________________________________________________________________________ Behavioral Addictions
Variants of CBT have been adapted for patients with gambling disorder, with mixed results [118].
• Failure to recognize net losses with intermittent small wins (e.g., spending $400, a $50 win is deemed a suc- cess, despite the $350 net loss) • The idea of intensely needing to win makes winning likely • Beliefs about luck Therapies targeting erroneous cognitions, gambling urges, and motivations are effective. A meta-analysis of behavioral therapy outcomes in gambling disorder found an effect size of 2.01 at the end of treatment and 1.59 at follow-up (mean: 17 months). Efficacy seems to diminish over time, but the effect sizes were robust [84; 115]. Cognitive-Behavioral Therapies In the treatment of gambling disorder, cognitive therapy is based on the idea that gambling-related cognitive distortions contribute to disordered behavior. With this approach, the therapist helps patients identify and correct gambling-related cognitive distortions, with the goal of improving gambling abstinence by greater use of logical behavioral choices. One cognitive approach provides up to 20 weekly sessions until the patient stops gambling. Short-term outcomes show superior improvement relative to control groups. A frequent component is relapse prevention, which identifies high-risk situations for relapse and maladaptive beliefs related to control over gambling [113; 116]. Behavioral therapies target gambling urges primarily with exposure-based therapies. Exposure therapy is based on clas- sical conditioning paradigms, whereby gambling urges are eliminated through cue exposure with extinction processes. Exposure therapy is thought by some to be more beneficial in gambling disorder than other behavioral therapies, such as aversive therapy [71]. CBT focuses on changing gambling-related cognitions and behaviors; it is effective and improves treatment engagement and outcomes [114]. Brief, four- to six-session CBT interven- tions show some promise in problem and disordered gambling, but they require further evaluation in broader samples of treatment-seeking gamblers [113; 117]. An eight-session CBT intervention for gambling disorder may follow the specific therapeutic focus outlined here [95; 113]: • Recognizing gambling triggers that precipitate gambling episodes: days/times, people, cues (cash), events (cel- ebrations, arguments), and emotions (negative affect) • Examine gambling episodes using functional analysis • Increase alternate pleasurable activities • Manage anticipated and unanticipated triggers • Relaxation techniques to manage responses to gambling urges • Interpersonal conflicts, practice gambling refusal skills • Cognitive biases and distortions with gambling disorder • Relapse prevention, coping with major life events
According to a Cochrane Review, cognitive- behavioral therapy (CBT) is effective in reducing gambling behavior and other symptoms of pathologic and problem gambling immediately following therapy. However, the durability of therapeutic gain
is unknown. (https://www.cochranelibrary.com/cdsr/ doi/10.1002/14651858.CD008937.pub2/full. Last accessed April 19, 2024.) Level of Evidence : Meta-Analysis Functional analysis teaches patients with gambling disorder to identify triggers, related feelings, and resultant behaviors; examine the positive and negative consequences of their trig- gers; and identify cognitive biases, such as luck-related beliefs in their gambling behaviors [84]. The process of developing improved strategies to identify and manage triggers related to craving may increase PFC control over motivational drives involving subcortical brain regions [84]. Increased awareness and understanding of irrational cognitions, such as those related to luck, near-miss events, and chasing behaviors, may increase the balance in activity of brain circuits that code conflicting motivational states [84; 119]. Skills training in CBT can include interpersonal skills and conflict resolution methods through role-playing and skills training. These skills are intended to help the person recognize that gambling may provide short-lived reward and enjoyment but problematic long-term consequences of debt, interper- sonal conflicts, and/or legal system involvement. This type of intervention further addresses finance management and debt settlement—important concerns in gambling disorder [120]. Brief Motivational Interventions Brief motivational intervention shows promise in reducing gambling when delivered alone or with other therapies. Brief motivational interventions are often directed at patients with subclinical diagnoses, defined as negative gambling-related consequences without meeting the criteria for gambling dis- order. Brief motivational intervention is useful for engaging patients with poor problem recognition in further treatment or for spurring self-directed change. Therapy sessions focus on personalized feedback, brief advice, review of options (e.g., treatment options, change goals), and building self-efficacy, delivered in an empathic manner. In one study, telephone brief motivational intervention combined with a self-help workbook was effective in improving gambling outcomes in problem gam- blers [121]. Single-session stand-alone motivational sessions are effective compared with assessment-only control groups [117]. Direct comparisons of motivational therapy and CBT
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