’ dismissal of internal processes left a void that was later occupied by cognitive theory. Since the late 1970s, authors have pointed out how random outcomes in chance games influenced cognition and how distorted thinking is associated with gambling persistence (31–33). To crack the mind’s “black box,” researchers have applied a method called “thinking aloud,” which includes subjects taking part in gambling and in talking about their reactions and interpretations of the outcome (34). Initially, this method was used in the laboratory (6,34,35) and then further validated in actual gambling settings (36–40). These studies demonstrated that a series of small wins prompted illusions of skill and control over chance games, as well as a direct relation between irrationality and increased values per bet (41). Moreover, cognitive researchers have pointed out that, in addition to the variable intermittent schedule of reinforcement prompted by chance, other features have been added to games that may further reinforce false beliefs of control and skill. Games like Keno allow the player some choices, such as controlling the speed of the draw and selecting the numbers before the draw takes place. Although none of these actions can influence the outcome, the players are more confident in a positive outcome if they are the ones choosing rather than having to endorse a predetermined setting (42). The other mechanism is the so-called “near-miss effect,” (43), which is more readily observed in scratch cards, slot machines, and other games that require the gambler to obtain a series of numbers or symbols, (for example, 2 cherries in a row when the minimum prize combination is 3). Usually by law, gambling operators are forced to ensure game fairness by guaranteeing the randomness of the general outcome and by assuring a minimum proportion between wins and losses. Near misses occur more frequently than expected if due to chance, and they augment the reinforcing properties of gambling at no extra expense to the game’s owner (44).
Recently, Toneatto catalogued several types of cognitive distortions that are held by pathological gamblers (45). In summary, the distortions evolve around misconceptions about randomness and its main derivatives: unpredictability and independence of events (46). Prediction skills play, at best, only a partial role in gambling (that is, in horse races, sports betting, or cards), and virtually no role in games such as craps, slot machines, lotteries, and video lottery machines. Likewise, because each draw is independent, the next outcome will hold no commitment to past results or to the gambler’s needs. Nevertheless, gamblers believe that their actions, their betting choices, or their personal attributes are likely to influence the outcome. This is usually expressed in terms of “gambling systems,” held by heavy gamblers (47), which combine reading spurious signs in the environment, becoming confident in their ability to persuade fate, and using betting methods with varying degrees of complexity that deny the independence of events.
Cognitive restructuring therapy is based on identifying false beliefs about gambling and replacing these with realistic understandings (6). Cognitive restructuring is most likely the most studied treatment modality for pathological gambling (48), but most reports are still based on uncontrolled case series (6,7,49–52). So far, 2 controlled studies have evaluated cognitive restructuring for pathological gambling. In 1 study, cognitive restructuring was part of a treatment package that also included problem-solving, social skill training, and relapse prevention (53). This study, however, did not discriminate between whether therapeutic success was due to cognitive restructuring or to other techniques in the package. Hence, Ladouceur and colleagues compared a cognitive restructuring that solely combined with relapse prevention, with a wait-list control group (46). In general, the studies showed that treated subjects had significantly improved on various measures, such as frequency of gambling, perception of control, perceived self-efficacy, and desire to gamble.
Eliciting and Addressing Cognitive Distortions in Gambling Treatment
As originally proposed, cognitive restructuring should be carried out on an individual basis in weekly sessions. In the first session, the therapist trains the patient to keep a journal, with the intent to monitor gambling behaviour and related thoughts and triggers. The subsequent sessions open with a review of the previous week and with an examination of the journal in a search for triggers and gambling cognitions to be challenged (46). Although proven efficient, this structure has constraints, 2 of which are limiting therapeutic interventions to 1 patient at a time and depending upon the patient’s ability and willingness to provide an adequate journal. In our treatment centre, we have worked on adapting cognitive restructuring and other therapeutic tools for group therapy. To complement the journal, we developed group exercises that were meant to elicit and address common misconceptions about gambling. Each exercise takes 1 session.
For instance, the most common distortion about gambling, “gambler’s fallacy,” refers to gamblers who assume that machines that have produced several losing outcomes are more likely to produce a win on the next bet. Some of these beliefs include the following: “If you take your time, or ask the bartender, you will find out the machine that has taken too much money that day. That machine is due!” or “It is best to go to the casinos when they are about to close because by then the machines are full and they have to give back some of the money they’ve taken.” To deal with such misconceptions, we play the following exercise: 1 patient sits in a corner of the room, holding 3 stacks of plastic chips, while another holds a die in the opposing corner. The therapist assumes the role of a desperate gambler about to place a bet, while the patients represent different parts of the machine. The die keeper is the computer with its random number generator; the stack holder represents the money compartment. The therapist explains to the “machine” that it has taken a lot of money from several people including himself, and now it is time to pay back. The following is a session’s excerpt:
Therapist: How are you feeling John?
John (the stack holder, laughing): I am loaded. I wouldn’t mind sharing some with you.
Therapist: How about you Anne?
Anne (the die holder): I feel terrible. I certainly would like to help you.
Therapist: Yes, but you are a machine—you obey a program, and all you can do is throw the die. I will win if number 6 comes up, and I will lose if any other number comes up. But before you throw the die, let’s talk to John again. John, what can you do?
John: Nothing!
Therapist: Are you sure? Explain to Anne that you are full.
John: She will throw the die anyway.
Therapist: Then yell at the die; do something!
John: It won’t make a difference—wait a second, isn’t there any sensor that can indicate to the program that I am full?
Therapist: There is no such thing. You are different parts of the machine, and you do not communicate. Even if you did, all she could do is throw the die, and my chances are still 1 out of 6.
