About 75 per cent of people who complete treatment for problem gambling are abstinent after six months (Toneatto & Ladouceur, 2003). This number decreases to approximately 50 per cent after one year and to just over 25 per cent after two years (Toneatto & Ladouceur, 2003).
Given the high rate of relapse, it is critical to develop a relapse prevention plan with your clients to ensure they have the knowledge and skills they need to achieve their treatment goals.
This page gives an overview of the evidence supporting the use of relapse-prevention approaches for clients with gambling problems and what you can do to help your clients stay in recovery. This information is intended for providers of mental health and addiction services. It is based on a review of the literature and was reviewed by an expert in the field.
About relapse prevention
Relapse prevention is an approach that helps people who are trying to change their behaviour learn to anticipate and cope with situations that might cause them to relapse (Marlatt & George, 1984). The goal of treatment in this model can either be to stop the behaviour entirely, or to establish limits or controls over the behaviour (Marlatt & George, 1984).
While there is a lack of consensus on what constitutes a relapse in problem gambling, it can be helpful to understand the distinction between a lapse and a relapse as defined in the field of substance use research (Ledgerwoord & Petry, 2006).
In a lapse, the person briefly behaves in a way that is inconsistent with their behaviour change plan (e.g., having one drink after deciding to abstain entirely) (Ledgerwoord & Petry, 2006). In a relapse, the person feels they are unable to control their drinking or continues to drink after a period of abstinence (Ledgerwoord & Petry, 2006).
The goal of relapse prevention approaches is to identify the situations that put the person at high risk of relapse and increase the person’s ability to cope with them (Echeburúa et al., 2000). In problem gambling, these approaches are traditionally implemented after the client has completed a course of treatment, however they can also be implemented as soon as they start treatment (Echeburúa et al., 2000).
What does the evidence say?
While there is limited literature on the use of relapse-prevention approaches for problem gambling, research suggests these approaches can reduce the frequency of gambling and the amount of money lost up to 12 months after treatment (Echeburúa et al., 2000; Korn & Shaffer, 2004).
Evidence suggests that specific types of situations can trigger gambling relapses, such as certain settings (e.g., casinos and lottery outlets), difficult feelings (e.g., depression, boredom and stress) and interpersonal problems (e.g., financial, work and family) (Korn & Shaffer, 2004; Ledgerwoord & Petry, 2006).
Studies also show that clients can reduce the frequency of their gambling and money lost if they identify the situations that place them at high risk for gambling and if they learn to avoid or cope with these situations (Echeburúa et al., 2000; Korn & Shaffer, 2004).
Cognitive-behavioural therapy has been shown to help people with gambling problems recognize and correct their mistaken beliefs about randomness and high-risk gambling situations (Ladouceur et al., 2001). In addition, cognitive-behavioural therapy has been found to help clients learn to manage their gambling urges, be assertive when feeling pressured to gamble and cope with gambling lapses (Petry et al., 2007).
One important component of relapse prevention is to help clients identify and engage in recreational activities, other than gambling, that are meaningful to them and increase their interaction with others (Dowling et al., 2008; Hodgins & el-Guebaly, 2004; Jackson et al., 2013; Petry, 2005). This component can prevent relapses caused by boredom and an excess of free time that can arise after the client stops gambling (Dowling et al., 2008; Hodgins & el-Guebaly, 2004; Jackson et al., 2013; Petry, 2005).
In one study, running out of money or lacking funds to gamble were the most frequent reasons for quitting. These findings support the use of stimulus control, such as limiting access to money by getting rid of debit and credit cards (Thygesan & Hodgins, 2003).
Mindfulness-based interventions, which cultivate a person’s non-judgmental awareness of their gambling triggers and urges have been shown to reduce gambling behaviours and improve quality of life and mental functioning (Griffiths et al., 2016; Maynard et al., 2018; McIntosh et al., 2016). These interventions may be more likely to be effective when used alongside cognitive-behaviour therapy (Toneatto et al., 2007; Toneatto et al., 2014). However, the long-term benefits in terms of preventing relapses have not been confirmed (de Lisle et al., 2011).
Since problem gambling has a strong impact on family members, it may be beneficial to involve a partner. However, the evidence of family involvement’s effect on long-term relapse prevention is divided at this time (Jiménez-Murcia et al., 2017; Johnson & Nora, 1992; Zion et al., 1991).
Self-exclusion programs, in which the client registers voluntarily with their preferred casino to have themselves barred from the premises, are sometimes used for relapse prevention. The evidence from various studies on the long-term benefits of these programs is inconclusive (Ariyabuddhiphongs, 2013; Ladouceur et al., 2007).
How do I put the evidence into practice?
The first step for relapse prevention is to identify the situations that might put your client at risk of returning to gambling (Korn & Shaffer, 2004; Marlatt et al., 2002).
One tool you can use for this purpose is the Inventory of Gambling Situations, a 63-item self-report questionnaire that can help you and your client develop a relapse-prevention plan that is tailored to their situation and needs (Littman-Sharp et al., 2009).
The next step is to find out if your client’s challenges are due to a lack of awareness of—and capacity to cope with—high-risk situations or lack of motivation, low self-efficacy or anxiety (Marlatt et al., 2002). Interventions that will help your client develop the skills they need will be an important part of the relapse-prevention plan (Korn & Shaffer, 2004).
You may also want to teach your client to visualize different types of gambling situations and ways to deal with them, help them set gambling limits and monitor their money and the time they spend gambling (Korn & Shaffer, 2004).
