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Cognitive-Behavioural Therapy (CBT)

Cognitive-behavioural therapy (CBT) is the most empirically validated therapy that has been proven effective for the treatment of problem gambling. CBT teaches people to shift their thoughts and behaviours related to gambling and respond to their urges in a more productive way (CAMH, 2012).

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Cognitive Behavioural Therapy (CBT)

  
  
  
  
Cognitive-Behavioural Therapy and Problem Gambling11/23/2017PGTS OnlyIn-Person Training

This section will explore how cognitive-behavioural therapy (CBT) can help your clients make changes to their gambling behaviours. Research has shown that CBT can be very beneficial to people with gambling problems, as it helps them identify the thoughts, attitudes and beliefs that lead them to gamble. Once identified, clients can develop strategies that support changes to their thought processes and decision-making. A CBT approach also addresses the client’s cognitive distortions—faulty thinking about the problem behaviour—to help with maintaining the changes.​​​​​​​​​

Key Concepts​

This section provides a general overview of cognitive-behavioural therapy (CBT) as well as the best available evidence on the use of CBT to treat people with gambling problems. Learn more about how to apply CBT in your practice.

Background

Thoughts-Feelings-Behaviours Cycle
Thoughts-F​eelings-Behaviours Cycle

CBT is an intensive, short-term (six to 20 sessions), problem-oriented approach. It was designed to be quick, practical and goal-oriented and to provide people with long-term skills to keep them healthy.

The focus of CBT is on the here and now—on the problems that come up in a person’s day-to-day life. CBT helps people examine how they interpret and evaluate what is happening around them and the effects these perceptions have on their emotional experiences.

In CBT, your client will learn to identify, question and change the thoughts, attitudes, beliefs and assumptions related to his or her problematic emotional and behavioural reactions to certain kinds of situations.

By monitoring and recording thoughts during situations that lead to emotional upset, your client will begin to understand how the way in which he or she thinks can contribute to feelings of depression and anxiety. In CBT, your client will learn to reduce and/or better manage these emotional problems by:

  • identifying distortions in his or her thinking
  • seeing thoughts as ideas rather than as facts
  • “standing back” and considering situations from different viewpoints.

In the context of problem gambling, your client may think to him or herself “I’m due for a win” when playing at the same slot machine for a long period of time. This common cognitive distortion is regarded as fact, rather than as thought, even though slot machine outcomes are randomly generated. This faulty thinking can keep a person playing beyond what they intended to play.


What are some key approaches to using CBT to treat problem gambling?

Functional analysis

In order to perform a functional analysis of their problematic gambling behaviours, clients are taught to break down their gambling episodes as follows:

  1. identify their triggers
  2. determine the thoughts and feelings that result from these triggers
  3. evaluate the positive and negative consequences of their resulting behaviours.

The purpose of functional analysis is to help clients understand their gambling activities and identify steps that can be taken to stop or interfere with their decision-making process at different points. This way, they can reduce their gambling behaviour in the future when presented with a similar trigger.

Cognitive restructuring

Faulty beliefs have been shown to contribute to problem gambling. For example, a core belief of many people with gambling problems is that they can, through specialized knowledge or personal attributes, predict the outcome of games that are in fact not predictable. The person selectively recalls evidence that supports these beliefs and discards contrary evidence. In order to try to bring these underlying assumptions to the surface, you may ask how your client makes betting decisions, then ask the client to explain his or her beliefs in some detail. Bringing these beliefs to a conscious level can raise doubts in the client’s mind, and make it possible for the client to challenge his or her own thinking.

There are many types of cognitive distortions, including:

  • all-or-nothing (black-and-white) thinking
    • e.g., “The only way I can pay off my debt is by gambling.”

  • disqualifying the positive
    • e.g., “Last year, I went six months without gambling but that was just because I ran out of money.”

  • overgeneralizing
    • e.g., “I never win with that caller.”

  • catastrophizing.
    • e.g., “Because I relapsed, I’ve wrecked everything.”

Relapse prevention methods

Relapse prevention in problem gambling treatment focuses on the maintenance stage of problem gambling behaviour change. It has two main goals:

  1. To prevent the occurrence of initial lapses after a commitment to change has been made.
  2. To prevent any lapse that does occur from escalating into a full-blown relapse.

These goals are achieved through the development of coping strategies to deal with high-risk situations without relying on the unhealthy gambling behaviour.


What happens in a typical CBT session?

CBT sessions can be offered to clients individually or in groups. Both formats tend to follow the same predictable structure.

