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The most frequently studied treatment type for gambling disorder is Cognitive Behavioral Therapy (CBT). This type of treatment attempts to change the thoughts and behaviors that are fundamental to maintaining a pattern of behavior (e.g., gambling disorder). The goal of CBT for intemperate gambling is to identify and change “cognitive distortions and errors” that are associated with excessive gambling and its adverse sequelae. For gambling, CBT can include at least four components: (a) correcting cognitive distortions about gambling; (b) developing problem solving skills; (c) teaching social skills; and (d) teaching relapse prevention. There are a number of CBT trials that suggest that it is an effective form of treatment for gambling.
Motivational enhancement strategies (e.g., motivational counseling; resistance reduction) are brief therapeutic strategies designed to lower resistance and enhance motivation for change. Motivational enhancement strategies augment pre-existing motivation by improving the therapeutic alliance. Further, by attending to the dynamics of ambivalence, clinicians improve the quality of treatment; treatment providers establish a therapeutic context that resonates with the client’s mixed motivations toward their object of addiction (e.g., gambling). These interventions typically accompany other types of interventions as a supplement; however, clinicians can use motivational enhancement interventions on their own. Studies of motivational enhancement suggest that it yields clinically meaningful changes in gambling behavior and symptom experiences. Studies of a single session of motivational enhancement therapy found benefits associated with this treatment persisted as long as 12 months after the intervention. Studies with longer follow up periods are needed to determine whether such clinical effects extend beyond a year.
Self-help interventions for gambling include self-guided activities and information workbooks designed to reduce or eliminate gambling. Sometimes these approaches can be accompanied by planned support from a helpline specialist, clergy, a community health specialist, a therapist, or some other treatment provider. More specifically, guided self-help approaches that have been tested include workbooks accompanied by a brief explanatory or informational phone call related to the intervention, motivational interviewing, and/or motivational enhancement. These studies generally show that individuals who engage in guided self-help tend to do better over time than others who do not engage in self-help, such as those who are in a wait list control group. However, some studies do not fully support this outcome; for example, one study reported that workbooks can help people progress toward abstinence, but did not find any benefit for the addition of an explanatory or informational phone call to workbook self-help. Another study also found limited benefit to guided self-help itself.
Personalized Feedback interventions provide individuals with information that compares their own behavior to similar others for a specific activity. This type of intervention requires individuals to report upon their behavior, such as gambling, drinking, or drugging; then, a professional or an automated system (e.g., computer software) provides a report that indicates whether the individual’s behavior is similar to, or different from, how most people behave. People often view Personalized Feedback approaches as “brief” interventions. These interventions might require, for example, a 60-90-minute discussion of the feedback. Some Personalized Feedback interventions might not include an in-person discussion at all. This kind of feedback relies upon software to provide the comparative report. Studies suggest that Personalized Feedback might help alleviate individuals’ gambling-related symptoms. However, findings for this intervention are mixed. For example, one study showed that Personalized Feedback resulted in gambling-related improvements only when investigators controlled for other mental health symptoms. Another study found that, although feedback was associated with a reduction in days gambled, the addition of comparative information did not provide added benefit. This study examined the website, checkyourgambling.net.
Relapse prevention and recovery training are treatment components that clinicians design and use to increase a person’s ability to identify and cope with high-risk situations that can precipitate relapse. Gambling risk situations might include environmental settings (e.g., casinos, lottery outlets), intrapersonal discomfort (e.g., anger, depression, boredom, stress), and interpersonal difficulties (e.g., finances, work and family). The Inventory of Gambling Situations is one tool that can help individuals identify circumstances that increase their risk of gambling. Relapse prevention’s goal is to help individuals develop coping methods to deal effectively with those specific high-risk situations without relying on unhealthy and maladaptive gambling behavior. A number of studies have incorporated relapse prevention as a component of their trials. These studies suggest that relapse prevention in combination with other cognitive therapy (e.g., cognitive correction) is associated with clinically favorable outcomes, like reducing time and money spent gambling. Cognitive correction is a technique that seeks to correct individuals’ misconceptions of basic gambling-related concepts (e.g., randomness). Other studies have determined that both individual and group relapse prevention treatment for gambling disorder are superior to a no-treatment control group. Taken together, these findings suggest that relapse prevention is a promising and developing treatment approach for gambling.
