Clinical Applications Of Responsible Gambling Tools
What is Clinical Decision Support (CDS)?
This training will provide the most up-to-date research on gambling disorders and effective methods to screen clients and will cover the pertinent changes to the diagnostic code for gambling disorder in the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and will provide an overview.
Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.
Clinical decision support (CDS) can significantly impact improvements in quality, safety, efficiency, and effectiveness of health care. The Office of the National Coordinator for Health IT (ONC) supports efforts to develop, adopt, implement, and evaluate the use of CDS to improve health care decision making.
We aim to help the health care industry create the technical infrastructure needed to allow health systems to share data with each other electronically to provide the most complete information possible into CDS systems. Complete records allow CDS systems to help with diagnoses and track for negative drug interactions by having a better view of a patient’s whole health.
CDS has a number of important benefits, including:
- Increased quality of care and enhanced health outcomes
- Avoidance of errors and adverse events
- Improved efficiency, cost-benefit, and provider and patient satisfaction
CDS is a sophisticated health IT component. It requires computable biomedical knowledge, person-specific data, and a reasoning or inferencing mechanism that combines knowledge and data to generate and present helpful information to clinicians as care is being delivered. This information must be filtered, organized and presented in a way that supports the current workflow, allowing the user to make an informed decision quickly and take action. Different types of CDS may be ideal for different processes of care in different settings.
Health information technologies designed to improve clinical decision making are particularly attractive for their ability to address the growing information overload clinicians face, and to provide a platform for integrating evidence-based knowledge into care delivery. The majority of CDS applications operate as components of comprehensive EHR systems, although stand-alone CDS systems are also used.
Optimizing Strategies for Clinical Decision Support
ONC collaborated with the National Academy of Medicine (NAM) to engage key experts and develop a series of strategies and recommendations to optimize CDS in support of improved care. The project’s goals were to identify actionable opportunities to accelerate progress in CDS creation, distribution, and use; inspire action on priority opportunities amongst diverse stakeholder groups; and to drive progress towards a usable, interoperable CDS.
Abstract
Several types of psychotherapy are currently used to treat pathological gamblers. These include Gambler's Anonymous, cognitive behavioral therapy, behavioral therapy, psychodynamic therapy, and family therapy. Research into which types of psychotherapy are the most effective for pathological gambling is limited but is a growing area of study. Group therapy, namely Gambler's Anonymous, provides peer support and structure. Cognitive behavior therapy aims to identify and correct cognitive distortions about gambling. Psychodynamic psychotherapy can help recovering gamblers address core conflicts and hidden psychological meanings of gambling. Family therapy is helpful by providing support and education and eliminating enabling behaviors. To date, no single type of psychotherapy has emerged as the most effective form of treatment. As in other addictive disorders, treatment retention of pathological gamblers is highly variable. Understanding the types of psychotherapy that are available for pathological gamblers, as well their underlying principles, will assist clinicians in managing this complex behavioral disorder.
Introduction
Pathological gambling is a complex biopsychosocial disorder that can have dramatic and devastating consequences on individuals and families. Given the expansion of legalized gambling and society's current acceptance of gambling, the development of effective treatments (pharmacological and nonpharmacological) to stem the development of pathological gambling is crucial. At the present time, a number of different treatment modalities have been applied to pathological gamblers, but no standardized practice guidelines have been developed. In the clinical setting, pathological gamblers are offered a variety of treatment options, including pharmacotherapy, individual psychotherapy, group therapy, and family therapy. Of these, the most likely treatment modality to be used is psychotherapy. Several types of psychotherapy have been employed with pathological gamblers and range from psychoanalysis, cognitive behavioral therapy, psychodynamic psychotherapy, behavioral therapy, family therapy, and group support.
The principles of psychotherapy for pathological gamblers tend to share those used in substance abuse treatment settings; this is due to shared themes of loss of control, preoccupation, and continued engagement in the behavior despite negative consequences. Despite there being a wide variety of psychotherapies practiced with pathological gamblers, the current evidence demonstrating their effectiveness has only recently been the subject of more intense study. Clinical experience suggests that these psychotherapies work by improving motivation to change and self control; precisely how these changes take place and what specific factors are responsible have been the subject of ongoing investigation.
