Adapted Couple Therapy (ACT) for pathological gamblers: a promising avenue

Integrative couple treatment for pathological gamblers with an emphasis on forgiveness processes: A case study with three couples

Gambling's impact on a couple's relationship is an essential element in the gambling disorder (GD). Gamblers tend to lie to their partner to conceal the extent of their gambling problems and debts, which can lead to a serious relational transgression for the couple. One promising avenue is a couple treatment focusing on forgiveness processes. The objective of this study was to determine whether the Integrative Couple Treatment for Pathological Gamblers (ICT-PG) with an emphasis on forgiveness processes helped couples to enhance these processes. A Single-Case Research Design (SCRD) was used with three couples in which one of the members had a GD. The results highlight the importance of jointly analyzing the forgiveness processes between the gamblers and their partner, which constantly influenced each other. These promising results illustrate the relevance of integrating forgiveness processes in treatment for couples where one of the members has a GD.

Beratung Angehöriger pathologischer Glücksspieler/-innen: Status quo und Unterstützungsbedarf

Ziel Angehörige von Menschen mit Glücksspielproblemen sind mit gesundheitlichen, sozialen und emotionalen Belastungen konfrontiert. Bis dato existiert jedoch kein etabliertes Konzept zur Unterstützung für diese Zielgruppe. Deshalb sollen in dieser Studie zum einen relevante Rahmenbedingungen und inhaltliche Aspekte der Arbeit mit Angehörigen von Menschen mit Glücksspielproblemen geklärt und zum anderen die Grundlage für die Entwicklung einer Kurzintervention geschaffen werden.

Methodik Onlinegestützte deutschlandweite Befragung von Suchthilfe-Mitarbeitenden (n=102) sowie Gruppendiskussion mit Angehörigen (n=4) im Herbst 2019.

Ergebnisse Die befragten Mitarbeitenden in der Suchthilfe nannten als die wichtigsten Themen für die Beratung von Angehörigen von Menschen mit Glücksspielproblemen das Verhalten Angehöriger gegenüber Betroffenen, Geldmanagement, den Umgang mit Emotionen, Beziehungsberatung und Psychoedukation. Die meisten Befragten gaben an, die Angehörigen im Einzelsetting (68%) in durchschnittlich 3 Sitzungen (Median 2,5; Min=1; Max=15) zu beraten. Der Abstand zwischen den Sitzungen beträgt durchschnittlich 3 Wochen (Median 2 Wochen). Für die zu entwickelnde Kurzintervention wurden Verantwortungsrückgabe und Selbstfürsorge (69%), Problem-/Belastungsexploration (42%) und Tipps zur finanziellen Existenzsicherung (28%) als die drei wichtigsten Themen ausgewählt. Sowohl als Erfolgsfaktor für eine gelingende Angehörigenberatung als auch für die Adhärenz der Angehörigen wurde eine positive bzw. wertschätzende Beziehungsgestaltung am häufigsten genannt. Die Ergebnisse aus der Gruppendiskussion mit Angehörigen deuten in eine ähnliche Richtung: Die Themen Verhalten als Angehörige gegenüber Betroffenen, Abgrenzung/Verantwortlichkeiten und konkrete Verhaltenstipps wurden als wichtig erachtet; jedoch ging es den Angehörigen eher darum, sich „richtig“ zu verhalten, während der Fokus der Suchthilfe auf der Abgrenzung und Selbstfürsorge lag.

Schlussfolgerungen Die Studie liefert wichtige Hinweise auf relevante Themen und Inhalte für die Beratung Angehöriger von Menschen mit Glücksspielproblemen. Auf Basis dieser Ergebnisse soll im nächsten Schritt eine Kurzintervention entwickelt werden. Hinsichtlich der Beratungsmethoden herrscht jedoch weiterer Forschungsbedarf. Zum anderen sollte untersucht werden, wie der Zugang der Angehörigen zum Hilfesystem und dessen Bekanntheit optimiert sowie bestehende Barrieren vermindert werden können.

