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Excessive Gambling and Cognitive Therapy: How to Address Ambivalence Claude Boutin, Michel Dumont, Robert Ladouceur and Patrizia Montecalvo Clinical Case Studies 2003; 2; 259 DOI: 10.1177/1534650103256297 The online version of this article can be found at: http://ccs.sagepub.com/cgi/content/abstract/2/4/259

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10.1177/1534650103256297 CLINICAL Boutin et al. CASE / EXCESSIVE STUDIES GAMBLING / October 2003 AND AMBIVALENCE

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Excessive Gambling and Cognitive Therapy How to Address Ambivalence CLAUDE BOUTIN MICHEL DUMONT ROBERT LADOUCEUR PATRIZIA MONTECALVO Université Laval, Québec, Canada

Abstract: In this article, the authors provide clinical recommendations for addressing issues frequently encountered with gamblers during the course of cognitive treatment. The main clinical topics covered are ambivalence toward abstinence, denial of the gambling problem, lying, and relapse prevention strategies. The authors begin the article with a brief review of the gambling literature, after which they present the case of a 53-year-old gambler to illustrate clinical interventions. Clinical recommendations also are offered. Keywords: gambling; ambivalence; abstinence; treatment; cognitions

1 THEORETICAL AND RESEARCH BASIS The legalization of new forms of gambling is increasing in most Western countries. This trend has created a situation in which increasing numbers of people will develop serious gambling problems for which they will need to seek professional help (Becoña, Labrador, Echeburua, Ochoa, & Vallejo, 1995). It is now acknowledged that the prevalence of pathological gambling is related to the availability of gambling opportunities, legal or illegal (Jacques, Ladouceur, & Ferland, 2000; Ladouceur & Walker, 1996; Volberg, 1994). Current prevalence rates of this disorder vary from 1% to 2% in the United States and Canada (Shaffer, Hall, & Vander Bilt, 1997). Despite prevalence of gambling disorder, few treatment programs have been developed to treat pathological gamblers; controlled studies assessing their efficacy are rare (Petry & Armentano, 1999; Toneatto & Ladouceur, in press). Toneatto and

AUTHORS’ NOTE: Correspondence concerning this article should be addressed to Claude Boutin, Centre Québécois d’Excellence pour la Prévention et le Traitement du Jeu, 1030 rue Cherrier, Suite 505, Montréal, Québec, Canada. Email may be to [email protected]. CLINICAL CASE STUDIES, Vol. 2 No. 4, October 2003 259-269 DOI: 10.1177/1534650103256297 © 2003 Sage Publications

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Ladouceur (in press) identified only nine studies using randomized controlled trials in the treatment of pathological gamblers. All studies used either behavioral or cognitivebehavioral approaches. Although these studies yielded positive outcomes, few of these interventions were based on empirically validated theories of gambling. Further complicating treatment of pathological gamblers is the finding that approximately 50% of excessive gamblers who seek therapy drop out before completion (Ladouceur, Gosselin, Laberge, & Blaszczynski, 2001; Ladouceur, Sylvain, Boutin, & Doucet, 2002). A recent study reveals that elevated scores on a psychometric measure of impulsivity significantly differentiates participants who drop out from those participants who complete their treatment. These results strongly suggest that impulsivity interferes with treatment adherence (Leblond, Ladouceur, & Blaszczynski, in press). Moreover, evidence suggests that gamblers who do persist in the course of their treatment often manifest ambivalence toward abstinence, preferring a controlled mode of gambling. There has been substantial controversy surrounding the abstinence issue among clinicians and researchers. In this article, we offer some clinical guidelines specifically aimed at countering ambivalence and present examples of patient-therapist interactions to illustrate these guidelines.

2 CASE PRESENTATION Peter is a 53-year-old married policeman and the father of one child. He is well educated, attractive, and easygoing. He is currently experiencing marital difficulties, and he and his wife live in separate households. Peter has a tendency to seek out prostitutes, whom he meets in bars where he gambles on video lottery machines. He occasionally consumes alcohol and drugs. His family doctor referred him to us for a severe gambling problem, which began 2 years ago and is restricted to video lottery machines. Peter’s ambivalence toward abstinence was evident at the onset of therapy.

3 PRESENTING COMPLAINTS Peter reported a major concern about his increasing lack of control over his gambling behavior. He was not as preoccupied about his poor social functioning as he was about his poor psychological well-being. He reported feeling very anxious and depressed when asked to rate intensity of his emotions on a Likert-type scale ranging from 0 to 5. His suicidal ideation was directly linked to his gambling problem. Peter blamed accumulation of stress as being the trigger of his problem. Surprisingly, he was not complaining about his $22,000 debt nor was he complaining about the loss of his retirement savings.