Comprehensive treatment for pathological gambling involves more than psychotherapy, most notably the emerging use of medications to contain the symptoms of this disorder. For those interested in the psychopharmacological management of pathological gamblers, there are a number of well-written reviews by Grant and Hollander.2,
This article is the last of a three-part series focusing on pathological gambling. Part 1 described the biopsychosocial consequences of gambling, and Part 2 focused on portraying the vulnerable faces of pathological gambling. This part will describe the currently available psychotherapeutic strategies that are used with pathological gamblers. Particular emphasis will be placed on illustrating psychotherapy principles that are unique to treating pathological gamblers. Psychotherapeutic treatments for pathological gambling are likely to be used with more frequency and by more providers as additional funding becomes available for pathological gambling treatment and as more gamblers present to treatment. Therefore, it is essential that the clinician be familiar with the various types of psychotherapies that have been formally examined in pathological gamblers.
Throughout history, a number of different approaches have been utilized to deal with pathological gamblers. Some have been dramatic, including eviction from the community to cutting off of the hands, while others have been more supportive, such as individual and group psychotherapy. The primary aim of psychotherapy for pathological gamblers is to achieve total abstinence from gambling. More specifically and more realistically, psychotherapies aim to improve self control, identify ways to deal with risky situations, provide an outlet to address guilt/shame, and teach ways to deal with gambling urges and cravings. Treatment outcomes for pathological gamblers demonstrate that pathological gamblers respond to treatment and that many demonstrate benefits even if they are in treatment for short periods of time.4 Although there are numerous forms of psychotherapy that have been applied to pathological gambling, only a few have been subjected to rigorous study, and the following will be reviewed here: Gambler's Anonymous, cognitive behavioral therapy, the behavioral therapies, psychodynamic psychotherapy, and family therapy.
Gambler's Anonymous
The most available form of psychotherapeutic treatment is Gambler's Anonymous (GA). Formed from the model of Alcoholics Anonymous, GA is widely available in most states and internationally; there are over 1,000 GA chapters in the United States. GA was created in 1957 in Los Angeles, and the meetings follow the 12-step self-help model. The twelve steps are identical to those utilized for substance abuse, except that gambling replaces alcohol or drugs. Meetings are either open or closed and can be found through Internet and phone directories; they are free to members and are available seven days a week in many urban cities. The treatment philosophy of GA is similar to that of other addictive self-help groups—in order to recover, one must “work the steps,” which include gaining a sponsor, completing the 12 steps outside of the meetings, and gaining emotional support and strength by a peer support group. GA members are not allowed to bail members out and are not allowed to take monetary donations. Directives of GA include: 1) attend as many meetings as possible; 2) don't gamble for anything (even office pools); 3) take life “one day at a time;” and 4) utilize the members of the meeting for support. Gambler's Anonymous has a sister organization, Gam-Anon, which is modeled after Ala-Anon and is a support group for family and friends of pathological gamblers. Often, meetings are held at the same time and place as GA meetings and these groups provide a much needed source of emotional support, problem solving ideas, and understanding of pathological gambling.
Although GA is probably the most referred to form of treatment for pathological gamblers, it only has a small amount of empirical data supporting its efficacy. Stewart prospectively followed 232 members of Gambler's Anonymous and found that eight percent of GA members remained totally abstinent after one year and that seven percent remained totally abstinent at two years. This finding has not been replicated and deserves further attention.
In another study, Taber found that 74 percent of clients in a gambling treatment program who were sober went to at least three GA meetings a week, suggesting that GA participation might predict better outcomes. Effectiveness for Gam-Anon has also not been definitely shown. Johnson compared spouses who went to GA versus spouses who did not go to GA and did not find any differences in total time of abstinence from gambling.
