divider

Cognitive behavioural therapy (CBT) for problem gambling

Introduction

Cognitive behavioural therapy (CBT) is a best practice for treating gambling problems (Cowlishaw et al., 2012; Menchon et al., 2018; Yakovenko & Hodgins, 2016). In an effort to minimize the harm that gambling behaviour has on a person’s life, CBT teaches them to identify, question and change their thoughts and behaviours(Rector, 2010).

People who have gambling problems often experience cognitive distortions (faulty thinking), impulsiveness and poor decision-making. Challenging these cognitive distortions is an effective way to reduce gambling behaviour and stay in recovery (Fortune & Goodie, 2012; Rossini-Dib et al., 2015). Research has shown that CBT reduces gambling behaviour by helping the person identify the thoughts, attitudes and beliefs that lead them to gambling (Cowlishaw et al., 2012; Menchon et al., 2018; Yakovenko & Hodgins, 2016). After identifying what leads a person to gamble, they can then develop strategies to help them change their thought processes, which ultimately can impact their decision-making (Fong & Rosenthal, 2009; Raylu & Oei, 2010).

This page considers the scientific evidence for CBT and problem gambling and offers practical advice on how to use CBT to help clients gamble less. The content is based on a review of the evidence and was reviewed by an expert in the field of problem gambling.

About CBT

CBT is an intensive, short-term form of structured psychotherapy that takes a problem-oriented and goal-focused approach (Cowlishaw et al., 2012; Menchon et al., 2018; Yakovenko & Hodgins, 2016). CBT focuses on the relationship between a client’s thoughts, feelings and behaviours, and teaches them strategies and skills to identify and change problematic thoughts and behavioural patterns (Rector, 2010).

When used to treat problem gambling, CBT includes the following elements (Fong & Rosenthal, 2009; Raylu & Oei, 2010):

In CBT, the clinician works with the client to identify, question and change thoughts, attitudes and beliefs that may be at the root of their emotional and behavioural difficulties (Rector, 2010). The client learns to better manage problems by identifying and correcting cognitive distortions and by seeing thoughts as ideas and beliefs rather than as facts (Rector, 2010). For instance, a client may believe that wearing a lucky hat will increase the odds of winning at slots. Logically, wearing the hat does not influence the outcome of the client’s play, but believing that it does could cause the person to gamble beyond their intended limit (Fortune & Goodie, 2012).

Other examples of cognitive distortions in problem gambling include believing that skills or knowledge can influence the likelihood of winning at cards or sports betting, that playing longer will allow them to recoup losses, and that a certain outcome, such as a rolling a “6,” is due to happen (Fong & Rosenthal, 2009).

For an overview of CBT approaches to problem gambling, watch the video below.

 

Download transcript

What does the evidence say?

A Cochrane systematic review found that CBT reduces both the amount of money lost and the severity of gambling (Cowlishaw et al., 2012). Another systematic review and meta-analysis found that CBT is highly effective in reducing problem gambling for all types of gambling up to 24 months after people complete therapy (Gooding & Tarrier, 2010).

Research also shows that CBT is effective for problem gambling in diverse populations, offering equal chances of recovery regardless of the person’s age, gender, ethnicity or psychiatric comorbidity (Fortune & Goodie, 2012; Champine & Petry, 2010).

CBT is effective not only in an in-person, one-on-one format, but also when delivered in group settings or through self-directed online programs with minimal therapist support (Carlbring et al., 2012; Carlbring & Smit, 2008; Marceaux & Melville, 2011). A systematic review of internet-based CBT also found that this format is as effective as in-person CBT (Hedman et al., 2012).

How do I put the evidence into practice?

One main goal of CBT when treating clients with problem gambling is to help them become aware of their cognitive distortions related to winning and losing (Cowlishaw et al., 2012; Fong & Rosenthal, 2009; Menchon et al., 2018; Raylu & Oei, 2010; Yakovenko & Hodgins, 2016). You can help your client become aware of their cognitive distortions by helping them trace the development of their gambling problem. In addition, you can teach clients how to analyze their gambling-related decisions and motivations, as well as their adoptions of rituals, techniques or strategies that they believe will increase their likelihood of winning (Fong & Rosenthal, 2009; Raylu & Oei, 2010).

Once the client is aware of their own cognitive distortions, you can then help your client modify the distortions by highlighting the discrepancies between their beliefs and reality (Cowlishaw et al., 2012; Fong & Rosenthal, 2009; Menchon et al., 2018; Raylu & Oei, 2010; Yakovenko & Hodgins, 2016). The objective here is to refute the cognitive distortions by helping clients realize that there is no connection between gambling beliefs and gambling outcomes (Fortune & Goodie, 2012; Rossini-Dib et al., 2015).

The next step is to work with your client to identify and implement strategies to manage gambling urges. At the intermediate stages of therapy, the goal is to develop a plan to prevent potential relapses (Fong & Rosenthal, 2009; Raylu & Oei, 2010). Clinical experience indicates that both identifying a client’s reasons for gambling, along with recognizing the role of gambling in coping with their challenges or life circumstances, are key when using CBT to treat problem gambling.

The Inventory of Gambling Situations (IGS) is an evidence-based tool that you can use to help your client identify the situations that lead them to gamble and create an effective plan for relapse prevention (Littman-Sharp et al., 2009).

Healthy equity considerations

As you and your client discuss their feelings toward gambling and their treatment goals, keep in mind that cultural beliefs and values may shape their ideas about gambling and their help-seeking behaviours (Okuda et al., 2009; Raylu & Oei, 2004). For example, people from cultures that favour gambling, such as some Asian cultures with a strong belief in luck, are more likely to gamble and to develop problems with gambling compared to people from other cultures (Raylu & Oei, 2004).