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4 HISTORY Prior to when he started playing video lottery machines, he had not gambled. Peter started to gamble in the midst of a midlife crisis. In his early 50s, he started to realize that women did not seem as interested in him as in the past. To remedy this situation, Peter tried to impress prostitutes by “feeding” the machines a lot of money. Although sex, drugs, alcohol, and gambling were meant to alleviate his midlife crisis, they only combined to aggravate it.

5 ASSESSMENT A complete assessment was undertaken prior to treatment. As part of the standard assessment for pathological gamblers, Peter completed the South Oaks Gambling Scale (Lesieur & Blume, 1987), the Beck Depression Inventory (Beck & Steer, 1987), the Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988), and the Diagnostic Interview for Pathological Gamblers (Ladouceur, Sylvain, & Boutin, 2000; Ladouceur, Sylvain, et al., 2002). Peter’s score on the South Oaks Gambling Scale indicated that he was a probable pathological gambler and revealed that he had never received treatment for his gambling problem prior to now. His score on the Beck Depression Inventory revealed that he was depressed. The most prominent symptoms of his depression were related to sleep, weight, appetite, and health. Given that Peter was suicidal, a nonsuicidal pact was contracted with him. Despite Peter’s high score on the Beck Depression Inventory, he was very collaborative and eager to begin treatment. Peter’s score on the Beck Anxiety Inventory was high, and his anxiety symptoms were suggestive of a panic attack syndrome. Given that his anxiety symptoms were long-standing rather than stemming from his gambling problem, the therapist did not deem it necessary to address his anxiety before treating his gambling problem. Finally, completion of the Diagnostic Interview for Pathological Gamblers revealed that Peter got “lucky” the first time that he gambled and won $500 after only wagering $40. It also revealed that he then continued gambling to recuperate subsequent losses. Given that Peter consumed alcohol and drugs only a small percentage of the time that he gambled, substance abuse was not considered to underlie the gambling problem. Finally, Peter met 8 of the 10 DSM-IV (American Psychiatric Association, 1994) diagnostic criteria for pathological gambling, which are included in the Diagnostic Interview for Pathological Gamblers. Peter was ambivalent toward abstaining from gambling. He was not eager to go through a “mourning period,” and he still believed that he could gamble in a controlled manner. He did, however, score 10 on a 0 to 10 scale when asked about his readiness to put in the effort to attain abstinence. His main motivation for quitting was his desire to conquer women. He believed that eliminating such a bad habit would make him more appealing to women.


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6 CASE CONCEPTUALIZATION The cognitive treatment developed by Ladouceur, Sylvain, et al. (2001) was implemented to treat Peter. This treatment is aimed at identifying and correcting erroneous beliefs regarding gambling. The intervention was tested on 66 gamblers who met DSMIV criteria for pathological gambling. Findings indicate that 87% of gamblers receiving the 12-hour, individually based treatment no longer met DSM-IV criteria for pathological gambling 12 months following the end of treatment (Ladouceur, Sylvain, et al., 2001). Cognitive modification begins with the observation of a gambling session. As the name implies, this technique requires that the client describe his last gambling session while the therapist inquires regarding the origin of the urge to gamble. During the observation of a gambling session, the client reconstructs the inner dialogue that transpired from the moment the first thought related to gambling was triggered to the moment he returned home. For example, a gambler may recall that his urge to gamble began when he received his paycheck. His first thought at that moment might have been “I worked hard for this money. Why not have a little fun with it? After all, I can limit myself to $20, and if I win, I can pay off all of my expenses.” The therapist systematically asks questions about the gambler’s thoughts and actions prior to, during, and after a gambling episode: How does he choose where he gambles, and why does he choose that place over another? Does the gambler have a preferred location or a favorite game? Does he have favorite numbers, certain habits, or a particular ritual when he gambles? Does he have a personal way of betting? Does he use any strategies? If so, what are they? How does he determine whether he will increase, decrease, or maintain his bets? Does he have any clues that indicate when he should bet? Does he believe he can recuperate his losses? Does he think he will eventually be able to beat the game? After having won or lost a sum of money, what does he tell himself? Does the gambler keep statistics on past gambling sessions? As the therapist searches for erroneous thoughts, the extent of the gambler’s confidence about winning and the moment at which this confidence settles in is assessed. Is he confident from the moment the urge to gamble appears? Does this confidence manifest itself throughout the gambling session? Does the gambler attribute certain credibility to intuitions or have any superstitions? The therapist keeps a log of these responses to address them during the therapeutic process. The therapeutic process consists of teaching the gambler to identify maladaptive thoughts (i.e., thoughts that increase the urge to gamble) and to replace them with thoughts that foster abstinence. Identification and correction of these errors are undertaken during and between treatment sessions using homework assignments. The reader is referred to Ladouceur, Boutin, Sylvain, and Lachance (2002) for an in-depth description of cognitive errors and modification guidelines. Gamblers who apply techniques needed for modifying erroneous thoughts increase their chances of successful abstinence. However, as there are not yet any mira-



