Cognitive versus exposure therapy for problem gambling: Randomised controlled trial
Introduction
Maladaptive gambling behaviour is harmful to individuals, families, and communities with consequences including financial ruin, broken marriages, problems with the law, depression, anxiety and suicide. There is an urgent need to identify and develop effective treatments for problem gambling that are consistent with the inclusion of Gambling Disorder as an addiction in DSM-5 (American Psychiatric Association, 2013). The current evidence-base for gambling treatments suggests that psychological interventions, mainly variations of cognitive behavioural therapy (CBT), are the most promising (Cowlishaw et al., 2012).
The theoretical underpinnings of CBT include cognitive and psychobiological processes which are the basis of two dominant approaches to explaining decision-making during gambling (Clark, 2010). Cognitive therapy (CT) for problem gambling focuses on teaching the concept of randomness, increasing awareness of inaccurate perceptions and restructuring erroneous gambling beliefs (Ladouceur et al., 2001). Treatments that target gambling related psychobiological states (e.g. the “urge” to gamble) are predominantly behavioural (exposure-based) (Battersby et al., 2008, Oakes et al., 2008, Tolchard et al., 2006). Of the few randomised trials that have investigated behavioural (exposure-based) techniques for disordered gambling over the past 30 years none have attempted to isolate and compare their efficacy with pure cognitive therapy (Grant et al., 2009, McConaghy et al., 1983, McConaghy et al., 1991). It is important to dismantle combined CBT approaches to determine if each core component can be delivered independently and if one is more efficacious than the other. This has major clinical and policy implications if single modalities can be as efficacious and delivered in less time than combined approaches.
Therefore, in this randomised controlled trial, the research question we addressed was: Among treatment seeking problem gamblers can exposure therapy alone improve gambling related outcomes across intervention period and 6-month follow-up compared with cognitive therapy alone? The broader aims of the study were to establish whether exposure and cognitive therapy for problem gambling could be isolated, manualised and administered in a reliable and consistent manner across therapists whilst maintaining fidelity. As a phase II study, it would provide the basis for a phase III randomised trial comparing cognitive, exposure and combined cognitive and exposure therapy to assess the relative benefits of the individual and combined elements of CBT and determine underlying mechanisms of change.
Section snippets
Study design and participants
A detailed description of the study protocol has been published elsewhere (Smith, Battersby, Harvey, Pols, & Ladouceur, 2013). Comparing outcomes of cognitive and exposure therapy for problem gamblers was conducted using a two-group randomised, parallel design, with outcomes assessed up to 9 months after randomisation for treatment seeking problem gamblers. The study site was the Statewide Gambling Therapy Service (SGTS) in South Australia. The service offers free mental health and
Participant recruitment and flow
The flow of participants through each stage of the study is shown in Fig. 1. Participants were recruited from 151 consecutive referrals to SGTS. The most common reason for study exclusion was non-EGM use as the primary form of problem gambling. Of the 99 participants randomized, 12 did not attend and commence the allocated intervention. One participant allocated to the CT group received ET due to inconsistent application of the study protocol. No significant differences were found between
Discussion
To our knowledge this study is the first to test a direct comparison between CT alone and ET alone in problem gambling with fidelity testing confirming that there are valid and reliable CT and ET techniques that can be taught and delivered in manualised form. Exposure therapy achieved similar clinical outcomes as CT alone and gambling-specific CBT programs typically comprise CT as the core element (Cowlishaw et al., 2012). However, due to a shortfall in participant numbers, a true difference
Declaration of interest
This work was funded by the Victorian Department of Justice, Office of Gaming & Racing (tender 061/09), and management of the grant was transferred to the Victorian Responsible Gambling Foundation in July 2012. The SGTS is funded by the Office of Problem Gambling, Department of Families and Social Inclusion, Government of South Australia. The authors have no other conflicts of interest to declare.
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