Background
Problem gambling-specific cognitive therapy (CT) and behavioural (exposure-based) therapy (ET) are two core cognitive-behavioural techniques to treating the disorder, but no studies have directly compared them using a randomised trial.
Aims
To evaluate differential efficacy of CT and ET for adult problem gamblers at a South Australian gambling therapy service.
Methods
Two-group randomised, parallel design. Primary outcome was rated by participants using the Victorian Gambling Screen (VGS) at baseline, treatment-end, 1, 3, and 6 month follow-up.
Findings
Of eighty-seven participants who were randomised and started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET = 21). Both groups experienced comparable reductions (improvement) in VGS scores at 12 weeks (mean difference −0.18, 95% CI: −4.48–4.11) and 6 month follow-up (mean difference 1.47, 95% CI: −4.46–7.39).
Conclusions
Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates and reduce drop-out.
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 and 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 and 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.