  • Mood check: The therapist asks about the client’s mood since the previous session.
  • Bridge: The focus of the previous session is reviewed to create a bridge to the current session.
  • Agenda: The therapist and client identify issues to address in the current session, which will act as the agenda.
  • Homework review: Homework from the previous session is reviewed to note progress and troubleshoot any difficulties.
  • Agenda items: Agenda issues are addressed using cognitive and behavioural strategies.
  • New homework: Exercises and tasks for the upcoming week are assigned.
  • Summary and client feedback: The session is wrapped up.

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Research Snapshot​

​​​Why cognitive-behavioural therapy (CBT) for problem gambling?

CBT is currently recommended as the treatment of choice for problem gambling, given the available outcomes research (McIntosh et al., 2016). The most recent Cochrane review of psychological therapies for problem gambling argues that CBT should be classified as best practice in problem gambling treatment (Cowlishaw et al., 2012). In their review of the literature, Cowlishaw and colleagues found that CBT led to significant improvements in how often people gambled, their gambling-symptom severity and financial losses from gambling, up to three months post-treatment.

Note: It is important to consider the following points with respect to the available literature on CBT and problem gambling:

  1. A substantial amount of literature included in the Cochrane review had a number of limitations, which may have overestimated treatment efficacy of CBT.
  2. Group and individual CBT, along with stand-alone cognitive therapy and behaviour therapy, were examined as a whole. Future research should consider examining these therapies separately.
  3. There is insufficient evidence to support long-term effects of CBT treatment (Cowlishaw et al., 2012).

These limitations highlight the need for more robust research to examine the efficacy of CBT in problem gambling situations as well as its effectiveness in the long term.


Problem gambling and cognitive distortions

Preliminary research has demonstrated that cognitive distortions, impulsiveness and poor decision-making are crucial factors in the initiation and maintenance of problem gambling. More specifically, higher incidences of gambling-related cognitive distortions have been linked to problem gambling, while reductions have been associated with recovery (Fortune & Goodie, 2012; Rossini-Dib et al., 2015). Although the research linking cognitive distortions and gambling recovery is scarce, these preliminary results show promise and demonstrate the need for further investigation.

Examples of cognitive distortions in people with problem gambling:

Viewing luck as a personal attribute

Gambler's fallacy: Having misperceptions around randomness, trends and control

Being overconfident

Memory bias: Having a tendency to remember wins more than losses


Source: Fortune & Goodie, 2012.


Cultural considerations

Gambling activities exist in almost every culture, yet most people who engage in gambling do not go on to develop a problem. As with other psychiatric disorders, cultural factors play a key role in the development and maintenance of problem gambling. Cultural beliefs and values help shape normative patterns as well as help-seeking behaviours (Okuda et al., 2009). Miranda and colleagues (2005) highlighted the importance and advantages of learning about a client's culture in order to provide appropriate and effective treatment, which helps in building a strong rapport, establishing openness and trust and adapting treatment to use one's cultural beliefs as a source of strength and support, rather than as a barrier.

A recent study by Wong and colleagues (2014) demonstrates preliminary results for the use of CBT in other cultures. They adapted CBT for people with gambling problems within a Chinese community in Hong Kong. Using this method, they found significant decreases in the severity and frequency of gambling behaviours as well as a shift in cognitive distortions. The authors note, however, that a more vigorous research design and larger sample size are required in order to provide more definitive evidence of this culturally responsive form of CBT.


Dissenting opinion

Toneatto (2016) reports that "Single-session interventions for problem gambling may be just as effective as longer treatments" (p. 58). In his study, Toneatto recruited 99 people with problem gambling (74% were male; mean age 47.5 years) and randomized them to one of four groups receiving either:

  1. six sessions of cognitive therapy (focused on cognitive restructuring)
  2. six sessions of behavioural therapy (focused on stimulus control, coping with urges and increasing behavioural and social reinforcements)
  3. six sessions of motivational interviewing (based on Miller & Rollnick's Stages of Change model)
  4. one single-session intervention (which included CBT self-help tools, 90-min motivational interviewing and handouts).

What were the results? All four treatment groups yielded significant improvements in gambling frequency, severity and expenditure post-treatment and at 12-month follow-up. The participants who were in the single-session interventions group performed as well as participants who were in the six-session cognitive, behavioural and motivational interviewing treatment groups. Therefore, Toneatto (2016) concludes that, although preliminary, "durable reductions in gambling behaviour can be achieved with a very modest intervention, combining the most effective cognitive, behavioural, and motivational interventions into a focused psychoeducational treatment, beyond which longer treatments confer minimal advantage" (p. 63).

Toneatto also notes that people with problem gambling tend to prefer shorter treatment modalities, highlighting the importance of adapting strategies so that they are not only brief, but equally as effective as the treatment-as-usual.


