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Special Section: JGI Scholar’s Award, Category A
Motivation-Matched Approach to the Treatment of Problem
Gambling: A Case Series Pilot Study
Melissa J. Stewart,
1
Parnell L. Davis MacNevin,
1
David C. Hodgins,
2
Sean P. Barrett,
1
Jennifer Swansburg,
1
& Sherry H. Stewart
1,3
1
Department of Psychology & Neuroscience, Dalhousie University, Halifax, NS,
Canada
2
Department of Psychology, University of Calgary, Calgary, AB, Canada
3
Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
Abstract
The aim of the present case series was to provide a preliminary assessment of the
utility of a motivation-matched treatment for problem gamblers. On the basis of
their primary underlying motivations for gambling, 6 problem gamblers received
either action-motivated (n= 4) or escape-motivated (n= 2) treatment. Drawing upon
a cognitive-behavioural framework, this 6-session motivation-matched treatment
was designed to address gamblers’maladaptive motivations for gambling (i.e., the
need or desire for ‘‘ escape’’ or ‘‘ action’’ ), as well as the effects of conditioning and
maladaptive thinking patterns unique to each gambling motive subtype. Assessments
were conducted at pre-treatment, post-treatment, and 3- and 6-month follow-up.
Primary outcome measures included gambling behaviour (i.e., gambling frequency,
time, and money spent gambling), severity of gambling problems, and gambling-
related impairment or disability; secondary outcome measures included gambling-
related craving, gambling abstinence self-efficacy, positively and negatively
reinforcing gambling situations, and gambling outcome expectancies. Overall,
participants showed pre- to post-treatment improvements on the majority of these
measures, with relatively less immediate post-treatment treatment gains observed on
measures that assessed positively and negatively reinforcing gambling situations and
gambling-related impairment or disability. However, treatment gains at the 3- and
6-month follow-up were shown for most participants on these latter measures as well.
Findings suggest promise for this novel treatment approach. The next step in this line
of research is to conduct a randomized, controlled trial to compare the efficacy of
this motivation-matched treatment for disordered gambling with treatment as usual.
Keywords: Problem gambling, motivation, treatment, pilot study, reliable change
index, motivation-matched treatment, case series
124
Journal of Gambling Issues
Issue 33, September 2016 DOI: http://dx.doi.org/10.4309/jgi.2016.33.8
http://igi.camh.net/doi/pdf/10.4309/jgi.2016.33.8
Résumé
L’objectif de la présente étude de série de cas était d’effectuer une évaluation
préliminaire de l’utilité d’une thérapie tenant compte des motivations chez les
personnes ayant un problème de jeu. En fonction de leurs principales motivations
sous-jacentes à l’égard du jeu, six joueurs excessifs ont rec¸u un traitement axé sur
le jeu motivé par l’action (n = 4) ou motivé par la fuite (n = 2). S’inspirant du
cadre cognitivo-comportemental, les six séances de thérapie tenant compte de la
motivation ont été conc¸ues dans le but de traiter les motivations au jeu relevant
d’une mésadaptation (soit le besoin ou le désir de )fuite *ou d’)action *) ainsi que
défaire le conditionnement et les schèmes de pensée mésadaptés propres à chaque
sous-type de motivation au jeu. Des évaluations ont été réalisées avant et après la
thérapie, et par la suite un suivi a été effectué trois et six mois plus tard. Les mesures
des principaux résultats touchaient les comportements associés au jeu (la fréquence
des séances de jeu, leur durée et le montant d’argent dépensé), la gravité des
problèmes de jeu et les pertes ou incapacités liées au jeu, alors que les mesures des
résultats secondaires concernaient l’envie de jouer, l’auto-efficacité de l’abstinence à
l’égard du jeu, le renforcement positif et négatif des situations de jeu et les attentes
quant à l’issue des jeux de hasard. De manière générale, la plupart de ces mesures ont
donné lieu chez les participants à une amélioration entre les évaluations précédant et
suivant la thérapie, quoique que les gains observés dans l’évaluation faisant
immédiatement suite à la thérapie aient été relativement moins importants dans le
cas des mesures portant sur le renforcement positif et négatif des situations de jeu et
sur les pertes ou les incapacités liées au jeu. Toutefois, des améliorations concernant
ces mesures ont été observées chez la plupart des participants lors des suivis effectués
trois mois et six mois après la thérapie. Les constatations de l’étude laissent supposer
que cette nouvelle approche thérapeutique est prometteuse. La prochaine étape dans
ce domaine de recherche sera de mener un essai clinique randomisé afin de comparer
l’efficacité d’une thérapie contre le jeu excessif tenant compte des motivations par
rapport à l’approche thérapeutique habituelle.
Introduction
Despite advances in research and treatment, problem gambling (PG) is a significant
public health concern. Further, research examining theoretical models and evidence-
based treatments for PG is still in its infancy compared with research on other
addictive behaviours (Ledgerwood & Petry, 2005). One potential reason for this
lack of research is that problem gamblers are often viewed as a homogeneous
population. Currently, the standard intervention for PG is cognitive behaviour
therapy (CBT); however, the usual ‘‘ one-size-fits-all’’ approach is only moderately
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
effective (see Ledgerwood & Petry, 2005). With the emerging recognition that
problem gamblers are a heterogeneous population who may respond well to
treatments that target this heterogeneity (e.g., Blaszczynski & Nower, 2002), it has
been recommended that interventions be geared towards specific subtypes of
gamblers (Suomi, Dowling, & Jackson, 2014).
Within addiction research, previous studies highlight the value of designing matched
treatments that account for particular personality characteristics of at-risk
individuals, as well as comorbid psychopathology (Conrod et al., 2000), while also
targeting underlying motives for substance misuse (see Watt, Stewart, Conrod, &
Schmidt, 2008). Substance use disorders and PG have increasingly been conceptua-
lized as part of the same category of disorders (i.e., addictive disorders), given that
they share many features (e.g., tolerance and withdrawal; for a review, see Mudry et
al., 2011). This conceptualization has recently been reflected in the 5th edition of the
American Psychiatric Association (APA) Diagnostic and Statistical Manual of
Mental Disorders (DSM-5; APA, 2013), as pathological gambling, previously
categorized as an impulse control disorder, was reclassified within the substance-
related and addictive disorders and renamed gambling disorder. Despite these
similarities, the effectiveness of matched-treatment interventions has not been tested
among problem gamblers. The present case series aims to address this gap by
providing a preliminary assessment of the utility of a motivation-matched treatment
intervention approach with this population.
