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Exploring Patterns of Change Processes Over Distinct In-Treatment Phases of Cognitive and Exposure Therapies for Electronic Gaming Machine Problem Gamblers

Published online by Cambridge University Press:  06 August 2018

David Smith*
Flinders University, Department of Psychiatry, Adelaide, South Australia, Australia
A. Kate Fairweather-Schmidt
Flinders University, Department of Psychiatry, Adelaide, South Australia, Australia
Rene Pols
Flinders University, Department of Psychiatry, Adelaide, South Australia, Australia
Peter Harvey
Deakin University, School of Medicine, Warrnambool, Victoria, Australia
Malcolm Battersby
Flinders University, Department of Psychiatry, Adelaide, South Australia, Australia
*Corresponding author. David Smith, Flinders Human Behaviour and Health Research Unit, GPO Box 2100, Adelaide SA 2001, Australia. Email:


Little is known about the change processes in gambling disorder-specific cognitive therapy (CT) and exposure therapy (ET). These therapies are underpinned by the cognitive approach (i.e., restructuring gambling cognitions) and the psychobiological approach (i.e., elimination of gambling urges) to treating problem gambling. Here, piecewise-linear modelling is used in a secondary analysis of randomised trial data for a CT group (n = 44) versus an ET group (n = 43) with the aim to open a discourse on how individuals respond to CT and ET relative to theory. Measures were administered between therapy sessions (average = 6.2 per individual) across 18 weeks for gambling urge (GUS) and gambling cognitions (GRCS). Results indicated the ET group had a stronger reduction in GUS (p < .01) in the first 4 weeks of treatment. Between 4–12 weeks, improvement in GUS (p < .01) and GRCS (p = .02) was more rapid in the CT group. Both groups experienced comparable improvements from 12–18 weeks. These findings have implications for further treatment development, including a combined cognitive and exposure approach that is flexibly adapted to the patient. A larger trial is needed to formally establish change processes and identify differences in problem gambler subgroups. This would provide therapists capacity to offer each patient a clear direction and an expedited pathway to their preferred outcome.

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Copyright © The Author(s) 2018 

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Acosta, MC, Possemato, K, Maisto, SA, Marsch, LA, Barrie, K, Lantinga, L, … Rosenblum, A (2017). Web-delivered CBT reduces heavy drinking in OEF-OIF veterans in primary care with symptomatic substance use and PTSD. Behavior Therapy 48, 262276.CrossRefGoogle ScholarPubMed
Addis, ME and Jacobson, NS (2000). A closer look at the treatment rationale and homework compliance in cognitive-behavioral therapy for depression. Cognitive Therapy and Research 24, 313326. doi: Scholar
American Psychiatric Association (APA). (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author.Google Scholar
American Psychiatric Association (A)A). (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Washington, DC: Author.Google Scholar
Balodis, IM, Lacadie, CM and Potenza, MN (2012). A preliminary study of the neural correlates of the intensities of self-reported gambling urges and emotions in men with pathological gambling. Journal of Gambling Studies 28, 493513. doi: ScholarPubMed
Battersby, M, Oakes, J, Tolchard, B, Forbes, A and Pols, R (2008). Cognitive behavioural treatment for problem gamblers. In Zangeneh, M, Blaszczynski, A & Turner, NE (Eds.), In the pursuit of winning (pp. 179197). New York, NY: Springer.CrossRefGoogle Scholar
Beck, AT (1991). Cognitive therapy: A 30-year retrospective. American psychologist 46(4), 368CrossRefGoogle ScholarPubMed