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cle treatments, the issue of relapse is addressed and gamblers examine the different scenarios that are likely to make them give in to their urge to gamble. To maintain therapeutic gains, cessation of therapy is gradual. Therapy terminates when the client masters the technique of cognitive modification and has a realistic plan for dealing with potential relapse.

7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS From the outset, Peter adhered very strongly to the cognitive approach. He was collaborative and spoke freely about his last gambling session, which made it easy to identify his erroneous cognitions. He quickly understood the distinction between games of chance and games of skill. When he received a text about the pitfalls of gambling, he read it with much interest. He completed his homework assignments regularly. Within 14 therapy sessions, he had overcome his gambling problem. The following sections outline some of the important considerations in cognitive therapy, using patient-therapist dialogue derived from Peter’s case. Helpful analogies or metaphors that were offered to Peter to clarify certain concepts also are presented.

8 COMPLICATING FACTORS It was important to convey a positive self-image to Peter throughout the therapeutic process. When Peter made the decision to consult a professional, he naturally felt overwhelmed. Although he was conscious that he was losing money, he also realized that he was betting more. Faced with this obvious paradox and his increasing loss of control, he felt quite helpless. In fact, the absurdity of his behavior overwhelmed and discouraged him. To avoid reinforcing this self-defeating perception of himself and of his gambling problem, Peter’s therapist made every effort to never treat him as a “sick” person. With the goal of increasing self-esteem, gambling excesses were not personalized but rather presented as a loss of control associated with a destructive “passion.” Moreover, the therapist avoided using the words dependent, compulsive, or excessive when referring to Peter’s problem. Finally, emphasis was placed on the erroneous character of thoughts and the feasibility of correcting them rather than on excessive personality traits. The objective of such positive self-regard was to create a sane environment and a positive relationship between Peter and his therapist. The following is an analogy that Peter’s therapist used to explain the cognitive approach to him: Therapist: I would like you to consider the image of a lion, a strong and powerful animal guided by instinct. When a lion tamer attempts to make the lion obey, the lion naturally resists with all its strength. It is only with perseverance that


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the lion tamer is able to tame the lion. We all possess a lion and a lion tamer within ourselves. Our logical or rational side may be considered our lion tamer, while our instinct corresponds to the lion. Right now, your instinct for gambling is very strong and your lion continually roars. It is up to your lion tamer to take control. With therapy, you will gain new tools to help you do so. This image gave Peter hope because it allowed him to see that he had the ability to tame his excessive gambling behavior. It suggested that he was not without resources and that he could act on his problem. Peter’s task as a lion tamer consisted of detecting and fighting off spontaneous erroneous thoughts in order to take control over his behavior. Given Peter’s ambivalence toward abstinence, it was appropriate to stimulate his adherence to treatment at the beginning of therapy. There are two ways of stimulating adherence. In Peter’s case, the therapist opted for a paradoxical approach by indicating to Peter that there was a strong chance that he would not complete the treatment given that one out of two individuals drop out. The paradoxical approach was aimed at stimulating Peter’s combative nature by providing him with the challenge of proving that he would not become one of those people who could not finish therapy. However, the opposite approach could just as easily have been employed. In this case, the therapist would have spoken of the success rate of the treatment (i.e., 87% of gamblers who complete treatment no longer meet DSM-IV criteria) in order to favor greater adherence. Ambivalence toward abstinence may manifest itself in many ways. A simple question such as the following one is indicative of such ambivalence: Peter: Can I still buy lottery tickets? Must I stop gambling on all games? I only have a problem with video lottery machines! Therapist: The treatment that you’re undertaking involves the cessation of all games of chance. It is your only protection against relapse. To pursue certain gambling activities, even in a controlled manner, constitutes risky behavior. What would happen if, by misfortune, you would win a small sum of money with an inoffensive lottery ticket? Is it possible that this would give you the desire to test your luck at video lotteries? Here is an amusing analogy that the therapist used with Peter to speak about the risks of controlled gambling. It is common knowledge that a Slinky is a flexible spring that is sold as a toy for children. It can slide from one hand to the other or go down stairs (see Figure 1). In this analogy, each step of the staircase represents a gambling session. Each curvature of the Slinky represents a win. It is apparent from watching the Slinky go down the stairs that for every win the gambler experiences during any given gambling session, there is a progressively greater loss over the long run. The gambler’s greatest problem is that he fails to see the complete staircase. In other words, he has a tendency to focus on the present, on only one step of the staircase at the time. By doing so, the gambler does