Culture also influences both the types of gambling that are socially acceptable as well as the likelihood that a person will seek help for their problem gambling (Raylu & Oei, 2004). For some immigrants, stresses related to acculturation can increase the likelihood of developing problem gambling (Raylu & Oei, 2004).

Clinical Simulation

This clinical simulation video shows what CBT may look like when working with a client who has problem gambling. This video represents the fourth session between the therapist and client. The client and clinician have already identified problem areas and treatment goals, and have a good therapeutic alliance and trust. Note the clinician’s use of CBT to prevent relapses by identifying triggers and the function of gambling in the client’s life.

 

Download transcript

Additional resources

CBT Overview

Understanding Your Gambling

Changing Your Thinking

Dealing with Urges

Slipping and Relapses

References

Carlbring, P., Degerman, N., Jonsson, J. & Andersson, G. (2012). Internet-based treatment of pathological gambling with a three-year follow-up. Cognitive Behaviour Therapy, 41 (4), 321–334.

Carlbring, P. & Smit, F. (2008). Randomized trial of Internet-delivered self-help with telephone support for pathological gamblers. Journal of Consulting & Clinical Psychology, 76 (6), 1090–1094. Available: https://doi.org/10.1037/a0013603. Accessed February 25, 2021.

Champine, R.B. & Petry, N.M. (2010). Pathological gamblers respond equally well to cognitive-behavioral therapy regardless of other mental health treatment status. American Journal on Addictions, 19 (6), 550–556. Available: https://doi.org/10.1111/j.1521-0391.2010.00085.x. Accessed February 25, 2021.

Cowlishaw, S., Merkouris, S., Dowling, N., Anderson, C., Jackson, A. & Thomas, S. (2012). Psychological therapies for pathological and problem gambling. Cochrane Database of Systematic Reviews, 2012 (11), 1–91. Available: https://doi.org/10.1002/14651858.CD008937.pub2. Accessed February 25, 2021.

Fong, T.W. & Rosenthal, R. J. (2009). Individualized treatment for problem gamblers. Available: https://www.idph.iowa.gov/Portals/1/userfiles/83/Treatment%20Tool%20Chest/CBT-Therapist.pdf. Accessed April 6, 2021.

Fortune, E.E. & Goodie, A.S. (2012). Cognitive distortions as a component and treatment focus of pathological gambling: A review. Psychology of Addictive Behaviors, 26 (2), 298–310. Available: https://doi.org/10.1037/a0026422. Accessed February 25, 2021.

Gooding, P. & Tarrier, N. (2009). A systematic review and meta-analysis of cognitive-behavioural interventions to reduce problem gambling: Hedging our bets? Behaviour Research and Therapy, 47 (7), 592–607. Available: https://doi.org/10.1016/j.brat.2009.04.002. Accessed February 25, 2021.

Hedman, E., Ljóttson, B. & Lindefors, N., (2012). Cognitive behavior therapy via the Internet: A systematic review of applications, clinical efficacy, and cost-effectiveness. Expert Review of Pharmacoeconomics & Outcomes Research, 12 (6), 745–764. Available: https://doi.org/10.1586/ERP.12.67. Accessed February 25, 2021.

Littman-Sharp, N., Turner, N.E. & Toneatto, T. (2009). Inventory of Gambling Situations: User’s Guide. Toronto: Centre for Addiction and Mental Health. Available: https://learn.problemgambling.ca/PDF%20library/IGSUserGuide_2009.pdf. Accessed February 25, 2021.

Marceaux, J.C. & Melville, C.L. (2011). Twelve-step facilitated versus mapping-enhanced cognitive-behavioral therapy for pathological gambling: A controlled study. Journal of Gambling Studies, 27, 171–190. Available: https://doi.org/10.1007/s10899-010-9196-y. Accessed February 25, 2021.

Menchon, J.M., Mestre-Bach, G., Steward, T., Fernández-Aranda, F. & Jiménez-Murcia, S. (2018). An overview of gambling disorder: From treatment approaches to risk factors. F1000Research, 7 (434). Available: https://doi.org/10.12688/f1000research.12784.1.

Accessed February 25, 2021.

Okuda, M., Balán, I., Petry, N. M., Oquendo, M. & Blanco, C. (2009). Cognitive-behavioral therapy for pathological gambling: cultural considerations. The American Journal of Psychiatry, 166 (12), 1325–1330. Available: https://doi.org/10.1176/appi.ajp.2009.08081235. Accessed February 25, 2021.

Rector, N.A. (2010). Cognitive-behavioural therapy: An information guide. Available: https://www.camh.ca/-/media/files/guides-and-publications/cbt-guide-en.pdf?la=en&hash=BDA5FF472AA16E82C6AAE307EBCD3BE50347 FBFE. Accessed February 25, 2021.

Rossini-Dib, D., Fuentes, D. & Tavares, H (2015). A naturalistic study of recovering gamblers: What gets better and when they get better. Psychiatry Research, 227 (1), 17–26. Available: https://doi.org/10.1016/j.psychres.2015.03.003. Accessed February 25, 2021.

Raylu, N. & Oei, T. P. (2004). Role of culture in gambling and problem gambling. Clinical Psychology Review, 23 (8), 1087–1114. Available: https://doi.org/10.1016/j.cpr.2003.09.005. Accessed February 25, 2021.

Raylu, N. & Oei, T. P. (2010). A Cognitive Behavioural Therapy Programme for Problem Gambling: Therapist Manual. New York: Routledge.

Yakovenko, I. & Hodgins, D. C. (2016). Latest developments in treatment for disordered gambling: Review and critical evaluation of outcome studies. Current Addiction Reports, 3 (299). Available: https://doi.org/10.1007/s40429-016-0110-2. Accessed February 25, 2021.