One of the reasons why abstinent rates may be so low is that many gamblers do not stay with GA. Much more research is needed to understand the factors for why certain gamblers remain in GA and others do not. Gamblers that have comorbid attention deficit/hyperactivity disorder (ADHD), and high expression of impulsivity (verbally and behaviorally) may have difficulty in engaging and retaining information from GA. Secondly, understanding how abstinent members use GA, in particular what is meant by “working the steps,” would be an important contribution.
Another important characteristic of GA is that all gamblers are considered to have the same disease—there is little distinction between machine gamblers and non-machine gamblers or between male and female gamblers. As a result, clinicians are urged to be aware of what the demographics are of the GA meeting to which they refer patients. Knowing this may be especially important in retaining patients. Finally, clinicians need to be aware that there are clinical differences between gamblers who remain in GA versus those who do not go. Gamblers who attend GA tend to be older, have more severe gambling problems, and more interpersonal tension at home. Most significantly, those who have a past history of attending GA are more likely to remain engaged in professional, individual therapy, suggesting that GA may promote treatment retention. Overall, despite the lack of definitive evidence, the widespread availability and accessibility of GA make it a viable therapeutic option.
Cognitive Behavioral Therapy
The basic principle of cognitive behavioral therapy for pathological gambling is to identify negative thoughts, cognitive distortions, and erroneous perceptions about gambling that are responsible for continued gambling. CBT has been shown to be effective in a number of other psychiatric and addictive disorders., Based on this experience, clinicians and researchers turned toward CBT for pathological gambling in the hopes of achieving the same degree of effectiveness.
Cognitive behavioral therapy for pathological gamblers can occur in a variety of methods ranging from individual to group therapy. CBT may employ a range of techniques from didactic to role-playing to challenging beliefs and attitudes. In most outpatient settings, CBT for pathological gamblers usually lasts for 8 to 15 sessions. The therapy is very active and often includes assignment of homework, feedback, and direction from the therapist.
In etiological theories of pathological gambling, the presence of cognitive distortions about gambling often fuel continued gambling. For instance, Ladoceur showed that erroneous thoughts about gambling persist regardless of what type of game is being played. Commonly, gamblers might believe that they are “due to win” or “I won't lose while I am wearing my lucky shirt.” The “gambler's fallacy” is the persistent belief that a win will be coming soon even though outcome of bets are based on random chance. Pathological gamblers also believe their gambling abilities are unique in that they are able to control random events. Pathological gamblers also feel that gambling is the solution to life's problems, especially financially. Finally, gamblers often have distorted views of the odds of a game or how the casino industry contributes to gambling addiction. Once these erroneous perceptions are identified, clients are directed to alternative ways of thinking, which, in theory, will lead to reduced gambling or improved control over gambling.
The cognitive component of CBT deals with identifying cognitive distortions, erroneous perceptions, and false expectations of gambling. A common exercise is to describe risky life situations that might trigger relapse. This might include driving by a local casino, having extra cash on hand, or recently being paid. Once identified, the therapist and the client devise a problem-solving approach on how to avoid or handle that situation. CBT for gamblers appears to work best for highly motivated and insightful gamblers. It is not recommended for those who are struggling with insight, have extensive comorbid disorders, or who have trouble sustaining attention. One of the strength's of CBT is that it can identify an individual's unique erroneous thoughts or cognitive distortions (i.e., not all gamblers have the same cognitive distortion), and this type of therapy provides the flexibility to identify each of them separately.
Behavioral management techniques to use with pathological gamblers include limiting access to money and/or increasing the degree of difficulty to gamble. For example, Internet gamblers are encouraged to disconnect the Internet while casino gamblers may be eligible to sign up for a self-exclusion ban from the casino. Ongoing data regarding the effectiveness of self-exclusion on lifetime gambling rates is ongoing, but early evidence suggests this type of intervention may be helpful for motivated gamblers with strong social supports., Recovering gamblers are also encouraged to take themselves off mailing lists from the casino, to meet with a financial planner, to cancel all credit cards, and to turn over control of money to another person. Each of these behavioral interventions is designed to increase the difficulty of obtaining access to money to gamble. Much like the philosophy of limiting access to drugs of abuse, there has been very little data to empirically support these behaviors even though they may appear to be quite sensical on the surface.