Motivations for Gambling
Motivational models of addictive behaviour have proven useful in understanding the
development and maintenance of addictive behaviours (e.g., alcohol; for review, see
Cooper, Kuntsche, Levitt, Barber, & Wolf, 2015) and assert that people consume
substances to obtain desired outcomes (e.g., regulate positive and negative emotions;
Cooper et al., 2015). Given the similarities between gambling disorder and substance
use disorders as addictive disorders (e.g., APA, 2013; Mudry et al., 2011) and the co-
occurrence of both disorders (e.g., Hodgins & Racicot, 2013), it is likely that
common motives underlie gambling and substance use. Indeed, many motivational
models argue that desires for mood alteration (i.e., negative affect reduction or
positive mood enhancement) underlie various addictive behaviours (Cooper et al.,
2015), including gambling (Stewart & Zack, 2008).
Drawing upon such findings, research (Shead & Hodgins, 2009; Stewart, Zack,
Collins, Klein, & Fragopulous, 2008) suggests that gamblers can be reliably and
validly categorized into one of three subtypes on the basis of their underlying
motivations for gambling: (1) escape-motivated gamblers (gamble to cope with or
escape from negative emotions, worries, and life concerns); (2) action-motivated
gamblers (gamble for enhancement, emotional reward, or the excitement and
‘‘ rush’’ ); and (3) low emotion regulation gamblers (primary motivation to gamble is
unclear, but they are not motivated to gamble to alter internal affective states;
instead, they appear to be motivated by external factors, e.g., social affiliation).
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
The validity of this subtyping scheme has been demonstrated with a variety of
clinically relevant criteria, including severity of gambling problems, gambling
frequency, and specific gambling outcome expectancies. For example, Yi and
colleagues (2015) reported that action-motivated gamblers endorse reward gambling
outcome expectancies, whereas escape-motivated gamblers tend to endorse relief
gambling outcome expectancies. Research has also found that escape and action
motives are strongly associated with PG, whereas social-affiliative motives are more
likely to be primarily endorsed by non-problem gamblers and low emotion
regulation gamblers (Stewart & Zack, 2008). Escape and action motives are both
strongly associated with PG, and problem gamblers with these motives tend to be
more resistant to treatment (Daughters, Lejeuz, Lesieur, Strong, & Zvolensky, 2003;
Leblond, Ladouceur, & Blaszczynski, 2003). However, escape-motivated gambling is
normally characterized by more severe gambling problems and action-motivated
gambling by more frequent and excessive gambling behaviour (Stewart & Zack,
2008). This finding is consistent with the broader addictions literature that has
consistently found motivations involving coping with negative emotions to be most
strongly associated with problematic forms of addictive behaviours (e.g., Birch,
Stewart, & Zack, 2006; Cooper, Russell, Skinner, & Windle, 1992). However, the
utility of this subtyping scheme for informing treatment-matching efforts aimed at
improving PG treatment outcomes remains to be determined.
The most common treatment for PG is CBT (Daughters et al., 2003; Leblond et al.,
2003; Rash & Petry, 2014). Despite a range of CBT-based treatments for PG,
however, only moderate response rates have been found among gamblers who receive
such treatments (see Gooding & Tarrier, 2009, for a review), and this is particularly
the case among escape and action-motivated gamblers (Daughters et al., 2003;
Leblond et al., 2003). Such findings clearly point to the need to improve on the current
therapeutic interventions for PG. One strategy to accomplish this is by designing
treatments that target specific subtypes of gamblers. Drawing upon a cognitive-
behavioural framework, the premise of motivation-matched treatment for gamblers is
to expand on traditional CBT by including components that differentially identify and
modify the types of psychological factors (e.g., maladaptive beliefs) related to
gambling exhibited by each subtype of gambler (action- and escape-motivated).
Over and above traditional CBT, the goal of gambling-matched treatment is to
target the beliefs that impede control of gambling behaviour and to extinguish
operant and classic conditioning related to gambling activities, environments, and
associated stimuli (i.e., sounds, images, and objects such as money) that make
gamblers susceptible to approaching gambling situations. Because these processes
are distinct to each subtype of gambler (e.g., action-motivated gamblers perceive
gambling as a means of excitement, whereas escape-motivated gamblers perceive it
as a means of relieving distress), and because gambling-matched treatment accounts
for such differences (Stewart et al., 2011), we hypothesized that matched treatments
would lead to positive treatment outcomes in both escape- and action-motivated
gamblers. The purpose of the present pilot case series was to conduct a preliminary
assessment of the effectiveness of a novel, motivation-matched treatment for PG
127
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
before recommending it for more rigorous experimental assessment (i.e., via a
randomized controlled trial).
Method
Participants
Participants were recruited from clinician referrals (local community addictions
prevention or treatment programs), posters, and referrals from a gambling telephone
helpline. Inclusion criteria for the current pilot case series were as follows: (1)
classification as a problem gambler
1
(i.e., Problem Gambling Severity Index [PGSI]
score of 8 or more; Ferris & Wynne, 2001); (2) proficiency in written and spoken
English; (3) minimum 19 years of age; and (4) ability to provide written informed
consent. Exclusion criteria included (1) gambling abstinence longer than 2 months
prior to intake; (2) concurrently seeking treatment for PG from another therapist;
(3) current or lifetime history of psychosis; (4) current alcohol or substance depen-
dence; and (5) current suicidal intent or suicide attempts within the past 5 years. The
latter three criteria were exclusionary because of concerns that the needs of problem
gamblers with these comorbidities might not be met within this brief intervention.