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Putting It Into Practice

The content in this section demonstrates how the key concepts of cogntive-behavioural therapy (CBT) can be applied to working with clients with problem gambling. Many clinicians use a preferred framework or multiple frameworks in their practices, including holistic, anti-oppressive, systems-theory, disability or social-determinants-of-health frameworks. The information provided here is meant to complement whatever framework or theory may be guiding your clinical practice.


A CBT approach to gambling treatment

We have all experienced some form of cognitive distortion in our lives. It is something everyone can relate to at one level or another. For example, many of us have, at times, assigned luck to certain numbers, events, feelings or inanimate objects.

Cognitive distortions develop from certain thought patterns or habits of thought. People affected by problem gambling are often unaware that they have developed such distortions (e.g. "I am due for a win"). One of the fundamental principles of CBT is that people must be aware of the thought processes that motivate their behaviours before they can change them.

The goal of CBT for problem gambling is to help clients become aware of the cognitive distortions that motivate their behaviours, not just tell them that they have a cognitive distortion. Pointing out cognitive distortions directly can result in resistance and disbelief.

This process can be supported by reviewing the client's gambling history with them. Tracing the development of the problem, analyzing clients' decisions about which kinds of gambling to pursue, their motivations for gambling, their adoption of specific rituals, techniques or strategies to increase the likelihood of winning, etc., can help bring distortions to light.

Another goal of CBT is to modify or weaken cognitive distortions by making clients aware of the discrepancies between what is actually happening and their beliefs about, or interpretations of, what is happening. The goal is to help clients understand that their beliefs and the outcomes they desire are not connected. For instance, the slot machine has no way of knowing the client is wearing a lucky hat, and therefore wearing the hat has no influence on the outcome of the client's play. As the client recognizes the independence of the actual outcome from his or her belief, the cognitive distortion is weakened.

You can then help your client replace faulty assumptions and beliefs with correct ones. It is important for clinicians to have a good understanding of odds and probabilities, and knowing how gambling games work and are played.

Therapeutic Alliance

According to Raue & Goldfried (as cited in Beck, 2011, p.17), “Research demonstrates that positive alliances are correlated with positive treatment outcomes.” This rings true when using CBT with clients experiencing gambling problems. A strong therapeutic alliance will be invaluable when working through cognitive distortions.

To this end, Beck (2011) outlines the six key tasks to developing a strong therapeutic alliance with your clients. These include:

  • demonstrating good counselling skills and accurate understanding
  • sharing your conceptualization and treatment plan
  • collaboratively making decisions
  • seeking feedback
  • varying your style
  • helping patients solve their problems and alleviate their distress.

Treatment challenges

Based on clinical experience, some challenges that you might encounter when using CBT with clients are outlined below.

  • Clients not completing their homework: Some clients may have difficultities in understanding the homework, without letting you know in advance, or not completing the homework for a variety of different reasons (e.g., forgetting, not having enough time).
  • Therapy does not seem to be working: Does the client feel you are being too manual-focused and do they not feel as though their needs are being met? Is the client's or your expectations of CBT unrealistic? Are they struggling with their goal choice(s)? Are they mandated to be in treatment and have no desire to change their behaviour(s)? Do they have co-existing mental health and/or addiction issues that need to be addressed in order for CBT to progress?
  • Emotional difficulties: Some clients can become overwhelmed when discussing their feelings and can feel flooded by those feelings.
  • Unchanging gambling beliefs: Some clients have deeply held beliefs about their gambling, luck, gambling systems and/or cultural ties to gambling or luck.

This list is not exhaustive, but highlights some common roadblocks. Your clients' needs will be different and require different levels of support.

Training in CBT for clinicians

The appropriate and effective use of CBT presumes that you, the CBT practitioner, are a qualified health practitioner with training in assessment and treatment of mental health problems. It also presumes that specific training in CBT has been taken.

It is thought to be important, if not essential, for the CBT practitioner to not only be familiar with specific CBT techniques but to also have a thorough understanding of the theoretical underpinnings of CBT. This is important, as the theory guides the practitioner in the continuous creative process of assessing the client, formulating the problem and making ongoing treatment decisions.