In terms of data to support CBT for gamblers, there have been several studies documenting its effectiveness. Ladouceur has demonstrated that CBT is quite effective for early intervention of pathological gamblers. In this study, 66 gamblers were assigned to either CBT or to a wait-list control condition. Those who received CBT had significantly improved outcomes in perception of control, frequency of gambling, perceived self-efficacy, and desire to gamble. Sylvain reported similar results of CBT effectiveness versus waiting-list controls in 29 male pathological gamblers. Most recently, Petry evaluated the efficacy of a manualized CBT delivered by counselors versus CBT that is self-administered.
Future research will emphasize whether lessons learned during cognitive behavioral therapy last or whether they fade with time. Furthermore, client matching of CBT and the appropriate gamblers is a future need of development. Pathological gamblers who may not be indicated for CBT included those with psychotic disorders, active suicidal ideation, or ongoing substance abuse, which may lead to intoxicated states. Nevertheless, CBT appears to be a promising psychotherapeutic treatment for pathological gamblers and should be employed wherever possible.
Behavioral Therapies
These types of therapy for pathological gambling are based on the principles of classical conditioning or operant theory. One of the reinforcing properties of pathological gambling is the intermediate reinforcement schedule. Treatment methods that attempt to change this behavior include aversion therapy, imaginal desensitization, and in-vivo exposure with response prevention. Theoretically, behavior is reshaped by changing learned responses and by reducing arousal or other rewarding sensations experienced from gambling. Behavioral therapies for pathological gambling received significant attention during the late 1960s and 70s but are not as widely available as other forms of psychotherapy for pathological gambling.
Aversion therapy consists of reducing the frequency of a behavior by associating gambling with an unpleasant stimuli, such as an electrical shock. Two case reports describe the use of electric shock in reducing gambling behavior., Larger studies were never performed and aversion therapy fell out of popularity as other, less ethically challenging, types of therapies emerged.
McConaghy and Blasczynski have published several case reports and case series on the use of imaginal desensitization and imaginal relaxation as a therapy to reduce pathological gambling. This is a variant of systematic desensitization and is designed to deal with the hyperactivation of the arousal state-caused gambling-related cues. Essentially, the therapist guides the gambler through an imagined gambling session, evoking physical and emotional responses. The therapist then employs breathing and relaxation techniques to create an alternative response to gambling by reducing aroused states to a manageable level.
Echebura23 used individual stimulus control and exposure with response prevention in 69 male slot machine gamblers. This form of therapy was found to result in an 83-percent total abstinence rate 12 months after completion of the therapy. This type of therapy is designed to deal with the cravings and urges for gambling by increasing confidence in the ability to impose self control over gambling. Despite the high response rate, this particular form of therapy has not been replicated in other types of pathological gamblers or within the US.
Psychodynamic Psychotherapy
During the early 20th century, psychoanalysts viewed pathological gambling as an unconscious drive to punish oneself, often in order to diminish themes of self hatred and hostility toward authority figures. Several psychoanalysts have applied fundamental techniques to pathological gamblers, primarily during the 1950s and 60s. There have been very few efforts to document the effectiveness of psychoanalysis; one case series by Bergler reports having treated 60 pathological gamblers with a total abstinence rate of 75 percent.25 Unfortunately, he does not provide specifics on the types of gamblers treated and what specific techniques of psychoanalysis were used. Psychoanalysis is thought to be helpful to pathological gamblers by resolving interpersonal conflicts within therapy, and presumably a reduction in gambling behavior would follow.