Nineteen prospective participants passed the telephone screening and were invited
for intake assessment (described in the following section). Twelve completed intake
assessment and met the inclusion and exclusion criteria. Of these, two withdrew prior
to treatment, one after session two, two after session four, and one after session five
(all for unknown reasons). As outcome data were not collected for these latter six,
they were excluded. The remaining participants who completed all treatment
sessions, the post-treatment assessment, and at least one of the follow-up sessions
consisted of six Caucasian males who ranged in age from 34 to 56 years (M= 46.33,
SD = 9.97). All were employed, four were married, one was single, and one was
separated; all had a grade 12 education and three had postsecondary education; and
all were classified as problem gamblers on the PGSI (M= 17.17, SD = 5.71, range
10–23). On the basis of their primary motivations for gambling (Gambling Motives
Questionnaire [GMQ]; Stewart & Zack, 2008), participants received either action-
motivated (n= 4) or escape-motivated (n= 2) treatment.
Measures
Screening measures.
PG symptoms. The nine-item PGSI scale of the Canadian Problem Gambling
Index (CPGI; Ferris & Wynne, 2001) assessed the presence and severity of gambling
problems during pre-treatment screening. For each item (e.g., ‘‘ Have you bet more
1
Although the current study recruited problem gamblers whose gambling problem severity was
classified as ‘‘ high risk’’ on the CPGI (i.e., score of 8 or more), the BEAT Gambling treatment is also
designed for use in individuals who exhibit scores in the ‘‘ moderate risk’’ range of problem gambling
severity (PGSI score 3–7).
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
than you could really afford to lose?’’ ), respondents indicated how frequently they
engaged in the behaviour or experienced the consequence in the last 12 months on a
scale that ranged from 0 (never)to3(almost always), and those who had a total score
of 8 or more were classified as ‘‘ high risk’’ or ‘‘ problem gamblers.’’
Comorbid mental health issues. The Structured Clinical Interview for DSM-IV-
TR Axis I Disorders, Research Version, Patient Edition with Psychotic Screen
(SCID-I/P W/PSY SCREEN; First, Spitzer, Gibbon, & Williams, 2002) established
current and lifetime Axis I disorders for descriptive purposes and to determine
eligibility.
Gambling motives. The 15-item GMQ (Stewart & Zack, 2008) assessed reasons
for gambling (i.e., coping, enhancement, social motives). Participants rated how
frequently they gambled for each of 15 reasons (e.g., ‘‘ to relax’’ ;‘‘ because it’s
exciting’’ ;‘‘ to be sociable’’ ) on a scale that ranged from 1 (almost never or never)to
4(almost always) and the result was used to categorize participants as ‘‘ escape’’ -or
‘‘ action’’ -motivated gamblers (based on which subscale had the highest z-score by
using means and standard deviations from Stewart & Zack, 2008) and to assign them
to the appropriate matched treatment.
Primary outcome measures.
Gambling participation. A modified Gambling Activities Screen (GAS; Doiron &
Nicki, 2007) assessed changes in gambling participation (e.g., frequency, time spent,
money spent) over the past 7 days.
PG severity. The National Opinion Research Center DSM Screen for Gambling
Problems (NODS; Gerstein et al., 1999) assessed gambling problems by using 17 items
(scored yes or no), with higher scores indicating increased levels of gambling problems.
Questions were framed to assess gambling problems over the past 3 months.
Impairment or disability. The three-item Sheehan Disability Scale modified for
gambling (SDS-G; Hodgins, 2013) assessed impairment (work, family, social
functioning) related to gambling problems. Participants rated each item (e.g., ‘‘ To
what extent has your gambling problem disrupted your work or studies in the past
month?’’ )onascalethatrangedfrom0(not at all)to10(extremely).
Secondary outcome measures.
Craving to gamble. Drawing upon previous research (Tavares, Zilberman,
Hodgins, & el-Guebaly, 2005), a five-item modified version of the Penn Alcohol
Craving Scale (PACS; Flannery, Volpicelli, & Pettinati, 1999) measured gambling-
related craving over the past 7 days. Participants rated frequency, time spent
thinking about gambling, difficulty in resisting relapse opportunities, and strength of
craving (e.g., ‘‘ How often have you thought about gambling or about how good
gambling would make you feel during the past seven days?’’ ) on a scale that ranged
from 0 (never, none, not at all) to six (nearly all, strong, all the time).
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Gambling abstinence self-efficacy. The 21-item Gambling Abstinence Self-Efficacy
Scale (GASS; Hodgins, Peden, & Makarchuk, 2004) measured participants’
confidence in their ability to control, reduce, or abstain from gambling. For each
item, participants indicated how confident they were that they would not gamble
(or gamble heavily) in a specific situation (e.g., ‘‘ Iwantedtowin’’ ;‘‘ I felt pressured by
financial debts’’ ) on a scale that ranged from 0 (not at all confident)to5(extremely
confident).
Positively and negatively reinforcing gambling situations. The 63-item Inventory of
Gambling Situations (IGS; Turner & Littman-Sharp, 2001) assessed the frequency of
gambling in high-risk situations. Previous research (Stewart et al., 2008) found that the
original 10 subscales load on two factors: one that positively reinforces gambling
situations (e.g., pleasant emotions, need for excitement) and one that negatively
reinforces gambling situations (e.g., worried over debt, unpleasant emotions).
Participants rated each item (e.g., ‘‘ When I was worried about my debts’’ ;‘‘ When I
felt confident about my gambling skills’’ ) on a scale that ranged from 1 (almost never or
never gambled heavily in that situation)to4(almost always gambled heavily in that
situation).
Affect-regulation gambling outcome expectancies. The 18-item Gambling Affect
Expectancy Questionnaire (GAEQ; Shead & Hodgins, 2009) assessed self-reported
positive affect-regulation gambling outcome expectancies for reward (e.g., ‘‘ It would
be wonderful to gamble now) and relief (e.g., ‘‘ I would feel less tense if I gambled
now’’ ) expectancies. Participants indicated how much they agreed or disagreed with
each item on a scale that ranged from 1 (strongly disagree)to7(strongly agree).