Brief treatment can take a number of different forms, including limited motivational enhancement therapy, as we mentioned previously. Brief treatment does not necessarily need to include motivational enhancement, however. These interventions might include a 10 minute conversation or a few counseling sessions of cognitive behavioral therapy, for example, but not protracted clinical involvement. A brief treatment might include a gambling disorder screen, information about harmful consequences of excessive gambling, or simply advice for reducing gambling-related harm. Studies of brief advice suggest that it is associated with clinically significant changes in gambling behavior. Documented benefits of brief advice are apparent as early as six weeks following an intervention and as long as nine months later. Additional studies of brief advice from other sources will help confirm brief advice as an important treatment approach for gambling.
There is no specific FDA-approved pharmacotherapy for the treatment of gambling disorder. Researchers are testing a variety of drugs, and some show promise. To date, there are randomized clinical trials that show favorable outcomes for escitalopram, lithium, nalmefene, valproate, topiramate, paroxetine, and naltrexone. However, at this time, no single drug has sufficient support for us to classify it as a treatment with “High Quality Empirical Evidence.” Some of these medication trials are quite preliminary. For example, some randomized clinical trials meet the technical definition of a trial, but include as few as four individuals.
Escitalopram is a medication typically used to treat mood disorders. It is a selective serotonin reuptake inhibitor (SSRI). Lithium is a drug frequently used to treat bipolar disorder and major depressive disorder. It is considered a mood stabilizer. Nalamefene is an opioid antagonist. Most often providers use it to treat alcohol-related disorder. Valproate is an anticonvulsant that typically is used to treat seizures, bipolar disorder, and migraines. Topiramate is a nerve pain medication and anticonvulsant that acts on dopamine pathways and typically is used to treat seizures and migraines. Paroxetine is an SSRI; this medication often is used to treat mood disorders. Finally, naltrexone is an opioid antagonist usually used to treat alcohol and opioid use disorders. Additional research is necessary to study the effects of all these drugs before they are used routinely in a clinical setting for gambling-related problems; however, these early studies are promising, and suggest that some drugs might eventually be useful to treat gambling-related problems.
Cognitive therapies seek to help individuals learn to rethink certain matters including those that are intrapersonal and interpersonal. For gambling, this might mean developing a better understanding of randomness, or identifying and correcting erroneous beliefs and perceptions, like the illusion of control often associated with gambling and gambling disorder. Two clinical trials from the same source focusing on cognitive correction with relapse prevention suggested favorable clinical outcomes. Other studies with less rigorous designs (i.e., non-randomized or pre-post comparisons) also suggest that cognitive therapies are worthwhile approaches to the treatment of gambling. We are classifying this popular approach to treatment as “developing” for gambling because we need more studies that focus upon cognitive therapy in isolation from multiple sources. However, this treatment approach is quite promising for gambling disorder.
Behavioral therapy seeks to undo learned associations between a particular stimulus, such as gambling triggers, and an unwanted response, such as feeling an urge to gamble when in the presence of a trigger. One example, exposure therapy seeks to help people eliminate the experience of gambling-related urges in response to actual gambling experiences. Similarly, imaginal desensitization intentionally provokes gambling-related urges using imagery and immediately provides assistance with cognitive restructuring and the presence of incompatible responses (e.g., relaxation). One way of doing this is through the use of audiotaped recordings of gambling scenarios. Despite the popularity of this treatment type, most studies of behavioral therapy for gambling disorder rely upon weak experimental designs that make drawing causal attributions about treatment efficacy difficult. One trial, however, shows that, in combination with relapse prevention, imaginal desensitization can reduce key gambling-related urges effectively.
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