Individual psychotherapy for pathological gamblers depends on the skill, knowledge, and experience of the psychotherapist. Psychodynamic psychotherapy for pathological gamblers focuses on identifying the meaning behind ongoing gambling and resolving conflicts that may have led to it. Furthermore, psychodynamic therapy focuses on reducing the guilt and shame associated with the consequences of pathological gambling. Pathological gamblers, like other addictive disorders, often employ immature defense mechanisms, such as denial, acting out, rationalization, minimization, and rejection. Under stress, many of these defense mechanisms emerge. Individual psychotherapy focuses on identifying these mechanisms and developing healthier defense mechanisms.
To date, there is very little data to demonstrate the efficacy of psychodynamic psychotherapy in pathological gamblers. No recommendation of how many sessions of psychodynamic therapy has been established, nor has there been a systematic overview of the elements of therapy that confer success. Rosenthal and Rugle described a psychodynamic approach to treating pathological gamblers that includes reducing denial, addressing defense mechanisms, stopping the chasing cycle, clarifying motivations to gamble, and increasing the motivation of the client.
Based on clinical experience, the effectiveness of psychodynamic therapy is probably due to a number of factors, including having a venue to discuss guilt/shame, reflection, nonjudgement, and psychoeducation. As with GA, many gamblers come in and out of individual therapy. Many struggle with honesty, ambivalence, motivation, or a combination of all three. To assist patients in selecting resources, there are national and state certification programs for individual therapists in the treatment of pathological gambling, but the type of therapy offered is usually not made known until asked.
Family Therapy
One of the main areas of negative consequences of pathological gambling is the direct effects pathological gambling has on family functioning. Pathological gambling can lead to divorce, internal strife, domestic violence, and can reinforce enabling behaviors which perpetuate continued gambling. Family therapy with pathological gamblers focuses on identifying problematic family dynamics and seeks to lessen chaos and conflict. A secondary purpose of family therapy for pathological gamblers is to corroborate the pathological gamblers' report or denial of gambling behavior. Typically, methods used in family therapy of pathological gamblers may range from cognitive-behavioral to focusing on understanding reasons to gamble. To date, few studies have examined the impact of family therapy on individual gambling behaviors but research initiatives are ongoing. One study by Tepperman demonstrated improved marital functioning after brief marital therapy.27 Lee reported that eight couples improved on measures of well being and life satisfaction immediately after a short, systems-based couples therapy. Family therapy may be underused in pathological gamblers, namely because of lack of training, availability of therapy, and clinical evidence to support its use. Involving the family in treatment is essential in order to fully understand and address the consequences of continued gambling behavior.
Harm Reduction
Taken directly from the philosophy employed in drug abuse treatment, some therapists may attempt to apply these theories to pathological gambling. These would be interventions geared at controlling or limiting one's gambling. The premise is that if some pathological gamblers are driven by cognitive distortions and an unawareness of the possible consequences of ongoing gambling, then interventions in this area may be enough to restore control over gambling losses. At first glance, harm reduction may appear to also be indicated for pathological gamblers who are in the early stages of their disorder. Examples of harm reduction techniques include setting time limits to gambling, playing with cash instead of credit (less likely to gamble more with cash), and playing with predetermined loss limits. One study has investigated using controlled gambling as a treatment outcome; in this study, Blaszczynski, et al., followed 63 pathological gamblers after they had completed a behavioral treatment program. Social functioning and subjective distress were found to be equal between those who had achieved total abstinence and those who were considered controlled gambling.
Table 1
Available Psychotherapy Resources for Pathological Gamblers
| Gambler's Anonymous www.gamblersanonymous.org Phone: 213.386.8789 |
| Gam-Anon www.gam-anon.org |
| National Council on Problem Gambling www.ncpgambling.org |
| National Gambling Helpline Phone:800.522.4700 |
The spirit of harm reduction has a certain appeal for pathological gamblers—many gamblers are impulsive and have high expectations for themselves, so that any ongoing struggles to achieve total sobriety may be interpreted as yet another failure. Pathological gambling, though, carries some unique clinical features that complicate the utility of the harm reduction model. Gambling is not self-limiting; that is, it can continue forever provided there is enough money. More importantly, it is debatable whether a reduction in gambling frequency or wagering is an improvement at all. Gambling's unpredictability means that some gamblers may actually win. Furthermore, every time a patient gambles, there is always the risk of incurring significant damage in a very short amount of time. Pathological gambling is about consequences of gambling, which means that a lifetime of consequences can arise after one single session of gambling.