The reliability coefficients (i.e., Cronbach’s alpha) for these primary and secondary
outcome measures are presented in Table 1.
Table 1
Reliability Coefficients (Cronbach's Alpha) and Sources for Outcome Measures
Instrument Reliability (Cronbach’s alpha) Source
NODS 0.98 Gerstein et al., 1999
PACS 0.92 Ashrafioun et al., 2012
GASS 0.93 Hodgins et al., 2004
IGS
Positive 0.90 Turner et al., 2013
Negative 0.95
GAEQ
Reward 0.90 Yi et al., 2015
Relief 0.94
SDS-G 0.81 Hodgins, 2013
Note. NODS = National Opinion Research Center Diagnostic Screen for Gambling Problems; PACS = Penn Alcohol Craving
Scale; GASS = Gambling Abstinence Self-Efficacy Scale; IGS = Inventory of Gambling Situations; GAEQ = Gambling
Affect Expectancy Questionnaire; SDS-G = Sheehan Disability Scale modified for gambling.
130
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Procedure
Six sessions of individual treatment were delivered over 6 weeks. Assessments were
conducted at pre-treatment, post-treatment, and 3- and 6-month follow-up.
Assessment. Participants were screened by telephone and those who were
eligible were invited to the university for a pre-treatment intake assessment, where
they provided written informed consent, underwent the SCID-I/P (First et al., 1998),
and completed the GMQ (Stewart & Zack, 2008) and the pre-treatment outcome
measures. Eligible participants scheduled a time to commence treatment within
3 weeks of intake assessment. Self-report questionnaires were re-administered three
times following treatment: at post-treatment and at 3- and 6-month follow-up
sessions.
Treatment protocol. The treatment program Brief Escape and Action Treatment
for Gambling (BEAT Gambling) is a novel manualized treatment program for
problem gamblers (Stewart et al., 2011) consisting of six sessions of individual
treatment, delivered over 6 weeks. Sessions were held approximately 1 week apart.
Sessions one to four were 90 min long and sessions five and six were 60 min long.
Those who could not attend their session rescheduled the following week. Each
session taught skills to manage gambling. Drawing upon a cognitive-behavioural
framework, therapists (doctoral-level licensed psychologists, supervised clinical
psychology graduate students) delivered treatment designed to address specific
maladaptive motivations for gambling, as well as the conditioning and unhelpful
thinking patterns unique to each subtype.
In session one, all clients shared their history of PG and reflected on what brought
them to treatment. They were given feedback about their gambling, introduced to the
model of gambling maintenance for treatment (i.e., action-escape model of gambling
maintenance), and presented with a decisional balance exercise that examined
motivations for seeking treatment. Clients set their goal for treatment (i.e., controlled
gambling or abstinence), discussed strategies to help them succeed, and were given a
handbook that outlined options to consider when making changes in their gambling.
In session two, all clients were educated on how randomness works in games of
chance and were introduced to the functional analysis. Completing functional
analyses on any urges or slips that clients experienced formed the basis of a large
proportion of the homework assigned between sessions. In action-motivated
treatment, time was spent teaching clients to evaluate and consider alternatives to
gambling that may be as rewarding or exciting without the negative consequences. In
escape-motivated treatment, clients learned about healthier ways to manage stress
and negative emotions (e.g., progressive muscle relaxation).
During session three, internal and external triggers were introduced, with a focus
on functional analysis, but the action- and escape-based treatments differed in
131
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
the types of triggers discussed (i.e., action-motivated treatment included physical
sensations, thoughts, and feelings such as restlessness, boredom, or feeling the need
for excitement; escape-motivated treatment included stress, anxiety, or sadness).
Session four focused on either action-based or escape-based maladaptive thinking
patterns. This discussion was used to complete a more advanced functional analysis
and cognitive restructuring activity.
For action-based treatment, session five introduced the concept of urge surfing (i.e.,
letting thoughts, emotions, or urges to gamble ‘‘ just be’’ ; learning that these thoughts
or feelings come and go but do not have to lead to gambling). For escape-based
treatment, distress tolerance was introduced (i.e., learning to tolerate unpleasant
emotions rather than trying to control them). In both treatments, time was spent
introducing a relapse prevention plan worksheet (with emphases on either action or
escape situations with a high risk for relapse), which clients also worked on for
homework. Attention was given to discussing therapy termination and consolidating
skills learned in therapy. The sixth session served as a wrap-up with a review of the
model of gambling maintenance (i.e., action or escape) and the skills learned in
therapy, along with completion of the relapse prevention plan worksheet and
reflection on progress during treatment.
Data Analytic Strategy
To assess the clinical significance of treatment outcomes, we used three indicators of
individual-level change following treatment: (1) The Reliable Change Index (RCI;
Evans, Margison, & Barkham, 1998; Jacobson & Truax, 1991), which provides a
more liberal index of change; (2) clinically significant change cutoff scores, which
provide a more stringent index of change (Evans et al., 1998; Jacobson & Truax,
1991); and (3) reliable changes defined as being equal to or exceeding a decrease of
50% in gambling behaviour (e.g., Mohr, Boudewyn, Goodkin, Bostrom, & Epstein,
2001).
The RCI is a useful data analytic strategy for small sample sizes in which inferential
statistical techniques are deemed inappropriate, such as in a case series (Evans et al.,
1998). The RCI uses instrument reliability scores to indicate whether an individual
has demonstrated clinically significant improvement from their baseline pre-treatment
assessment scores by using the following formula:
SEDiff ¼SD1
ffiffiffi
2
pffiffiffi
1
pr
Normally, SD
1
denotes the standard deviation (SD) of the baseline observations across
study participants. Because of the small sample size (N= 6), instrument SDswere
identified in the literature and substituted to provide a more accurate value for the
population. This method has been previously used in other clinical pilot studies (e.g.,
Zlotnick, Johnson, Miller, Pearlstein, & Howard, 2001). Additionally, rdenotes the
reliability (Cronbach’s alpha) of the measure, which was drawn from the literature for
132
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
each outcome measure.