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Figure 1. A Slinky

not realize the extent of his losses. Rather, he focuses on intermittent gains, which only serve to fuel his appetite to wager again. The therapist’s task is to help the gambler see the full staircase and thereby help him realize that his accumulated losses far surpass momentary gains. Peter was told that he had a better chance of stopping his Slinky’s descent by eliminating any and all possibility of reinforcement through momentary gains by completely ceasing to gamble. The Slinky example helped Peter understand why he continued to gamble even after realizing that he was losing money. He did not realize the extent of his losses because he kept focusing on current gains rather than total losses. Other than the Slinky, two other phenomena could explain this paradoxical persistence to gamble. The first phenomenon is the gambler’s tendency to repeatedly apply ineffective solutions, and the second phenomenon is entrapment. Gamblers often begin wagering to escape from something. Gambling becomes a solution to deal with unpleasant life situations. Negative emotions, family problems, and work responsibilities are all forgotten while gambling. The problem is that although gambling allows a short-term refuge from life’s difficulties, it aggravates these difficulties in the long run. Work responsibilities become heavier given frequent absences from work, family problems are worsened by financial instability, and negative emotions not only resurface after the gambling session but they worsen as a result of failure and fear of bankruptcy. The gambler therefore is repeating an ineffective solution. This situation is likened to a fly trapped in a bottle. Therapist: Have you ever noticed that a fly trapped in a bottle flies around in circles continuously bouncing off one wall and onto another while trying to escape until it finally runs out of oxygen and drops to the floor? Although the fly “real-


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izes” that the solution of flying in circles is not working and instead of changing that solution, it keeps applying it more vigorously. You became like a fly in a bottle. Gambling has become your unique solution for dealing with problems. Together, we will work toward finding more permanent and less selfdestructive solutions. Finally, entrapment plays an important role in the perpetuation of gambling. Entrapment refers to the fact that as more and more is invested into something or someone, it becomes increasingly difficult to cut losses. Think about everything that the gambler has invested in gambling. In addition to the financial investment, it is not uncommon for gamblers to lose their employment, their families, and their social ties because of their gambling addiction. The principle of entrapment is evidenced in nongambling situations as well. To make Peter realize that he was trapped in a very normal process, the therapist spoke about the “bus syndrome”: Therapist: Do you know the “bus syndrome”? Just remember occasions when you are waiting for a street bus that never arrives. Should you leave or stay a little bit more before calling a cab? Heavy gamblers are trapped into a terrible dilemma. Should they leave or continue gambling? Because they “invested” so much time and energy into that activity, they cannot resign to give up. What if the next bet was the right one? These analogies, although simplistic, provide the gambler with an explanation for his gambling problem. More important, they provide an explanation that does not label the gambler as “defective” or “diseased.” Rather, they make use of generalizations regarding problem-solving and thought-processing strategies that apply to all humans. This lack of labeling is extremely important if self-mastery is to be fostered in the client. Although no major complications were encountered during the course of Peter’s treatment, one occurrence did give Peter’s therapist some food for thought. Occasionally, Peter’s therapist had the impression that Peter was lying to him or that he was in denial regarding the severity of the consequences that gambling had in Peter’s life. Lying and denial are major issues for most excessive gamblers. How to deal with them largely depends on the therapist’s approach. The therapist can be direct and confrontational when a lie is suspected, or he can completely ignore this suspicion. Many issues need to be considered in deciding if the gambler should be confronted. Confronting the client may jeopardize the therapeutic relationship or push the client to end treatment. On the other hand, exposing the client’s lies and subduing his denial may allow him to finally begin mourning his gambling losses. Not confronting the client may hinder the effectiveness of the treatment. There are, of course, no clear guidelines regarding whether a therapist should or should not be confrontational when the suspicion of untruthfulness is present. The ther-