Encourage your client to practise their new non-gambling behaviours and coping skills (Korn & Shaffer, 2004). Remind them that learning new behaviours in adulthood is not easy, so practising these new skills, with your support and encouragement, will help them prevent relapses (Korn & Shaffer, 2004).
Your client’s confidence in their own capacity to cope with stressful situations will be critical to their success (Marlatt et al., 2002). To this end, help them find opportunities to practise their new coping skills and offer positive feedback to reinforce new behaviours (Marlatt et al., 2002).
Let your client know that lapses and relapses are normal parts of changing any behaviour, including problem gambling (Ledgerwood & Petry, 2006; Marlatt et al., 2002). Help them view lapses and relapses as temporary setbacks and learning opportunities that are a normal part of the behaviour change process rather than failures that are due to a lack of willpower (Johnson & Nora, 1992).
Educate your client about the lapse and relapse processes (i.e., the impact of risk factors and triggers, as well as erroneous beliefs about the likelihood of winning) (Oakes et al., 2012), and the likelihood of lapses or relapses along the way. This will help them cope with the difficulties they will encounter during recovery (Marlatt & George, 1984; Marlatt et al., 2002).
In the following audio clip, a therapist discusses a recent lapse that her client experienced. The therapist uses the event as an opportunity for reflection and learning, asking the client to consider concrete actions she could take to prevent another lapse in the future.
Therapist: Now that you've had a chance to review your IGS results, do you feel that it fits your experience?
Client: Absolutely. It fits to a tee.
Therapist: Your highest score was confidence in skill. This category applies when someone may overestimate the degree to which their skill influences winning at gambling. Can you think of a particular situation where this relates to you?
Client: Oh, for sure. Last week was the hockey playoffs, and I had just gotten paid. I had not gambled for over a month, and I'd gone to a bar to meet some friends. They were talking about the game and who they thought was going to win. This got me excited, and I started to think I could make one bet, just this one time. I was feeling confident about who would win, and the money would help me pay off some of the debt I still had from before.
Therapist: So, what did you do?
Client: I struggled. It was difficult. I ended up betting $500 on the game. I thought it was a sure bet, so I figured I could bet just this one time and then I would stop completely.
Therapist: So, you gambled.
Client: Yes, and I lost. I kicked myself in the butt afterward. I have not told my girlfriend.
Therapist: So, what are you going to do now?
Client: I need to tell my girlfriend. She'll eventually find out.
Therapist: As we had discussed, relapses do happen. It's just like learning to ride a bicycle. You fall off and get back on again. It's part of any change process.
Client: It was a hard lesson to learn. I need to get back on track. I'd been doing so well. And I need to tell my girlfriend what happened.
Therapist: Reflecting back, what do you think you might have done differently?
Client: Well, for one thing, next time I need to meet up with friends, maybe I can choose another place to meet them instead of a sports bar.
Therapist: That's excellent. And what else?
Client: And maybe I won't carry so much money on me. I had just gotten paid. I was supposed to give the money to my girlfriend. She handles the money now. And I need to remember that in the long run, I will lose more than I win. But it was so tempting! The feeling was just overwhelming. I felt like I had no choice but to make the bet. I really believed I was going to win.
Therapist: Yes, finding another place to meet with your friends would be a good idea. As we had discussed previously, relapse does happen. Treat it like a learning experience. Maybe what we can discuss next are ways of coping with your feelings so that they don't become overwhelming. And we can also look at the other high-risk areas from your IGS. How does that sound?
In some cases, you might suggest that your client consider joining a 12-step program, such as Gamblers Anonymous. While this type of program will not be suitable for everyone, some clients find them to be a source of social support and coping skills development, which may help them sustain their motivation throughout the recovery process (Korn & Shaffer, 2004).
As people find themselves with more free time once they stop gambling, scheduling and engaging in pleasurable and meaningful activities will also be important (Dowling et al., 2008; McIntosh et al., 2016; Petry, 2005). Explain that these activities may not give them as much short-term pleasure as gambling did, but will likely provide more satisfaction and long-term benefits without having the negative impacts of problem gambling.
The Antecedent-Behaviour-Consequence (ABC) Model of Gambling Events can help clients break down their gambling episodes into the antecedents (triggers), behaviour (gambling) and consequences of gambling. This can be useful for understanding the role gambling plays in your client’s life. It is important to note that when using this handout in session with your client, the process does not need to flow from A to B to C; instead, you can adapt it to your client’s needs and the situation.
Triggers to Problem Gambling is a brainstorming activity that helps you and your client identify their triggers and classify them under three categories: events, thoughts and feelings. This activity can help your client understand the various ways that triggers can manifest and lead to gambling.
Early Coping Strategies is a worksheet that you can use to help your client brainstorm coping strategies they can implement to prevent relapse. You can use this worksheet in both one-on-one and group settings, as well as for brief interventions.
Dealing with urges is an exercise that helps you guide people with gambling problems evaluate their existing coping skills and think about the best ways to manage urges. It can also help in the development of an individualized treatment plan.
Mindfulness-Based Relapse Prevention for Problem Gambling is a manual for an eight-session mindfulness group aimed at people with gambling problems who want to add to their relapse-prevention skills. The manual includes lesson plans for facilitators as well as handouts for clients.
The inventory of gambling situations (IGS) is a 63-item self-report questionnaire that can be completed with the support of a therapist or alone. The tool helps users identify situations that put clients at risk for problem gambling or relapse for those who have a plan to reduce or eliminate their gambling (Littman-Sharp et al., 2009). The tool asks the client to consider their last 12 months and helps them understand different scenarios where they are more likely to gamble. The IGS user guide can help clinicians become more familiar with how to use the tool, the scoring and considerations when using it.
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