2
Reliability coefficients and sources are presented in Table 1;
means, SDs, and corresponding sources from the literature are presented in Table 2;
and the means and standard deviations from the literature are reported alongside those
from the sample in Table 3. In line with the recom-mendations of Jacobson and Truax
(1991), scores were deemed reliably changed if they exceeded the RCI (cutoff = 1.96) by
using the following formula:
RCI ¼X2
ðÞðX1Þ
SEdiff
Where X
1
denotes the subject pre-test score and X
2
the subject post-test score.
Calculating cutoff criteria for clinically significant change is another useful tool in
the assessment of clinical treatment efficacy. Cutoff scores were calculated by using
the following formula:
Cutoff ¼Meanclin SDnorm
ðÞþðMeannorm SDClinÞ
SDnorm þSDClin
Scores at or exceeding this cutoff are within the healthy population range and were
deemed clinically significant or recovered. Likewise, scores below this cutoff, but
exceeding the RCI, were deemed reliably changed or improved (Evans et al., 1998;
Jacobson & Truax, 1991).
The aforementioned data analytic strategy was used for all outcome measures
(NODS, PACS, IGS, GAEQ, GASS, SDS-G), but was not used to assess changes in
GAS outcomes. The GAS comprises a series of single-item measures, and so
reliability scores cannot be calculated. Therefore, reliable changes were defined as
being equal to or exceeding a decrease of 50% in each gambling behaviour, a method
previously used in similar studies in which the use of clinically significant change
indicators was inappropriate (e.g., Mohr et al., 2001).
Results
Five participants reported video lottery terminals (VLTs) as their preferred, most
problematic form of gambling. As their treatment goal, four chose abstinence from
VLT gambling, whereas one (Participant 4; P4) chose to limit VLT gambling to twice
per month and $40 per episode. During the third session, P4 reduced his goal to
$20 per session. The remaining participant (P3) reported horse racing, sports betting,
and poker as his preferred, most problematic forms of gambling and chose
abstinence as his goal. At post-treatment, one participant (P4) achieved abstinence,
2
Cronbach’s reliability coefficients were calculated for the sample (N= 6) and ranged from .84 (GAEQ
relief and SDS-G) to .97 (GAEQ reward and PACS), indicating good reliability of all outcome measures.
The results are consistent when either set of coefficients is used in data analysis (i.e., literature vs. sample).
133
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Table 2
Means, Standard Deviations, Sources for Outcome Measures, and Cutoff Scores
Population
Instrument
Healthy
control
Source
Pathological
gambling
Source
Reliable
change
(RCI)
Clinical
cutoff
score
MSD MSD
NODS 0.3 0.4 Ledgerwood et al., 2012 8 1.7 Ledgerwood et al., 2012 2.2 1.8
PACS 4.6 5.4 Ashrafioun, McCarthy, and Rosenberg, 2012 21.8 8.6 Caselli and Spada, 2015 6.7 11.2
GASS 73.7 36.6 Winfree, Meyers, and Whelan, 2015 46.3 23.9 Hodgins, Currie, Currie,
and Fick, 2009
17.5 57.1
IGS
Positive
6.9 2.2 Dowling, Lorains, and Jackson, 2015 64.3 17.8 Stewart and Wall, 2005 15.6 13.0
Negative 6.6 2.2 45.2 20.8 12.9 10.2
GAEQ
Reward
25.0 9.0 Stewart and Wall, 2005 32.4 10.5 Yi et al., 2015 9.2 28.4
Relief 15.9 7.7 32.6 12.0 8.1 22.4
SDS-G
Family
0.7 1.5 Huppert, Simpson, Nissenson, Liebowitz, and
Foa, 2009
3.2 2.8 Black et al., 2007 2.8 1.5
Work 0.9 2.3 4.0 3.1 2.4 2.2
Social 0.6 1.1 3.3 2.6 2.6 1.4
Note. RCI = Reliable Change Index; NODS = National Opinion Research Center Diagnostic Screen for Gambling Problems; PACS = Penn Alcohol Craving Scale; GASS = Gambling
Abstinence Self-Efficacy Scale; IGS = Inventory of Gambling Situations; GAEQ = Gambling Affect Expectancy Questionnaire; SDS-G = Sheehan Disability Scale modified for gambling.
134
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
whereas the remaining five reported gambling one to two times over the course of
treatment. Overall, all six treatment completers displayed significant reductions or
improvements from pre- to post-treatment on various outcome measures (Table 4).
Primary Outcome Measures
Gambling participation. On the GAS, four participants (67%) reported post-
treatment reductions in gambling activity (i.e., frequency, time, money). Three
participants (P3, P4, P6) considerably reduced gambling frequency, and four (P2, P3,
P4, P6) significantly reduced the amount of time and money spent gambling, which
were maintained at follow-up. P1 reported no change in gambling frequency and an
increase in the amount of time and money spent gambling post-treatment, whereas
P5 reported no significant change in gambling frequency, time, or the amount of
money spent gambling post-treatment. Despite this, significant reductions in all three
measures of gambling participation were observed at follow-up for these two
participants.
PG severity. For PG severity (NODS; Gerstein et al., 1999), three participants
(P4, P5, P6) showed significant reductions at post-treatment (50%), which were
maintained at follow-up. The remaining participants (P1, P2, P3) showed no
Table 3
Comparison of Population Means and Standard Deviations With Sample Means and
Standard Deviations
Population
Healthy control Pathological gambling Sample
Instrument M SD M SD M SD
NODS 0.3 0.4 8.0 1.7 7.7 2.9
PACS 4.6 5.4 21.8 8.6 15.5 8.0
GASS 73.7 36.6 46.3 23.9 50.7 23.1
IGS
Positive
6.9 2.2 64.3 17.8 41.8 21.8
Negative 6.6 2.2 45.2 20.8 42.4 18.1
GAEQ
Reward
25.0 9.0 32.4 10.5 32.1 17.4
Relief 15.9 7.7 32.6 12.0 29.8 11.5
SDS-G
Family
0.7 1.5 3.2 2.8 6.8 3.4
Work 0.9 2.3 4.0 3.1 3.8 3.1
Social 0.6 1.1 3.3 2.6 4.8 3.5
Note. NODS = National Opinion Research Center Diagnostic Screen for Gambling Problems; PACS = Penn Alcohol
Craving Scale; GASS = Gambling Abstinence Self-Efficacy Scale; IGS = Inventory of Gambling Situations; GAEQ =
Gambling Affect Expectancy Questionnaire; SDS-G = Sheehan Disability Scale modified for gambling.