Ben-Tovim, D, Esterman, A, Tolchard, B and Battersby, MW (2001). The Victorian Gambling Screen: Project report. Melbourne, Australia: Victorian Research Panel.Google Scholar
Bohn, MJ, Krahn, DD and Staehler, BA (1995). Development and initial validation of a measure of drinking urges in abstinent alcoholics. Alcoholism, Clinical and Experimental Research 19, 600606.CrossRefGoogle ScholarPubMed
Brown, RIF (1987). Classical and operant paradigms in the management of gambling addictions. Behavioural Psychotherapy 15, 111122.CrossRefGoogle Scholar
Cowlishaw, S, Merkouris, S, Dowling, N, Anderson, C, Jackson, A and Thomas, S (2012). Psychological therapies for pathological and problem gambling. Cochrane Database of Systematic Reviews 11, CD008937. doi: ScholarPubMed
Echeburua, E, Baez, C and Fernandez-Montalvo, J (1996). Comparative effectiveness of three therapeutic modalities in the psychological treatment of pathological gamblers: Long-term outcome. Behavioural and Cognitive Psychotherapy 24, 5172.CrossRefGoogle Scholar
Flora, DB (2008). Specifying piecewise latent trajectory models for longitudinal data. Structural Equation Modeling 15, 513533. doi: Scholar
Friedman, ES and Thase, ME (2008). Cognitive and behavioral therapies. In Fatemi, SH & Clayton, PJ (Eds.), The medical basis of psychiatry (pp. 635657). Totowa, NJ: Humana Press.CrossRefGoogle Scholar
Gadboury, A and Ladouceur, R (1989). Erroneous perceptions and gambling. Journal of Social Behavior & Personality 4, 411420.Google Scholar
Gooding, P and Tarrier, N (2009). A systematic review and meta-analysis of cognitive-behavioural interventions to reduce problem gambling: Hedging our bets? Behaviour Research and Therapy 47, 592607.CrossRefGoogle ScholarPubMed
Greene, ME, Rolfson, O, Garellick, G, Gordon, M and Nemes, S (2015). Improved statistical analysis of pre- and post-treatment patient-reported outcome measures (PROMs): The applicability of piecewise linear regression splines. Quality of Life Research 24, 567573. doi: ScholarPubMed
Guo, Y, Logan, HL, Glueck, DH and Muller, KE (2013). Selecting a sample size for studies with repeated measures. BMC Medical Research Methodology 13, 100. doi: ScholarPubMed
Hayes, A, Hope, DA and Hayes, S (2007). Towards an understanding of the process and mechanisms of change in cognitive behavioral therapy: Linking innovative methodology with fundamental questions. Clinical Psychology Review 27, 679681. doi: ScholarPubMed
Hembree, EA, Foa, EB, Dorfan, NM, Street, GP, Kowalski, J and Tu, X (2003). Do patients drop out prematurely from exposure therapy for PTSD? Journal of Traumatic Stress 16, 555562.CrossRefGoogle ScholarPubMed
Hendershot, CS, Witkiewitz, K, George, WH and Marlatt, GA (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention and Policy 6, 17. doi: ScholarPubMed
Hodgins, DC and el-Guebaly, N (2004). Retrospective and prospective reports of precipitants to relapse in pathological gambling. Journal of Consulting and Clinical Psychology 72, 7280. doi: ScholarPubMed
Ilardi, SS and Craighead, WE (1999). Rapid early response, cognitive modification, and nonspecific factors in cognitive behavior therapy for depression: A reply to Tang and DeRubeis. Clinical Psychology-Science and Practice 6, 295299. doi: Scholar
Jacobson, NS and Truax, P (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 59, 1219.CrossRefGoogle ScholarPubMed
Jimenez-Murcia, S, Aymamí, N, Gómez-Peña, M, Santamaría, JJ, Álvarez-Moya, E, Fernández-Aranda, F, … Menchón, JM (2012). Does exposure and response prevention improve the results of group cognitive-behavioural therapy for male slot machine pathological gamblers? British Journal of Clinical Psychology 51, 5471.CrossRefGoogle ScholarPubMed