Reasons for dropping out of internet-based problem gambling treatment, and the process of recovery – a qualitative assessment

Problem gambling (PG) is a condition affecting the economy, mental health, and relationships of both the individuals with gambling problems, and concerned significant others (CSOs). While PG is treatable, few individuals with gambling problems seek treatment, and many drop out of treatment. This qualitative study aims to investigate a) the reasons for individuals with gambling problems to drop-out from Internet-based PG treatment, and b) what individuals with gambling problems and CSOs find helpful and unhelpful processes in PG recovery. A total of 16 participants (8 individuals with gambling problems and 8 CSOs) who had participated in an Internet-based PG treatment were interviewed over the telephone in a semi-structured interview. The interviews were analyzed using thematic analysis. Drop-out from treatment was one aspect of an overarching theme identified as unstable path to recovery, where alternating periods of progress and setbacks delineate several aspects of PG. Relapses, negative emotions, and changing life circumstances were identified to separately, and in combination, contribute to drop-out. Drop-outs were also explained by participants’ experiences of a reduced need for treatment. Openness and a support from CSOs and peers were identified as themes important for recovery. The results suggest that PG treatments should consider the emotional state, and comorbidities of the patients, in order to reduce drop-out and improve chances of recovery.

How Can Partners Influence the Gambling Habits of Their Gambler Spouse?

An increasing number of clinical and empirical studies document the coping strategies used by partners of pathological gamblers (PGs). A postulate for this is that they may be useful for dealing with their partner's problematic gambling behaviors. Despite a widespread endorsement of this postulate, no study has yet documented their effectiveness: does the use of these coping strategies impact the gambler's behavior? To answer this question, semi-structured interviews were conducted with 19 participants (8 couples comprising one PG and his or her partner, one partner of a PG, and 2 PGs). Qualitative analysis of the interviews lead to a first main observation: via diverse coping strategies, partners of PGs can influence their spouse's gambling behaviors. The impact of these strategies may occur as initially expected by partners, that is by a reduction of gambling behaviors. However, the use of certain strategies can also increase the PG's gambling cravings, though this is not generally their partner's intention.

Behavioral couples therapy versus cognitive behavioral therapy for problem gambling: a randomized controlled trial

Background and aims

There is evidence that cognitive behavioral therapy (CBT) is effective for treating problem gambling (PG). Some research points to the possible benefits of involving concerned significant others (CSOs) in treatment. This study compared the efficacy of behavioral couples therapy (BCT) and CBT for both the gambler and the CSO.

Design

Two parallel‐group randomized controlled study comparing two different internet‐based treatments for PG. Follow‐up measures were conducted at treatment finish, and at 3‐, 6‐ and 12‐month post‐treatment.

Setting

Stockholm, Sweden.

Participants

A total of 136 problem gamblers and 136 CSOs were included in the study: 68 gamblers and 68 CSOs for each treatment condition. The gamblers were on average 35.6 years old and 18.4% were female. CSOs were on average 45.3 years old and 75.7% were women.

Interventions

A treatment based on BCT was compared with a CBT intervention. Both treatments were internet‐based, with 10 therapist‐guided self‐help modules accompanied by weekly telephone and e‐mail support from a therapist. CSOs were given treatment in the BCT condition, but not in the CBT condition.

Measurements

The primary outcome measures were time‐line follow‐back for gambling (TLFB‐G) and the NORC Diagnostic Screen for Gambling Problems (NODS) for problem gamblers, corresponding to DSM‐IV criteria for pathological gambling. Secondary outcomes measures were the Patient Health Questionnaire‐9 (PHQ‐9), the Generalized Anxiety Disorder seven‐item scale (GAD‐7), the Relation Assessment Scale Generic (RAS‐G), the Alcohol Use Disorders Identification Test (AUDIT), the Inventory of Consequences of Gambling for the Gambler and CSO (ICS) and adherence to treatment for both the problem gambler and the CSO.