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Table 4
Raw Scores and Percentage Change in Scores From Treatment Completers on Outcome Measures
Participant Measure Pre-
treatment
Post-
treatment
3-Month
follow-up
6-Month
follow-up
% Reduction from
pre- to post-
treatment
% Reduction from
pre-treatment to
3-month follow-up
% Reduction from
pre-treatment to
6-month follow-up
P1
a
GAS Frequency 1 1 1 - 0 0 -
Escape Time 30 120 120 - -300 -300 -
Money 45 140 140 - -211 -211 -
NODS 89 2
*- -13 75 -
SDS-G Work 3 1** 0** - 67 100 -
Social 9 8 3*-11 67 -
Family 9 9 3*- 0 67 -
PACS 20 4** 6** -80 70 -
GASS 65 97*71 - 49 9 -
IGS Positive 42.46 44.88 18.13 - -6 57 -
Negative 47.67 53.92 26.1*- -13 45 -
GAEQ Reward 51.5 11** 28** -78 46 -
Relief 39 12** 14** -69 64 -
P2
b, c
GAS Frequency 2 2 - 0*0 - 100
Escape Time 480 240*-0*50 - 100
Money 670 100*-0*85 - 100
NODS 88 - 7 0 - 14
SDS-G Work 6 9 - 5 -33 - 16
Social 6 7 - 7 -14 - -14
Family 7 9 - 7 -22 - 0
PACS 16 7** -8** 56 - 50
GASS 48 81** - 44 -25 - 8
IGS Positive 35.08 54.09 - 33.02 -54 - 6
Negative 42.49 52.19 - 36.5 -23 - 14
GAEQ Reward 25 24 - 17 4 - 32
Relief 39 22** -35 44 - 10
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Table 4
Continued
Participant Measure Pre-
treatment
Post-
treatment
3-Month
follow-up
6-Month
follow-up
% Reduction from
pre- to post-
treatment
% Reduction from
pre-treatment to
3-month follow-up
% Reduction from
pre-treatment to
6-month follow-up
P3
a
GAS Frequency 17 2*0*- 88 100 -
Action Time 3420 250*0*- 92 100 -
Money 1420 200*0*- 86 100 -
NODS 10 10 8 - 0 20 -
SDS-G Work 8 9 5 - -13 38 -
Social 8 9 5*- -13 38 -
Family 9 9 7 - 0 22 -
PACS 23 20 16*-13 30 -
GASS 16 55*44*- -71 -64 -
IGS Positive 76.55 56.27 45.63*-27 40 -
Negative 63.07 58.92 48.65*- 7 23 -
GAEQ Reward 51 42 41 - 18 20 -
Relief 31 38 38 - -23 -23 -
P4
a
GAS Frequency 3 0*3 - 100 0 -
Action Time 130 0*32*- 100 75 -
Money 128 0*48*- 100 63 -
NODS 20
** 0** - 100 100 -
SDS-G Work 0 0 0 - 0 0 -
Social 0 0 0 - 0 0 -
Family 0 0 0 - 0 0 -
PACS 0 1 4 - -100 -400 -
GASS 85 100 95 - -18 -12 -
IGS Positive 8.49 7.3 9.05 - 14 -7 -
Negative 10.42 15.5 10.71 - -49 3 -
GAEQ Reward 12 9 15 - 25 -25 -
Relief 9 9 9 - 0 0 -
P5 GAS Frequency 2 2 1*1*050 50
Action Time 200 120 5*1*40 98 100
Money 100 100 10*4*090 96
NODS 94
*3*4*56 67 56
SDS-G Work 5 5 0** 0** 0 100 100
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MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Table 4
Continued
Participant Measure Pre-
treatment
Post-
treatment
3-Month
follow-up
6-Month
follow-up
% Reduction from
pre- to post-
treatment
% Reduction from
pre-treatment to
3-month follow-up
% Reduction from
pre-treatment to
6-month follow-up
Social 2 4 0** 0** -100 100 100
Family 8 8 5*4*038 50
PACS 16 13 13 13 19 19 19
GASS 48 94** 87** 83** 96 89 81
IGS Positive 45.52 37.5 29.52*26.51*18 35 42
Negative 36.61 22.16*23.64*30.52 39 35 16
GAEQ Reward 38 17** 22** 22** 55 42 42
Relief 36 13** 13** 12** 64 64 67
P6 GAS Frequency 4 1*0*1*75 100 75
Action Time 101 1*0*1*99 100 99
Money 211 2*0*5*99 100 98
NODS (year/3
months)
91
** 0** 0** 89 100 100
SDS-G Work 1 0 0 0 100 100 100
Social 4 1** 0** 0** 75 100 100
Family 8 1** 0** 0** 88 100 100
PACS 18 16 0** 0** 11 100 100
GASS 42 85** 99** 100** 103 148 150
IGS Positive 42.62 42.26 31.83 25.04*125 41
Negative 53.85 44.58 34.36*19.14*17 36 65
GAEQ Reward 15 15 9 9 0 40 40
Relief 25 16** 9** 9** 36 64 64
Note. GAS = Gambling Activities Screen (over past 7 days); NODS = National Opinion Research Center Diagnostic Screen for Gambling Problems; PACS = Penn Alcohol Craving Scale;
GASS = Gambling Abstinence Self-Efficacy Scale; IGS: Inventory of Gambling Situations; GAEQ = Gambling Affect Expectancy Questionnaire; SDS-G = Sheehan Disability Scale modified
for gambling.
a
3-month follow-up data not available for P2.
b
6-month follow-up data not available for P1, P3, and P4.
c
P2 voluntarily abstained from gambling for 7 days prior to treatment
and so timeline follow-back data were used to calculate baseline GAS score.