Helplines
Although not a formal mechanism of therapy, gambling helplines exist in 35 states. These helplines are operational 24 hours a day and are answered by trained mental health professionals. Helplines provide information about pathological gambling, referrals to GA, and to gambling certified providers, and can also screen callers for gambling problems. They have also been known to manage acute crises, such as suicidality and financial desperation. Pathological gamblers do not easily enter treatment and when compelled to seek treatment, an immediate response may be beneficial. The effectiveness of helplines needs to be studied on a formal basis, particularly in understanding its impact on changing gambling behaviors.
Other Issues to Consider in Psychotherapy of Pathological Gamblers
Comparisons to substance abuse treatment. Although pathological gambling shares many clinical features with other addictive disorders, there are notable differences that need to be noted during the course of psychotherapy. Techniques that work for substance abuse may not work for pathological gambling. For instance, gambling cannot be detected by an objective test; thus, attendance and participation in meetings/ therapy does not necessarily mean abstinence. Another difference is that pathological gamblers may actually win money while engaging in their behavior. Few drug addicts report coming home with money. How does a therapist deal with these consequences when the gambler's behavior has resulted in profit? Lastly, pathological gamblers cannot blame their irrational behaviors on the intoxicating effects of drugs or alcohol. As a result, there is a stark realization that any destructive behavior that occurred is a direct result of themselves and not a result of intoxication. In turn, this often leads to intense feelings of guilt, shame, and embarrassment, which if not explored will undoubtedly lead to more gambling.
Addressing finances. By definition, pathological gamblers have altered views on money and what money represents to them. Any form of psychotherapy with pathological gamblers requires a discussion about money. A great number of pathological gamblers continue to gamble simply because debts are so large that they do not see any other way of recovering their money other than through gambling. Pathological gamblers who are seeking treatment are encouraged to turn their finances over to someone else. Most therapists do not receive any training on financial planning, bankruptcy laws, or loan repayments. As a result, therapists who intend to work with pathological gamblers must educate themselves about how to properly manage money, otherwise a significant contributing factor to pathological gambling will go unaddressed.
Future Directions
There are several emerging psychotherapies that are being examined for efficacy in pathological gamblers. Contingency management, a therapeutic strategy that has been shown to be effective for substance use disorders, particularly opiate and cocaine abuse, has not been extensively evaluated for pathological gamblers. Potential applications of this would include providing rewards to gamblers for not gambling or for completing portions of a treatment program. Contingency management operates using positive reinforcement and looks to identify ways to reward healthy behaviors instead of punishing ongoing addictive behavior.
Virtual counseling (Internet or computerized therapy) is another treatment option. Presently there are only a few gambling specialty treatment programs, and one way to expand treatment services is to provide telephone and Internet counseling. Some pathological gamblers may be reluctant to enter individual or group therapy due to stigma, lack of resource availability, or denial. Numerous chat rooms have emerged for GA 12-step fellowship and are available anonymously 24 hours a day.
Conclusions
There are several types of psychotherapy treatments available for pathological gambling. Most accessible is Gambler's Anonymous and Gam-Anon. Cognitive behavioral therapy and individual therapy (usually psychodynamic psychotherapy) are also frequently employed by gambling treatment providers. Compared to other psychiatric disorders, the amount of evidence supporting the effectiveness of these treatments is not nearly as extensive, but it is a growing field. Given that there are no FDA-approved pharmacotherapies for pathological gambling and that knowledge of the biological basis of pathological gambling is just recently emerging, this demonstrates how important it is to develop psychosocial treatments. The most effective psychosocial treatments appear to be a combination of treatment approaches, including GA along with individual and cognitive behavioral therapy. Research is also showing that treatment and early intervention works and that those with pathological gambling no longer have to rely solely on the passage of time to improve.
References