Findings

The outcomes of both gambler groups improved, and differences between the groups were not statistically significant: TLFB‐G: multiplicative effect = 1.13, 95% confidence interval (CI) = 0.30;4.31); NODS: multiplicative effect = 0.80, 95%, 95% CI = 0.24;2.36. BCT gamblers began treatment to a higher proportion than CBT gamblers: P = 0.002.

Conclusions

Differences in the efficacy of internet‐based behavioral couples therapy and cognitive behavioral therapy for treatment of problem gambling were not significant, but more gamblers commenced treatment in the behavioral couples therapy group.

The Experience of Couples in the Process of Treatment of Pathological Gambling: Couple vs. Individual Therapy

Context: Couple treatment for pathological gambling is an innovative strategy. There are some results supporting its potential effectiveness, but little is known about the subjective experiences of the participants. Objective: The aim of this article is to document the experiences of gamblers and their partners participating in one of two treatments, namely individual or couple. Method: In a study aiming to evaluate the efficacy of the Integrative Couple Treatment for Pathological Gambling (ICT-PG), couples who were entering specialized treatment for the addiction of one member who was a pathological gambler were randomly assigned to individual or ICT-PG. Nine months after their admission to treatment, gamblers and partners (n = 21 couples; n = 13 ICT-PG; n = 8 individual treatment) were interviewed in semi-structured interviews. A sequenced thematization method was used to extract the major themes. Results: This study highlighted five major themes in the therapeutic process noted by the gamblers and their partners mainly after the couple treatment but also partly through the individual therapy. These were: (1) the gamblers' anxiety about having to reveal their gambling problems in couple therapy; (2) the wish to develop a mutually beneficial understanding of gambling and its effects on the partners in the two types of treatments; (3) the transformation of negative attributions through a more effective intra-couple communication fostered by the couple therapy; (4) the partners' contribution to changes in gambling behavior and prevention of relapses, which were both better supported in couple therapy; and (5) the interpersonal nature of gambling and its connections with the couples' relationship. However, gamblers who were in individual treatment were more likely to mention that their partners' involvement was not necessary. Participants likewise made a few recommendations about the conditions underlying the choice of one treatment method or the other. Discussion: Participants reported satisfaction with both treatment models, but their experience was more positive in couple treatment. Complementary benefits emerged from each form of treatment, which points to future treatments involving both types. Future research should explore both the couple processes associated with attempts to stop pathological gambling and the various ways of involving partners in the gamblers' treatment.

Pathological buying and partnership status

This pilot study investigated the partnership status and the level of pathological buying (PB) in 157 female patients with PB and 1153 women from a German population-based sample. Slightly more than half of both samples were currently living with a partner. The results suggest a protective effect of being in a couple relationship in the representative sample. In contrast, having a partner was not related to the severity of PB among patients. Future studies should address the question of whether the characteristics and quality of partnership have an impact on the severity and course of PB, and vice versa.

Treatment Outcome in Male Gambling Disorder Patients Associated with Alcohol Use

Aims: The primary objective of this study was to analyze the association between alcohol consumption and short-term response to treatment (post intervention) in male patients with gambling disorder enrolled in a group cognitive behavioral therapy (CBT) program.

Methods: The sample consisted of 111 male individuals with a diagnosis of Gambling Disorder, with a mean age of 45 years (SD = 12.2). All participants were evaluated by a comprehensive assessment battery and assigned to CBT groups of 10–14 patients attending 16 weekly outpatient sessions lasting 90 min each.

Results: The highest mean pre- and post-therapy differences were recorded for the alcohol risk/dependence group on the obsessive/compulsive and anxiety dimensions of the SCL-90-R. As regards the presence of relapses and dropouts over the course of the CBT sessions, the results show a significant association with moderate effect size: patients with risk consumption or alcohol dependence were more likely to present poor treatment outcomes.

