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.
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.
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).
- Beck, J.S. (2011).
Cognitive Behavior Therapy: Basics and Beyond (2nd ed.). New York: Guilford Press.
- 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. DOI:
- Dixon, M.R. & Wilson, A.N. (2014).
Acceptance and Commitment Therapy for Pathological Gamblers. Carbondale, IL: Shawnee Scientific Press LLC.
- Dryden, W. & Branch, R. (2012).
The CBT Handbook. Thousand Oaks, CA: Sage Publications.
- Hassiotis, A., Serfaty, M., Azam, K., Martin, S., Strydom, A. & King, M. (2012).
A Manual Of Cognitive Behaviour Therapy for People With Mild Learning Disabilities and Common Mental Disorders: Therapist Version. London, England: Camden & Islington NHS Foundation Trust and University College London. Retrieved from [link].
- McGowan, V.M. & Nixon, G. (2004). Blackfoot traditional knowledge in resolution of problem gambling: Getting gambled and seeking wholeness.
Canadian Journal of Native Studies, 14 (1), 7-35. Retrieved from [link].
- Ministry of Health and Long-Term Care. (2012).
Health equity impact assessment. Retrieved from [link].
- Nagayama Hall, G.C., Hong J.J., Zane, N.W. & Meyer, O.L. (2011). Culturally-competent treatments for Asian Americans: the relevance of mindfulness and acceptance-based psychotherapies.
Clinical Psychology,18 (3), 215-231. DOI:
- Nelson, S.E. & Wilson, K. (2017). The mental health of Indigenous peoples in Canada: A critical review of research.
Social Science & Medicine, 176, 93-112. DOI:
- Somers, J. (2007).
Cognitive Behavioural Therapy: Core Information Document. Vancouver, BC: Centre for Applied Research in Mental Health and Addiction. Retrieved from [link].
- Wong, D.F.K., Chung, C.L.P., Wu, J., Tang, J. & Lau, P. (2015). A preliminary study of an integrated and culturally attuned cognitive behavioral group treatment for Chinese problem gamblers in Hong Kong.
Journal of Gambling Studies,
31 (3), 1015-1027. DOI:
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.