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apist’ s treatment style and the type of client he is dealing with will influence this decision. There are currently no studies that have addressed the issue of whether lies and denial affect treatment efficacy. In the absence of such empirical data, therapists must rely on their clinical intuition. Relapse prevention is a very important part of the therapeutic process, and no treatment is complete without this final component. Before the end of treatment, the therapist must ensure that the client’s expectations regarding long-term abstinence are realistic. It is quite common for clients to simplistically believe that their gambling problem will be “cured” by the end of treatment and that gambling will no longer be an issue for them. It is crucial that the therapist explain to the client that he will continuously be faced with submerging his urge to gamble and that relapse is always a possibility. The only protection against relapse is for the client to continue to identify and modify his cognitive misconceptions as they surface. The following is an example of how relapse prevention was presented to Peter, using the lion tamer analogy: Peter: Can you guarantee that I will no longer want to gamble when I leave therapy? Therapist: I’m afraid that we won’t be killing the lion and you should remain on the lookout. Rarely are there lion tamers who are not distrustful of their lions. Throughout their lives, they remain vigilant. This fear ensures their survival. Peter: Does that mean that I will always be bothered by gambling? Therapist: With time, your lion’s roars will be less intense but the challenge will always remain. After all, the lion tamer’s pride is not based on never hearing his lion’s roars but rather on being able to quiet them. Once the gambler possesses a realistic appraisal of prolonged treatment gains, it is time to arm him with tools to increase his chances of long-term abstinence. Increasing the likelihood of long-term abstinence entails developing a plan to cope with future urges. This plan should consist of identifying situations, emotions, and thoughts that place the gambler at greater risk of relapse and establishing ways of countering these risk factors. For instance, a gambler can anticipate a yearly Christmas party that always takes place at the casino. He can then plan to counter this risk by relocating the dinner. Planning in advance will help the gambler keep a clear head when the urge to gamble resurfaces.

9 FOLLOW-UP Six months following the end of treatment, Peter did not meet DSM-IV criteria for pathological gambling. However, his gambling problem seemed to have been replaced by a drug problem for which Peter is currently being treated as an outpatient. This substitution of addictions led Peter’s therapist to ponder if Peter’s drug problem was more


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severe than he admitted during the initial assessment. Could Peter have been in denial about his substance-abuse problem? And what will happen when his drug addiction is under control? Will he revert back to gambling? The substitution of addictions is very common among gamblers. Empirically validated treatments that incorporate drug and gambling addiction into a single treatment are obviously needed.

10 TREATMENT IMPLICATIONS OF THE CASE The reasons that motivate gamblers to consult a professional vary from one individual to another. Specifying what these reasons are provides precious information regarding the gambler’s motivation to engage in a therapeutic process. An inventory of the pros and cons of ceasing to gamble can be very useful. Gamblers who are cognizant of the consequences of gambling and of their severity improve their ability to strive for abstinence. Because ambivalence is at the root of dropout, dedicating an important segment of the treatment to countering ambivalence is worthwhile. If ambivalence is high and is not discussed at the onset of therapy, it will inevitably diminish the gambler’s motivation to reach abstinence.

11 RECOMMENDATIONS TO CLINICIANS AND STUDENTS The aim of cognitive treatment for pathological gambling is to enable the gambler to identify and modify erroneous misconceptions regarding gambling. It is fundamental for the therapist to avoid treating the client as a helpless and sick individual. Using analogies such as the lion tamer, the Slinky, and the fly in the bottle, the therapist can provide the gambler with answers he has been asking himself repeatedly but to which he has not found answers: Why do I keep gambling even though I am losing money? Why is it so hard for me to stop? The answers to these questions will help the client understand that intelligent people can fall into this trap and will replace his notion of himself as being weak of character, having no willpower, and being completely illogical. Moreover, given that the cognitive approach requires the client to take an active part in the therapeutic process, feelings of self-mastery and success will replace those of despair and failure. In the cognitive approach, the therapist’s main role is to provide the gambler with the tools to overcome his gambling problem and to help the gambler gain confidence in his ability to use these tools.

REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.



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Claude Boutin (MPs) is a clinical psychologist who works for the Center for Prevention and Treatment of Gambling in Montréal since 1997. He participated into the development of a treatment guide for excessive gamblers, which is endorsed by Québec government. Michel Dumont (MPs) is a clinical psychologist. He received his master’s degree in the gambling field, and he is specialized in cognitive therapy, strategic approaches, and hypnosis. Recently, he held many workshops about excessive gambling treatment. Robert Ladouceur (PhD) is a professor of psychology at Laval University in Quebec City. His work on gambling is internationally known. In 1996, he received a research award from the National Council on Problem Gambling, recognizing the high quality of his work. Patrizia Montecalvo (MPs) is a clinical psychologist who works as a full-time clinical consultant for an employee-assistance program. She specializes in cognitive-behavioral and brief-strategic therapy for patients with a range of disorders, with a specialization in gambling behavior.