Conclusions: Alcohol abuse was frequent in GD, especially in patients with low family income and high accumulated debts. High levels of somatization and high overall psychopathology (measured by the SCL-90-R) were associated with increased risk of alcohol abuse. Alcohol abuse was also associated with poor response to treatment.

Congruence Couple Therapy for Pathological Gambling: A Pilot Randomized Controlled Trial

A multi-site pilot randomized controlled trial of Congruence Couple Therapy (CCT) for problem gambling was conducted in Ontario and Alberta, Canada from 2009 to 2011. The purpose was to assess the feasibility of a full trial and to identify methodological modifications to enhance future trials. The sample (N = 30; 15 couples) consisted of 66% male gamblers and 34% female. Mean age of sample was 49.1 years. Baseline mean DSM-IV gambling score was 8.7/10. Retention of the treatment couples was 89% at 2-month follow-up. Retention of control couples was 78%. A randomized controlled design compared the status of couples in treatment condition to control condition. Treatment couples received 12-week CCT while control couples received three brief check-ins over 12 weeks. No significant difference was found between treatment and control group at baseline on all measures. At (1) week 12 post-treatment, and (2) week 20 follow-up, significant treatment effects were found for gambling symptoms (p = 0.008; p = 0.041), mental distress (p = 0.001; p = 0.035), and family systems function (p = 0.023; p = 0.054) between treatment and control group. Within group changes for treatment couples over time were significant for mental distress (p = 0.000), dyadic adjustment (p = 0.002), and family systems function (p = 0.000). On similar measures, control group showed non-significant improvement. Future methodological changes, advantages and disadvantages of multi-site partnerships with community treatment agencies are discussed. Of interest is that control participants showed unintended improvement. CCT as a treatment was favourably accepted by counselors, problem gamblers and their spouses. Positive outcome trends ranging from small to large effect size on key measures indicate that a full-scaled trial will require approximately 140 couples and is an investment worth pursuing.

The Pathological Gambler and his Spouse: How do their Narratives Match?

This case study compares the narratives of a pathological gambler and his spouse concerning family, marital and individual matters. It does so through identifying each of the key players' narratives individually (analysis of self-report questionnaires) and interactively (couples therapy sessions analysis). The results show that the gambler has a rather more positive view of gambling-related issues than does his spouse, and this fact is most apparent when it comes to marital and family issues. The gambler's perspective is less positive when it comes to non-relationship issues (financial and professional issues). A few hypotheses are put forward to explain these results and these are summarized in three effects: denial, idealization/guilt relief, and disappointment/retaliation. Some implications for clinical practice are also identified, such as the need to set therapy objectives which are truly shared by both members of the couple, as well as guidelines for future research, such as studies focused on gender differences.

Social strain, couple dynamics and gender differences in gambling problems: evidence from Chinese married couples

Knowledge of the influence of couple dynamics on gender differences in gambling behavior remains meager. Building on general strain theory from the sociology of deviance and stress crossover theory from social psychology, we argue that the strain encountered by one partner in a social setting may affect his or her spouse. For instance, the wife of a man under more social strain may experience more strain in turn and thus be at a higher risk of developing disordered gambling than the wife of a man under less social strain. Using community survey data of 1620 Chinese married couples, we performed multilevel dyad analyses to address social strain and couple dynamics, in addition to their roles as predictors of gambling behavior in both spouses. This was a community survey of Hong Kong and therefore was not representative of China. Based on the DSM-IV screen, the rates of probable problem gambling and pathological gambling among male partners (12.8% vs. 2.5%) were twice those among female partners (5.2% vs. 0.3%). We also found that the social strain experienced by a male partner significantly predicted both his and his wife's likelihood of developing gambling problems. Although a female partner's exposure to social strain was a significant correlate of her gambling problem, it had no significant association with her husband's gambling behavior. These results suggest that the cross-spouse transference of social strain may be a gendered process.