John pales: Then a machine is never due.
A third patient: You are lucky if you are in front of the machine when it turns the right way, but since it is random, you can never say when it is going to happen.
The therapist may allow some die throws for further illustration. In 1 situation, a patient threw the die several times, and the number 6 came up in the first 2 throws, prompting cheers from other group members and more distorted statements such as, “I feel lucky! Does anyone want to rub me?” These statements illustrate what Toneatto has called superstitious beliefs and perception of luck as contagious (45). The strategy to deal with this particular situation was to allow the client to throw the die more times until losses had clearly outnumbered wins. A cotherapist took note of all distorted statements prompted by the prolonged exercise, and they were addressed at subsequent sessions. In the same way, immediately following the group session, for the patient who threw the die, a brief 20-minute individual session was performed to prevent a relapse triggered by potential insufficient debriefing.
Integrating Behavioural and Cognitive Perspectives
Sharpe and Tarrier proposed an integration of behavioural and cognitive insights as follows: 1) operant conditioning factors that relate to gambling prompt initial persistence at gambling, 2) continuous exposure to variable intermittent schedules of reinforcement foster the development of unrealistic expectations toward gambling and further investment in the activity, 3) repeatedly experiencing the arousing effects of gambling consolidates the establishment of conditioned cues that prompt reoccurrence of the behaviour, even when the gambler contemplates reduction or abstinence (23). At the core of this model, however, lies the gambler’s lack of coping skills that result in vulnerability to craving and relapses. Attempts at empirically testing such integration have only begun and have yielded contradictory results. In fact, 2 studies reported a positive correlation between irrational verbalizations and heart rate, suggesting that cognitive processes could mediate arousal at gambling (37,54). Conversely, Coventry and Norman failed to find such association, indicating that, with persistence of gambling, the initial weight of cognition is transferred to automatic conditioned reactions (55).
Integrative models usually result in additional interventions that attempt to address the shortcomings of the cognitive-behavioural approach (for example, acknowledging the roles of individual differences, personality, and emotions). Blaszczynski and Silove noted that, if principles of behavioural conditioning sufficed, all subjects exposed to gambling would become pathological gamblers (8). The same can be said of misconceptions about randomness, whereby a game as simple as coin tossing can induce gambling in normal subjects (56). Brown adds to the classical conditioning model the components of optimum level of arousal theory, and the dissociation properties of gambling (24,25). According to Brown, excitement and temporary relief from negative emotional states would constitute the main reinforcements of gambling, but what remains to be explained is how these reinforcements could keep their strength in the face of obvious progressive damage. One possible explanation is that most often the positive outcomes of gambling are immediate, whereas negative consequences are delayed in time. Using a discount–delay paradigm, Petry has demonstrated that gamblers have difficulty refusing smaller gratification in the face of a bigger-but-postponed reward, indicating difficulties in appraising long-term consequences of their choices (57). This and other studies stress the association between impulsivity and problem gambling and thus could explain the vulnerability to behavioural conditioning by gambling (58).
Cognitive-Behavioural vs Traditional Addiction Approaches—What Is New?
Despite their different origins, cognitive-behavioural and traditional multimodal addiction treatments for gambling share common features; namely, relapse prevention (59) and motivation enhancement (60), as well as problem solving and social skill training (53). However, these techniques have been adapted to gambling without further empirical testing.
New behavioural and cognitive perspectives bring to gambling the treatment features that are alien to the older addiction model. For example, cue exposure, originating from the experience of anxiety disorder treatment, subverts the assumption held by a 12-step philosophy that avoiding triggers is the best strategy to keep relapses away (61). Craving models, on the other hand, hold that repeated exposure to addiction cues will increase craving rather than decrease it (62). However, McConaghy’s behaviour completion model suggested that habitual behaviours develop a mental schema (30). When facing a cue, the subject is stimulated to act; if the behaviour is not completed to the extension of its mental schema, arousal follows. Possibly the result of cue exposure in gambling is a habituation response to the tension caused by resisting gambling when there is an opportunity. Using a neo-Pavlovian model, Brown suggested that future behavioural research in gambling should address the interaction between personality factors and classical conditioning, which in turn could identify the clients who are best suited for this approach (24).
Cognitive psychology has provided the gambling field with original content by considering the unique features of gambling activity. Even so, several points remain to be clarified. Both problem and nonproblem gamblers have distortions. Why do some individuals act upon these false beliefs and others not? Jacobs suggests that, to establish an addiction, the substance or the behaviour has to provide wishful compensatory fantasies to an identity previously harmed by poor parenting or environment misfit (63). Understanding the role of cognitive distortions in filling developmental voids could lead to better treatments. Likewise, it remains to be clarified whether cognitive restructuring treatment is better than other nonspecific therapeutic approaches.
In summary, when treating pathological gamblers, clinicians should introduce techniques to address cognitive distortions toward gambling. A better understanding of gambling and chance processes foster treatment compliance. With the current explosion in gambling opportunities, cue exposure—whether in vivo or imaginal—may help deal with urges prompted by gambling triggers. Notably, such techniques were developed by working groups addressing different cultures (that is, cognitive restructuring by Ladouceur’s group in Canada, in vivo exposure by Echeburua in Spain, and imaginal desensitization by McConaghy in Australia). Such “regionalisms” call for an appraisal of the suitability of these techniques to the patient’s sociocultural background before they are introduced in the treatment.
The blending of these new techniques into a multimodal treatment of addiction potentially balances the rational and external orientation of the cognitive-behavioural approach with interpersonal and introspective components of the more traditional approach to addiction treatment.
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