Working with clients through a health equity lens

Health equity helps ensure that factors such as gender, race, ethnic background, ability to speak English, sexual orientation, immigration status, income and education do not affect a person's access to or the outcomes of timely, appropriate and high-quality care. The Health Equity Impact Assessment tool developed by the Ministry of Health and Long-Term Care (2012) recommends that all health care decision-making include evaluation of the unintended positive and negative impacts for various population groups, including:

  • Indigenous peoples (e.g., First Nations and Métis peoples and Inuit)
  • age-related groups (e.g., children, youth, seniors, etc.)
  • people with disabilities (e.g., physical, D/deaf, deafened or hard of hearing, visual, intellectual/developmental, learning, mental illness, addictions/substance use, etc.)
  • ethnoracial communities (e.g., racial/racialized or cultural minorities, immigrants and refugees, etc.)
  • Francophones (e.g., new-immigrant Francophones, deaf communities using LSQ/LSF, etc.)
  • people experiencing homelessness (e.g., marginally or underhoused, etc.)
  • linguistic communities (e.g., uncomfortable using English or French, communication affected by literacy, etc.)​
  • people receiving low income (e.g., unemployed, underemployed, etc.)
  • religious/faith communities (e.g., Buddhist, Muslim, Christian, etc.)
  • rural, remote or inner-urban populations (e.g., geographic/social isolation, underserviced areas, etc.)
  • groups defined by sex/gender (e.g., male, female, women, men, trans, transsexual, transgendered, two-spirited, etc.)
  • groups defined by sexual orientation (e.g., lesbian, gay, bisexual, etc.).

Please note that this list is not exhaustive, may not be fully inclusive and/or may not reflect the preferred terminology within the listed population groups. Clients may also identify with more than one of the above. It is important that your CBT programs/services incorporate the Health Equity Impact Assessment tool in planning and service delivery. This website will endeavor to provide more evidence-informed content for specific population groups in the future.

Indigenous peoples and ethnoracial groups

CBT is largely based on the values supported by North American culture, such as assertiveness, independence, verbal ability and literacy, with a focus on behavioural change. CBT may require cultural adaptation when working with clients from Indigenous and ethnocultural communities.

The development of cultural adaptations to CBT is still in the early stages. There is very limited research on the effectiveness of culturally-adapted CBT for people with gambling problems; however, the research that has been conducted to date has shown positive results.

Over the past decade, a number of CBT models have emerged that highlight efforts to accept, rather than directly change, distressing experiences, including thoughts, beliefs, feelings, memories and sensations. Acceptance and commitment therapy (ACT), for example, is one of these second-generation CBT models. These mindfulness and acceptance-based psychotherapies have shown promise for some populations and more broadly, for treating gambling problems.

People with disabilities

Historically, people with developmental delays, intellectual disabilities and/or severe psychotic symptoms have not been offered or have not received cognitive-behavioural interventions. Preliminary research on the use of CBT for people with intellectual disabilities and developmental disabilities has shown that, with a few modifications in therapeutic approach and communication style, CBT may be a successful intervention.

Some clients with significant mental illness (e.g., a severe mood disorder) may benefit from a trial of medication before starting CBT for their problem gambling, as the symptoms of their illness may pose a barrier to their attendance and adherence to treatment. CBT practitioners should routinely monitor the need for alternative treatments for patients with concurrent disorders (e.g., patients who are contemplating suicide).



Handouts for clients

In CBT, practitioners often use worksheets with their clients to help them identify and work with their thoughts and feelings connected to the problematic behaviour for which they are seeking support. Below are several CBT worksheets that you can use with your clients. Some are specific to clients with gambling problems and others are more general.​​​​​​




  
  
Changing Your Thinkingcbt-changing-your-thinking
Dealing With Urgescbt-dealing-with-urges
CBT Overviewcbt-handout
Thérapie cognitivo-comportementalecbt-handout-fr
Slipping and Relapsescbt-slipping-and-relapses
Understanding Your Gamblingcbt-understanding-your-gambling

Clinical simula​tion video

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This video clip shows a fictitious therapist and client session for teaching purposes.

The scenario shows part of a simulated therapy session between a therapist and client (Nia), highlighting some cognitive-behavioural therapy (CBT) strategies discussed in this website section. This is the fourth session between the therapist and client, and the client has already identified problem areas and established treatment goals. The therapist and client have also established a good therapeutic alliance and trust.

The video clip does not start at the beginning of the session; rather, it shows the middle portion of the session. The therapist and client have previously reviewed important concepts such as “triggers”, “functional analysis” and “testing personal control”, which are either directly or indirectly referred to. As such, the client is already quite familiar with these terms and does not need the therapist to describe them in detail. The therapist and client have also previously had a discussion around using the terminology “irrational thoughts” (sometimes called “distorted thoughts” or “unhelpful thoughts”) and the client feels comfortable using this term. The discussion also included what irrational thoughts are and the importance of identifying them. The client has engaged in a lot of practice with identifying irrational thoughts, and exploring how she can change these thoughts to ones that are more balanced and rational.

Please note that the video will pause and show the therapist’s internal thoughts throughout the session.

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