Predictors of Outcome among Pathological Gamblers Receiving Cognitive Behavioral Group Therapy

AIMS

The aim of this study was to evaluate posttreatment changes of individuals with a diagnosis of gambling disorder (GD) treated with group cognitive behavioral therapy (CBT), to assess the potential moderator effect of sex on CBT outcome, and to explore the best predictors of posttreatment changes, relapse, and dropout rates.

METHODS

A cohort design was applied with a prospective follow-up. The sample comprised 440 patients and the CBT intervention consisted of 16 weekly outpatient group sessions and a 3-month follow-up period.

RESULTS

Patients showed significant improvements in both the level of psychopathology and the severity of the gambling behavior. High self-transcendence and the involvement of the spouse or partner in the therapy predicted a higher risk of relapse. Younger age and low education predicted a higher risk of dropout.

CONCLUSION

Many patients with GD can be treated with strategies to improve self-control and emotional regulation, but other techniques should be incorporated to address the individual characteristics of each patient. This is particularly important in group therapy, in which the same treatment is applied to several patients simultaneously. The involvement of a family member needs to be carefully considered since it may have a negative effect on the response to treatment if not adequately managed.

Pathological gambling and couple: towards an integrative systemic model

This article is a critical literature review of pathological gambling focused in the family factors, particularly in the couple dynamics. Its main goal is to develop an explicative integrative systemic model of pathological gambling, based in these couple dynamics. To achieve that aim, a bibliography search was made, using on-line data bases (e.g., EBSCO Host) and recognized books in pathological gambling subject, as well as in the systemic approach in general. This process privileged the recent works (about 70 % of the reviewed literature was published in the last decade), however, also considered some classic works (the oldest one dates back to 1970). The guiding focus of this literature search evolves according to the following steps: (1) search of general comprehension of pathological gambling (19 references), (2) search specification to the subject "pathological gambling and family" (24 references), (3) search specification to the subject "pathological gambling and couple"(11 references), (4) search of systemic information which integrates the evidence resulted in the previous steps (4 references). The developed model is constituted by different levels of systemic complexity (social context, family of origin, couple and individual) and explains the problem as a signal of perturbation in the marital subsystem vital functions (e.g., power and control) though the regularities of marital dynamics of pathological gamblers. Furthermore, it gives theoretical evidence of the systemic familiar intervention in the pathological gambling.

Correlates of depressive symptom severity in problem and pathological gamblers in couple relationships

Problem and pathological gamblers (PPG) often suffer from depressive symptoms. Gambling problems have negative consequences on multiple aspects of gamblers' lives, including family and marital relationships. The objectives of the current study were to (1) replicate the results of studies that have suggested a stronger and more significant relationship between gambling and depression in PPG than in non-problem gamblers (NPG) and (2) explore specific correlates of depressive symptom severity in PPG in couple relationships. Variables demonstrated to be significantly correlated with depressive symptoms in the general population were selected. It was hypothesized that gender, age, gambler's mean annual income, perceived poverty, employment status, clinical status (i.e., problem or pathological gambler versus non-problem gambler), trait anxiety, alcoholism, problem-solving skills, and dyadic adjustment would be significant predictors of depressive symptoms. Sixty-seven PPG were recruited, primarily from an addiction treatment center; 40 NPG were recruited, primarily through the media. Results revealed that PPG reported significantly greater depressive symptoms than did NPG. Further, elevated trait anxiety and poor dyadic adjustment were demonstrated to be significant and specific correlates of depressive symptom severity in PPG. These findings contribute to the literature on depressive symptomatology in PPG in relationships, and highlight the importance of the influence of the couple relationship on PPG.