Kazdin, AE (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology 3, 127.CrossRefGoogle ScholarPubMed
Ladouceur, R, Sylvain, C, Boutin, C, Lachance, S, Doucet, C and Leblond, J (2003). Group therapy for pathological gamblers: A cognitive approach. Behaviour Research and Therapy 41, 587596.CrossRefGoogle ScholarPubMed
Ladouceur, R, Sylvain, C, Boutin, C, Lachance, S, Doucet, C, Leblond, J and Jacques, C (2001). Cognitive treatment of pathological gambling. Journal of Nervous and Mental Disease 189, 774780.CrossRefGoogle ScholarPubMed
Larimer, ME, Palmer, RS and Marlatt, GA (1999). Relapse prevention. An overview of Marlatt's cognitive-behavioral model. Alcohol Research and Health 23, 151160.Google ScholarPubMed
Laurenceau, JP, Hayes, AM and Feldman, GC (2007). Some methodological and statistical issues in the study of change processes in psychotherapy. Clinical Psychology Review 27, 682695. doi: Scholar
Lesieur, HR and Blume, SB (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry 144, 11841188. doi: ScholarPubMed
Loeber, S, Croissant, B, Heinz, A, Mann, K and Flor, H (2006). Cue exposure in the treatment of alcohol dependence: effects on drinking outcome, craving and self-efficacy. British Journal of Clinical Psychology 45, 515529. doi: ScholarPubMed
Marhe, R, Waters, AJ, van de Wetering, BJ and Franken, IH (2013). Implicit and explicit drug-related cognitions during detoxification treatment are associated with drug relapse: An ecological momentary assessment study. Journal of Consulting and Clinical Psychology 81, 112. doi: Scholar
McClernon, FJ, Hiott, FB, Liu, J, Salley, AN, Behm, FM and Rose, JE (2007). Selectively reduced responses to smoking cues in amygdala following extinction-based smoking cessation: Results of a preliminary functional magnetic resonance imaging study. Addiction Biology 12, 503512. doi: ScholarPubMed
Melville, KM, Casey, LM and Kavanagh, DJ (2007). Psychological treatment dropout among pathological gamblers. Clinical Psychology Review 27, 944958. doi: ScholarPubMed
Oakes, J, Pols, R, Battersby, M, Lawn, S, Pulvirenti, M and Smith, D (2012). A focus group study of predictors of relapse in electronic gaming machine problem gambling, part 1: Factors that ‘push’ towards relapse. Journal of Gambling Studies 28, 451464.CrossRefGoogle ScholarPubMed
Ougrin, D (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders: Systematic review and meta-analysis. BMC Psychiatry 11, 200. doi: ScholarPubMed
Ougrin, D, Zundel, T, Kyriakopoulos, M, Banarsee, R, Stahl, D and Taylor, E (2012). Adolescents with suicidal and nonsuicidal self-harm: Clinical characteristics and response to therapeutic assessment. Psychological Assessment 24, 1120. doi: ScholarPubMed
Paris, JJ, Franco, C, Sodano, R, Frye, CA and Wulfert, E (2009). Gambling pathology is associated with dampened cortisol response among men and women. Physiology and Behavior 99, 230233.CrossRefGoogle ScholarPubMed
Potenza, MN, Balodis, IM, Franco, CA, Bullock, S, Xu, J, Chung, T and Grant, JE (2013). Neurobiological considerations in understanding behavioral treatments for pathological gambling. Psychology of Addictive Behaviors 27, 380392. doi: ScholarPubMed
Potenza, MN, Steinberg, MA, Skudlarski, P, Fulbright, RK, Lacadie, CM, Wilber, MK, … Wexler, MD (2003). Gambling urges in pathological gambling: A functional magnetic resonance imaging study. Archives of General Psychiatry 60, 828836. doi: ScholarPubMed
Rabe-Hesketh, S and Skrondal, A (2012). Multilevel and longitudinal modelling using Stata (3rd ed.). College Station, TX: Stata Press.Google Scholar
Raylu, N and Oei, TP (2002). Pathological gambling. A comprehensive review. Clinical Psychology Review 22, 10091061.CrossRefGoogle ScholarPubMed
Raylu, N and Oei, TP (2004a). The Gambling Related Cognitions Scale (GRCS): Development, confirmatory factor validation and psychometric properties. Addiction 99, 757769. doi: Scholar
