Given the high rate of relapse, it is important 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 webpage 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 them stay in recovery. This information for providers of mental health and addiction services 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.2 In this model, the goal of treatment can be either to stop the behaviour entirely or to establish limits or controls over the behaviour.2
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.3
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).3 In a relapse, the person feels that they are unable to control their drinking or continues to drink after a period of abstinence.3
The goal of relapse prevention approaches is to identify the situations that put the person at high risk of relapse and increase their ability to cope with them.4 In problem gambling, these approaches are traditionally implemented after the client has completed a course of treatment, but they can also be implemented as soon as they start treatment.4
What does the evidence say?
While there is limited literature on the use of relapse prevention approaches for problem gambling, research suggests they can reduce the frequency of gambling and the amount of money lost up to 12 months after treatment.4,5
There is evidence 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).3,5
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.4,5
Cognitive therapy has been shown to help people with gambling problems recognize and correct their mistaken beliefs about randomness and high-risk gambling situations.6 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.7
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.8,9,10,11 This component can prevent relapses caused by boredom and an excess of free time that can arise after the client stops gambling.8,9,10,11
In one study, running out of money or lacking funds to gamble were the most frequent reasons for quitting. This finding supports the use of stimulus control, such as limiting access to money by getting rid of debit and credit cards.12
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 to improve quality of life and mental functioning.13,14,15 These interventions may be more likely to be effective when used alongside cognitive-behaviour therapy.16,17 However, the long-term benefits in terms of preventing relapses have not been confirmed.18
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.19,20,21
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 but the evidence from various studies on the long-term benefits is inconclusive.22,23
Putting the evidence into practice
The first step of relapse prevention is to identify the situations that might put your client at risk of returning to gambling.5,24
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.25
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.24 Interventions that will help your client develop the skills they need will be an important part of the relapse prevention plan.5
You may also 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.5
Encourage your client to practice their new non-gambling behaviours and coping skills.5 Remind them that learning new behaviours in adulthood is not easy, so practicing these new skills, with your support and encouragement, will help them prevent relapses.5
Your client's confidence in their own capacity to cope with stressful situations will be critical to their success.24 To this end, help them find opportunities to practice their new coping skills and offer positive feedback to reinforce new behaviours.24
Let your client know that relapse is a normal part of changing any behaviour, including problem gambling.3,24 Help them view lapses 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.21
Educate your client about the relapse process (i.e., the impact of risk factors and triggers, as well as erroneous beliefs about the likelihood of winning26), and the likelihood of lapses along the way. This will help them cope with the difficulties they will encounter during recovery.2,24 You can use the following flow chart at right when discussing the relapse process with your client.
(Adapted from: Marlatt GA, Gordon JR:
Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press; 1985.)
Relapse Process
Show transcript
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.5
As they find themselves with more free time once they stop gambling, scheduling and engaging in pleasurable and meaningful activities will also be important.8,9,15 Explain that these activities may not give them as much short-term pleasure as gambling did, but they will likely provide more satisfaction and long-term benefits without having the negative impacts of problem gambling.
Resources for clinicians
Inventory of Gambling Situations is a 63-item self-report questionnaire, which provides information that will help you and your client develop a relapse prevention plan.
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. Important to note is that when using this handout in session with your client, the process does not need to flow from A to B to C but instead can be adapted 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 both in a one-on-one and a group setting as well as for a brief intervention.
Dealing with urges is an exercise that helps you guide your client 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.
10 Guiding Principles to Promoting Meaningful Activities provides a framework for helping clients identify their skills and activity patterns, set goals, and use activity schedules to achieve their gambling-related goals.
Resources for clients
Mobile
Monitor Your Gambling and Urges is a free and anonymous mobile app for people who wish to change their gambling behaviours.
Worksheets to help clients identify and plan meaningful activities:
Self-help for Family and Friends is an online community that includes support and resources for people who are affected by, or concerned about, someone else's gambling.
References
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