Problem gambling and family violence: family member reports of prevalence, family impacts and family coping

There exists only a small number of empirical studies investigating the patterns of family violence in problem gambling populations, although some evidence exists that intimate partner violence and child abuse are among the most severe interpersonal correlates of problem gambling. The current article reports on the Australian arm of a large-scale study of the patterns and prevalence of co-occurrence of family violence and problem gambling in Australia, New Zealand and Hong Kong. The current study screened 120 help-seeking family members of problem gamblers in a range of clinical services for both family violence and problem gambling. The main results showed that 52.5% reported some form of family violence in the past 12 months: 20.0% reported only victimisation, 10.8% reported only perpetration and 21.6% reported both victimisation and perpetration of family violence. Parents, current and ex-partners were most likely to be both perpetrators and victims of family violence. There were no gender differences in reciprocal violence but females were more likely to be only victims and less likely to report no violence in comparison to males. Most of the 32 participants interviewed in depth, reported that gambling generally preceded family violence. The findings suggest that perpetration of family violence was more likely to occur as a reaction to deeply-rooted and accumulated anger and mistrust whereas victimisation was an outcome of gambler’s anger brought on by immediate gambling losses and frustration. While multiple and intertwined negative family impacts were likely to occur in the presence of family violence, gambling-related coping strategies were not associated with the presence or absence of family violence. The implications of the findings for service providers are discussed.

Treatment of Gambling Problems in Asia: Comprehensive Review and Implications for Asian Problem Gamblers

Much research has been conducted in the treatment of gambling problems. However, very little is reported specifically on treating Asian problem gamblers. Thus, this article reviewed the general problem gambling treatment literature as well as the limited Asian problem gambling treatment literature to provide a discussion of interventions that can be used with Asian problem gamblers. The general literature showed that behavioral, cognitive, and combined cognitive behavioral treatments (CBT) have the most treatment outcome literature and appear to be the most effective in treating gambling problems. Although, pharmacotherapy also looks promising, it may be more suitable for problem gamblers with comorbid mood problems or impulsivity. Research on other forms of treatments also exists (e.g., 12-step and psychodynamic treatment approaches) but are not as robust. Only three studies have reported on the effectiveness of treatment with Asian problem gamblers. The first study is case study. The second study presents data from a treatment program for Asian problem gambling and the last one presents preliminary findings of a telephone delivered treatment program with eight Asian American gamblers. These studies support the general treatment literature in showing that CBT and pharmacotherapy have a role to play in treating Asian problem gamblers. Based on the general and Asian problem gambling treatment literature, a discussion of treatment of Asian problem gamblers is provided including the use of CBT and other forms of treatment, issues to address in treatment, and variables that can assist treatment.

Does exposure and response prevention improve the results of group cognitive-behavioural therapy for male slot machine pathological gamblers?

INTRODUCTION

Cognitive-behavioural therapy (CBT) seems to offer effective treatment for pathological gambling (PG). However, it has not yet been established which techniques yield the best results, or whether exposure and response prevention (ERP) techniques are of additional use.

OBJECTIVES

To evaluate clinical and socio-demographic characteristics of a PG sample at baseline, comparing cognitive-behavioural group intervention, with and without exposure, with response prevention (CBT + ERP vs. CBT), to compare the results of therapy and to assess pre-post changes in psychopathology between both groups.

DESIGN

We applied a quasi-experimental design comprising intervention on the independent variable, but without random assignment.

METHODS

The sample comprised 502 males with PG, consecutively admitted to a specialist unit, who received standardized outpatient CBT group therapy in 16 weekly sessions. Scores on the Symptom Checklist-Revised (SCL-90-R), the Temperament and Character Inventory-Revised (TCI-R), the South Oaks Gambling Screen (SOGS), and other clinical and psychopathological scales were recorded.

RESULTS

Pre-post changes did not differ between groups, except for SCL paranoid ideation, being greater in the CBT therapy group. The risk of relapse during treatment was similar in the CBT + ERP and CBT patients. However, compliance with treatment was poorer in the CBT + ERP group, who presented higher drop-out rates during treatment. Drop-out during therapy was associated with shorter disorder duration and higher scores on the TCI-R novelty seeking scale.

CONCLUSIONS

Although the two CBT programs elicited similar therapy responses, patients receiving CBT alone showed higher adherence to therapy and lower drop-out rates.