*Reliable change.
** Clinically significant change.
138
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
improvement by post-treatment; however, P1 displayed a reliable improvement by
the 3-month follow-up (67%).
Impairment or disability. On the SDS-G (Hodgins, 2013), treatment decreased
functional impairment or disability for P1 and P6 post-treatment (33%), with
improvements by P1 at work and by P6 in social and family life, which were
maintained at follow-up. By the 3-month follow-up, P1 also significantly improved in
social and family functioning. P3 and P5 exhibited no immediate changes post-
treatment, but showed a significant decrease in impairment by follow-up. P2 and P4
did not report improvement in any of the domains of impairment. However,
P4 reported no functional impairment related to gambling problems at pre-
treatment, and this remained the same at post-treatment and follow-up. In summary,
67% of participants showed some improvements in functional impairment or
disability following treatment.
Secondary Outcome Measures
Craving to gamble. P1 and P2, both escape motivated, exhibited significant
post-treatment reductions in craving to gamble (PACS), which were maintained at
follow-up. Action-motivated gamblers did not exhibit post-treatment reductions, but
two additional participants (P3, P6) showed significant improvement by the 3-month
follow-up, increasing the proportion of significant responders to 67%. One action-
motivated participant (P4) was already within the clinically healthy range at baseline,
and so significant improvement on this measure was not anticipated. One participant
(P5-action) did not exhibit reductions in gambling-related craving at any of the time
points.
Gambling abstinence self-efficacy. Considerable improvements were observed in
participants’confidence in their ability to abstain from or to control gambling on
the GASS (Hodgins et al., 2004). All participants reported increased gambling
abstinence self-efficacy at post-treatment (83%), with the exception of P4, whose
baseline score was already within the clinically healthy range at baseline. Likewise,
P1 was already within the healthy range, but his gambling abstinence self-efficacy
nonetheless reliably increased from pre- to post-treatment. All treatment gains were
maintained with the exception of P2, whose score had returned to baseline by the
6-month follow-up.
Positively and negatively reinforcing gambling situations. In relation to the
assessment of high-risk situations associated with gambling (IGS; Turner & Littman-
Sharp, 2001), little improvement was observed post-treatment, with one participant
(P5) displaying a significant reduction in gambling in negatively reinforcing
gambling situations. In contrast to the overall lack of treatment gains on this
measure post-treatment, reliable improvements were shown by most participants at
follow-up. P1 and P6 improved in response to negative gambling situations by
the 3-month follow-up, and P6 improved in response to positive situations by the
6-month follow-up. P3 and P5 improved in positive and negative situations by
139
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
the 3-month follow-up, but only P5’s treatment gain in positive situations persisted
at the 6-month follow-up. P4’s baseline assessment was already within the clini-
cally healthy range at baseline, and so improvement was not anticipated. Taken
together, 67% of participants showed some improvements on this measure following
treatment.
Affect-regulation gambling outcome expectancies. On the GAEQ (Shead &
Hodgins, 2009), two participants (P1, P5) exhibited significant reductions in their
endorsement of reward and relief outcome expectancies by post-treatment, which
were maintained at follow-up. For reward outcome expectancies, three participants
(P2, P4, P6) were in the clinically healthy range at baseline, and so improvements
were not expected. For relief outcome expectancies, two participants (P2, P6)
displayed significant reductions in outcome expectancies; however, treatment gains
were maintained only for P6 at follow-up. Only one participant (P3) did not improve.
Again, P4 was already within the clinically healthy range at baseline, and so
improvements were not anticipated. In summary, 67% of participants showed a
reduction in their endorsement of reward and relief outcome expectancies following
treatment.
Discussion
The current pilot case series provided a preliminary investigation of the efficacy of
a cognitive behavioural treatment for PG (BEAT Gambling) that is matched to
gamblers’primary underlying motivations (i.e., escape-motivated vs. action-motivated
gamblers). Results provide support for the merits of this novel treatment as a
potentially effective intervention for PG. Participants’scores on the primary
outcome measures revealed considerable pre- to post-treatment reductions: 100% of
participants exhibited significant post-treatment gains on at least one primary
outcome measure. Overall, four participants (67% of the sample) exhibited a
significant reduction in gambling activity post-treatment, with five participants
(83% of the sample) displaying reduced gambling activity by follow-up. Specifically,
one participant (P4) abstained from gambling and three (P2, P3, P6) exhibited a
marked reduction in gambling. The gambling activity of two participants (P1, P5)
was not significantly reduced post-treatment, but P5 significantly reduced his
gambling activity across all domains (frequency, time, money) by the 3-month
follow-up, which was maintained at the 6-month follow-up. Post-treatment
reductions in PG severity were observed for three participants (50% of the sample),
with another participant exhibiting a delayed response; 67% of the sample exhibited
significantly reduced impairment in PG severity by the follow-up period. For
functional impairment or disability associated with gambling (SDS-G), two
participants (33%) exhibited significant improvements by post-treatment, which
were retained at follow-up. Two participants (P3, P5) exhibited a delayed response,
with no immediate improvements post-treatment, but improvement by follow-up.
Overall, 67% of the sample exhibited a significant reduction in the degree of
disability or impairment that resulting from gambling by the follow-up assessment.
140
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Secondary outcome measures revealed pre- to post-treatment reductions in craving
to gamble (33%) and the endorsement of reward (33%) and relief (67%) gambling
outcome expectancies, as well as noteworthy increases in participants’confidence in
their ability to control or abstain from gambling (83%) at post-treatment. These
treatment gains were largely maintained at the 3- and 6-month follow-up. Although
only modest changes were observed in participants’pre- to post-treatment scores
on measures assessing gambling in high-risk situations, in the majority of cases,
treatment gains were observed at the 3-month follow-up that were largely main-
tained at the 6-month follow-up.