Raylu, N and Oei, TP (2004b). The gambling urge scale: Development, confirmatory factor validation, and psychometric properties. Psychology of Addictive Behaviors 18, 100105. doi: Scholar
Riley, BJ (2015). The role of homework in exposure-based CBT outcome for problem gambling. International Gambling Studies 15, 394407. doi: Scholar
Smith, D, Pols, R, Lavis, T, Battersby, M and Harvey, P (2016). Experiences and perceptions of problem gamblers on cognitive and exposure therapies when taking part in a randomised controlled trial: A qualitative study. Journal of Gambling Studies 32, 12431260. doi: Scholar
Smith, D, Woodman, R, Drummond, A and Battersby, M (2016). Exploring the measurement structure of the Gambling Related Cognitions Scale (GRCS) in treatment-seekers: A Bayesian structural equation modelling approach. Psychiatry Research 237, 9096. doi: ScholarPubMed
Smith, DP, Battersby, MW, Harvey, PW, Pols, RG and Ladouceur, R (2013). Two-group randomised, parallel trial of cognitive and exposure therapies for problem gambling: A research protocol. BMJ Open 3(6). doi: ScholarPubMed
Smith, DP, Battersby, MW, Harvey, PW, Pols, RG and Ladouceur, R (2015). Cognitive versus exposure therapy for problem gambling: Randomised controlled trial. Behaviour Research and Therapy 69, 100110. doi: ScholarPubMed
Smith, DP, Pols, RG, Battersby, MW and Harvey, PW (2013). The Gambling Urge Scale: Reliability and validity in a clinical population. Addiction Research & Theory 21, 113122.CrossRefGoogle Scholar
Sormani, MP and Bruzzi, P (2012). Reporting of subgroup analyses from clinical trials. Lancet Neurology 11, 747; author reply 747–748.CrossRefGoogle ScholarPubMed
StataCorp. (2015a). Stata 14 base reference manual. College Station, TX: Stata Press.Google Scholar
StataCorp. (2015b). Stata: Release 14.1. Statistical software. College Station, TX: StataCorp LP.Google Scholar
Stinchfield, R (2002). Reliability, validity, and classification accuracy of the South Oaks Gambling Screen (SOGS). Addictive Behaviors 27, 119.CrossRefGoogle Scholar
Tamminga, CA and Nestler, EJ (2006). Pathological gambling: Focusing on the addiction, not the activity. The American Journal of Psychiatry 163, 180181.CrossRefGoogle Scholar
Terwee, CB, Bot, SDM, de Boer, MR, van der Windt, DA, Knol, DL, Dekker, J, Bouter, LM and de Vet, HC (2007). Quality criteria were proposed for measurement properties of health status questionnaires. Journal of Clinical Epidemiology 60, 3442.CrossRefGoogle ScholarPubMed
Tiffany, ST (1992). A critique of contemporary urge and craving research — Methodological, psychometric, and theoretical issues. Advances in Behaviour Research and Therapy 14, 123139. doi: Scholar
Tolchard, B and Battersby, M (2010). The Victorian Gambling Screen: Reliability and validity in a clinical population. Journal of Gambling Studies 26, 623638.CrossRefGoogle Scholar
Tolchard, B, Thomas, L and Battersby, M (2006). Single-session exposure therapy for problem gambling: A single-case experimental design. Behaviour Change 23, 148155.Google Scholar
Vale, K, Smout, M and Blaszczynski, A (2015). A clinician's quick guide of evidence-based approaches: Gambling. Clinical Psychologist 19, 147148.CrossRefGoogle Scholar
van Holst, RJ, van den Brink, W, Veltman, DJ and Goudriaan, AE (2010). Brain imaging studies in pathological gambling. Current Psychiatry Reports 12, 418425.CrossRefGoogle ScholarPubMed
Wilson, GT (1999). Rapid response to cognitive behavior therapy. Clinical Psychology-Science and Practice 6, 289292.CrossRefGoogle Scholar
Young, J and Beck, AT (1980). Cognitive therapy scale: Rating manual. Unpublished manuscript, University of Pennsylvania, Philadelpia.Google Scholar