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Advice to the Gambling Commission on a statutory levy

A paper by the Advisory Board for Safer Gambling advising the Gambling Commission on a statutory levy

  1. Contents
  2. Appendix 1: Summary of psychological treatment approaches

Appendix 1: Summary of psychological treatment approaches

Summary of psychological treatment approaches

This Appendix provides a summary of the current psychological therapies, which typically address psychological (cognitions, cognitive dissonance), emotional (emotional dysregulation), behavioural (impulse control) and contextual (e.g. environmental cues) factors that are associated with gambling in a problematic pattern. Cognitive Behaviour Therapy (CBT) currently has the strongest evidence base as an intervention, but other forms of intervention have also demonstrated effective outcomes.

Cowlishaw et al126, Rizeanu127, Menchon et al186 and Sancho et al129 have conducted problem and pathological gambling treatment reviews and have identified, based on the strength of the evidence, four types of psychological treatments:

1.1 Cognitive Behaviour Therapy (commonly referred to as CBT)

Cognitive Behaviour Therapy currently has a strong evidence base, which may be due to the availability of randomised clinical trials. CBT consists of a collaboration between client and therapist that seeks to engage the client in Cognitive Restructuring (re-evaluating erroneous beliefs e.g. about gambling randomness, ability to identify systems of winning or recoup losses), increase awareness of biases in information processing and thinking style, teach problem-solving training and social skills training. Relapse Prevention involves increasing awareness of the cues or triggers for relapse and identifying alternative adaptive coping strategies. Based on the available evidence Cognitive Behaviour Therapy is considered best practice at this time.

1.2 Motivational Interviewing Therapy

Motivational Interviewing Therapy currently has some evidence of effectiveness, although the available evidence is for less severe gambling problems. Motivational Interviewing is a client-centred counselling style that seeks, in a non-judgemental conversation, to increase awareness of the costs and benefits of a behaviour. It also seeks to create cognitive dissonance by shifting the motivational balance away from ambivalence toward eliciting change talk in the form of self-motivational statements and increasing the client’s perceived importance and confidence in the possibility of change. Motivational interviewing also includes motivational enhancement therapy.

1.3 Mindfulness-based interventions

Mindfulness-based interventions currently have some evidence of effectiveness. As applied to gambling problems, mindfulness-based interventions are based on the premise that emotional dysregulation and impulse control difficulties underpin pathological gambling. Mindfulness-based interventions comprise of a treatment that aims to promote increased mindful awareness of thoughts, feelings and bodily sensations, acceptance, paying attention in the moment to thoughts and feelings without judgement. A combination of psycho-education, mindfulness-based interventions plus CBT maybe able to improve to improve secondary emotional dysregulation in addition to the benefits of traditional Cognitive Behaviour Therapy.

1.4 Other Psychological Therapies

Other Psychological Therapies include Psychodynamic therapy, Aversion Therapy, 12-step (Gamblers Anonymous, GA), Integrative therapy and self-exclusion. They have weak or no evidence, this may be due to the lack of research trials. GA has been used as the control condition in some research trials.

2.0 Treatment Effectiveness

2.1 National Institute of Clinical Excellence (NICE) Recommendations

Currently there are no NICE guidelines available recommending the best treatment approach and models of service delivery, however, this Quality Standard (GID-QS10099) has been referred to NICE (July 2018) but has not been scheduled into the programme of work. Expected publication date to be confirmed.

2.2. Cognitive Behaviour Therapy, Motivational Interviewing, Twelve Step facilitated group therapy

The latest Cochrane review was published 14th November 2012. It reviewed psychological therapies for pathological and problem gambling. It systematically reviewed the literature and identified 14 randomised controlled research trials of psychological therapies for pathological and problem gamblers130. The review assessed the research trials for the efficacy and durability of treatment effects. The psychological therapies included Cognitive Behaviour Therapy (CBT) (11 research trials), Motivational Interviewing therapy (4 research trials), Integrative therapy (2 research trials) and Twelve Step facilitated group therapy (1 research trial). The interventions were delivered by highly trained Clinicians under supervision (e.g. Clinical Psychologists, Cognitive Therapists, Masters level Counsellors, Clinical professionals).

The control condition was no treatment controls or referral to Gamblers Anonymous. The primary outcomes they used to assess how effective treatment were: Gambling symptom severity, financial loss and gambling frequency. The secondary outcomes they used to assess how effective treatment was were symptoms of depression and anxiety. Assessment of outcomes was at 0-3 months post-treatment.

The review identified that Cognitive Behaviour Therapy (CBT) (11 research trials) compared to control groups significantly experienced beneficial effects from treatment in terms of reduced Financial Loss (medium effect size) and Reduced Gambling Symptom Severity (very large effect size). It found that Motivational Interviewing therapy (4 research trials) led to significantly reduced Financial Loss from gambling, however the participants in those research trials had less severe gambling problems. There were no significant effects of therapy for Integrative therapy (2 research trials). For Twelve Step facilitated group therapy (1 research trial) some beneficial effects were identified. The review concludes there is evidence supporting Cognitive Behaviour Therapy (CBT), Motivational Interviewing therapy and Twelve Step facilitated group therapy. The review supports the efficacy of CBT in reducing gambling behaviour and other symptoms of pathological and problem gambling. However, the review was unable to assess the longer-term durability of treatment effects. The finding that CBT is effective in the treatment of problem gamblers has been supported by later reviews and studies.

Abbot et. al.131 has published a research protocol to conduct a pragmatic randomised control trial that will seek to address the shortfalls of previous research trials. They will compare a motivational intervention to Cognitive Behaviour Therapy and randomly allocate participants in a community treatment agency in New Zealand to one of the treatments. The motivational intervention will consist of one session of face-to face motivational interviewing and a self-instruction booklet plus five follow-up telephone booster sessions. The Cognitive Behaviour Therapy will consist of ten face-to face sessions. They will assess outcomes over a longer time period up to 12 months. The primary outcomes will be days spent gambling and money spent gambling per day in month prior. The secondary outcomes will be problem gambling severity, urges, cognitions, mood, alcohol and drug use, psychological distress, quality of life and costs.

2.3 Mindfulness-based interventions

Sancho et al. (2018)132 conducted a systematic review of Mindfulness-based interventions for the treatment of a range of substance and behavioural addictions that included gambling as a behavioural addiction. The review sought to assess the efficacy of mindfulness-based interventions for the treatment of these addictions. They reviewed 54 randomised control trials between 2009-2017. The mindfulness-based interventions included some mindfulness-based relapse prevention and were typically weekly for between 1-3 hours, delivered in a group format by two therapists, for a total of between 7-12 sessions. The review found that for pathological gambling Mindfulness-based interventions were effective.

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Advice to the Gambling Commission on a statutory levy: Conclusions
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Appendix 2: Areas of treatment, education and research related to gambling harms covered by a statutory levy
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