For some participants, gains on certain measures were not observed post-treatment,
but were apparent at follow-up assessment (i.e., SDS-G, PACS, IGS). One
explanation for this finding is the ‘‘ sleeper effect,’’ in which treatment gains increase
over time—an effect that has been reported in previous clinical trials that assessed
the effectiveness of CBT (e.g., Carrollet al., 2009). The sleeper effect has been
attributed to learning mechanisms that improve affective control and cognitive
functioning over time (Potenza, Sofuglu, Carroll, & Rounsaville, 2011). In the
present study, treatment gains may have increased over time because participants
acquired skills in therapy but did not have an opportunity to fully apply them by
the post-treatment assessment. Once applied, the experience may have elicited
the extinction of gambling-related urges and behaviours in response to triggers, thus
accounting for treatment gains at follow-up assessment. In addition, one of the
outcome measures assessed gambling impairment or disability (i.e., SDS-G), and one
would expect to observe changes in gambling behaviour following treatment prior to
observed reductions in gambling impairment or disability (e.g., it would take some
time to recover from family and financial disruption due to gambling). Lastly, the
outcome measures used in the current study were previously validated instruments
for use with problem gamblers and used varying timelines (e.g., GAS: past 7 days vs.
NODS: past 3 months). It is possible that the minimal post-treatment change
observed on some outcome measures may be due to the long assessment time frame.
For example, the NODS assesses PG severity over 3 months. Because the time gap
between pre-treatment and post-treatment assessment was 6 weeks, immediate
improvements may not be apparent post-treatment but are observable at follow-up.
Future outcome studies may consider using a consistent time frame of assessment
across outcome measures.
A number of limitations of the current study should be noted. First, the retention
rate for this study was low (50%). Although high dropout rates are a commonly
reported barrier to CBT treatment of PG (Rash & Petry, 2014), it is important to
consider the possibility that the participants retained in this study may have differed
regarding their motivation to abstain from gambling relative to the dropouts.
Additionally, all but one participant in the current study reported VLTs as their most
problematic form of gambling. As such, results may not generalize to gamblers who
report other forms of gambling (e.g., poker, online gambling) as most problematic.
That said, VLT gambling is a relatively more addictive form of gambling (Doiron &
141
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
Nicki, 2001) and as a consequence, problematic VLT gamblers may be an ideal
population to assess the effectiveness of a novel PG treatment. Nonetheless, further
research should assess the clinical utility of this motivation-matched PG treatment in
samples of non-VLT problem gamblers.
One additional limitation relates to the means by which gamblers were classified in
the current study classification of gamblers. Specifically, participants were classified
within the motivational group on the basis of their highest z-score on the GMQ
coping and enhancement scales (Stewart & Zack, 2008). In the event that a
participant’s scores were high on both measures, they could not be classified as a
‘‘ pure’’ action or escape gambler. Future research could examine whether such
dually motivated gamblers respond differently to the matched treatment than do
those who are more purely motivated to gamble as a means of coping or excitement.
Baseline scores were consistently low for P4, who was already within the normal
population range on many of the outcome measures. This led to a potential floor
effect, in which treatment gains could not be observed at the post-treatment and
follow-up assessments. Regardless of this, P4 scored within the PG range on the
PGSI during pre-screening and responded well to treatment, exhibiting treatment
gains in overall gambling behaviour that were largely maintained at follow-up.
Because of the design of the present case series pilot study, treatment gains were
evaluated individually via indicators of reliable and clinically significant change
(Jacobson & Truax, 1991). Therefore, we decided to include P4 in the analyses,
despite low baseline scores on many of the outcome measures. It is important to note
that because P4 exhibited a reduction in gambling following treatment but no
reliable change on the secondary outcomes, conclusions cannot be drawn with
respect to the mediators of his changes in gambling behaviour (e.g., increased self-
efficacy to abstain from heavy gambling).
The results of the current research point to the possible utility of this intervention as
a potentially viable treatment for PG. They also provide support for a more
comprehensive assessment of the utility of the BEAT Gambling intervention. That
said, because of the small sample size, conclusions about overall treatment
effectiveness should be drawn tentatively. The goal of the present pilot case series
was to assess the potential of the motivation-matched treatment for further more
rigorous experimentation. In order to ensure that improvements from pre-treatment
levels observed in the present study reflect treatment effects rather than extraneous
factors (e.g., regression to the mean on the outcome measures), a replication of this
pilot study with a larger sample size, randomization, and comparison to a treatment-
as-usual control is needed.
In summary, given the positive outcomes in this study and the overall magnitude of
change on the majority of outcome measures, further research investigating the
efficacy of targeting underlying motives as part of interventions for PG is certainly
warranted. In addition to a randomized controlled trial, future research should
examine the role of theoretically relevant mediators of treatment change and assess
142
MOTIVATION-MATCHED APPROACH TO THE TREATMENT OF PG
whether such differences are due, for example, to matched treatment-induced
changes in affect-regulation gambling outcome expectancies (i.e., reward and relief
gambling outcome expectancies on the GAEQ; Shead & Hodgins, 2009), or to
co-morbid psychopathology (e.g., changes in co-morbid mood and anxiety disorder
diagnoses mediate the treatment effects in the escape-motivated treatment).
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*******
Submitted September 29, 2015; accepted March 23, 2016. This article was peer
reviewed. All URLs were available at the time of submission.
For correspondence:Melissa J. Stewart, PhD, Department of Psychology and
Neuroscience, P.O. Box 15000, Dalhousie University, Halifax, NS, B3H 4R2.
E-mail: stewart.melissa@dal.ca
Competing interests: None declared (all authors).
Ethics approval: obtained from the Nova Scotia Health Authority (NSHA-RS;
Ethics Approval number/code: 2008-082).
Acknowledgements: This study was funded by the Nova Scotia Health Research
Foundation.
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