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		[This article prints out to about 6 pages] The Gambling and Other Impulse Control Disorders Outpatient Unit in São Paulo, Brazil : Integrating treatment and research Hermano Tavares, Universidade de São Paulo, São Paulo-SP, Brazil E-mail: hermanot@uol.com.br Program background Gambling is deeply rooted in Brazilian culture, despite its partial prohibition in 1946 by President Dutra's conservative government. The presidential decree banned casinos, but kept lotteries and horse races. In the early 1990s, gambling machines were slowly reintroduced through breaches in a new law that allowed bingo games to foster amateur sports. Currently the bingo label covers a diverse array of electronic devices offered in venues of various sizes (from 20 machines up to 400) that largely resemble casinos, except for the absence of card games and roulette wheels. In the current year, a political scandal involving undeclared funds for electoral campaigns forced a temporary closure of bingo venues. The future of legal gambling in Brazil is an open question and the current debate is intense. While some pathological gamblers feel relieved at the closures, some have already turned to illegal alternatives. Despite these concerns, initiatives to produce epidemiological data on gambling are just beginning. Regarding service demand, we observed a natural growth of treatment-seeking for gambling problems in the mid 1990s. This phenomenon resulted in the opening of the Gambling and Other Impulse Control Disorders Outpatient Unit (in Portuguese AMJO) in 1997. AMJO is located at the Institute of Psychiatry at the University of São Paulo Medical School, the largest university medical center in Brazil with 200 beds and 70,000 outpatient appointments a year. It is one of only two centers specializing in gambling and behavioral addictions in Brazil. AMJO's services are divided into three major areas: research, treatment, and teaching.

		Research lines AMJO has counted on the support of the National Council of Research and Development (CNPq) and the São Paulo State Research Foundation (FAPESP). Our research lines include psychopathology and clinical research, neuropsychology, neuroimaging, and genetics. Since its foundation, the group has produced two PhD theses (Tavares, 2000; Martins, 2003), the former being the recipient of the National Council on Problem Gambling Doctoral Dissertation Award in June 2002 in Dallas, Texas. AMJO currently supports five graduate students completing two doctoral dissertations and three masters theses. Treatment delivery Our service is located in the city of São Paulo, the second-largest city in the world. The Greater São Paulo area, which includes four cities contiguous with São Paulo, comprises around 18 million people. Hence, treatment demand far exceeds treatment availability. Our first program was based on brief individual psychotherapy with a total of 40 sessions of 45 minutes each. Since the primary background of the majority of psychotherapists in Brazil is in psychoanalysis, sessions were psychodynamically oriented and therapists were either psychologists or psychiatry residents supervised by senior psychoanalysts. The first outcome measures of this program are under analysis, but the global impression is that this has been as effective as the cognitive-behavioral approaches described abroad. However, the individual approach has obvious quantitative constraints, hence our efforts to develop group therapies. Two new programs are under evaluation. One is a group cognitive-behavioral therapy (CBT). The group CBT is based on general principles of behavior therapy and Ladouceur's cognitive restructuring therapy (Tavares, Zilberman, & el-Guebaly, 2003). The original program was developed at the Addiction Centre of the University of Calgary during 2001 and 2002, where Dr. Tavares developed his postdoctoral fellowship in collaboration with Drs. Nady el-Guebaly and David C. Hodgins. The program consists of 12 sessions of 90 minutes each with some necessary adaptations to Brazilian realities. For example, the original set of 12 sessions had to be made flexible. The number of sessions that introduce the cognitive approach to gambling (originally 5), as well as the sessions on relapse prevention (originally 2), may take up to 10 and 4 sessions, respectively, as long as the whole program does not exceed the maximum of 18 sessions. Brazilians have a taste for polemics, and compared to North Americans, some feel that we lack objectivity and thrive on argumentation. Besides, although our clients accept a rational approach, most of them arrive expecting moral judgment, emotional suasion, and explanations based on childhood trauma. It takes time to deal with the concept that one has to analyze his or her present reactions and conscious thoughts in the search for the reasons for gambling persistence. Yet, we do not discard the beliefs that a patient may hold about remote causes for gambling problems, although we try to check with the client how such causes could be in action at the present time. Our experience tells us that a 16- to 18-session length is ideal. Further adaptations included replacing references to North American games with culturally compatible options, using proper idiomatic expressions and popular sayings to illustrate cognitive distortions, making analogies between electronic generation of random numbers in gambling machines and dice throwing, actual dice throwing to explain the generation of random number series, and role-playing with fake cash and scratch tickets. The other program offers a psychoeducational approach based on four sessions with the gambler and four sessions with a relative or a significant other appointed by the gambler. The sessions are based on self-help manuals developed by Hodgins, Currie, & el-Guebaly (2001), translated and adapted for Brazilian patients by AMJO's staff. All three programs are complemented by regular psychiatric assessments and the treatment of comorbid psychiatric conditions. A comparison of treatment efficacy between the programs is under development. Combining the three programs, AMJO has assessed and treated an average of 150 patients per year. Teaching and training Possibly our most important mission in AMJO is dedicated to teaching and training young mental health professionals in the recognition, diagnosis, and treatment of impulse-control disorders with a special focus on pathological gambling. The current staff has five senior professionals (three psychiatrists, two psychologists), seven recently graduated psychologists, and three undergraduate students. An equal number of different professionals have worked with us in the past. The goal is to raise clinical awareness and treatment capacity of professionals initiating in the mental field, aiming at the creation of new services. Future directions Considering the current state of gambling studies in Brazil, we believe the next natural steps should be the opening of new research lines focusing on epidemiology, public health, and pharmacologic treatment of impulse-control disorders. With this in mind, AMJO is pursuing partnerships with universities in Brazil and abroad and with the pharmaceutical industry. Brazil has continental dimensions with 170 million people. Therefore, the treatment of pathological gamblers cannot rest entirely on the shoulders of a few mental health professionals. Since its beginning, AMJO has supported all initiatives directed to self-help by trying to facilitate the opening of new Gamblers Anonymous (GA) chapters. Recently, we purchased the basic materials of the Self-Management and Recovering Training program (SMART® Recovery, 2004). Efforts for a fundraising campaign are starting. The goal is to produce low-price editions of AMJO's CBT Therapist Manual, the Client Manual, and the Concerned Family Member Manual. The manuals as well as the SMART® and GA basic literature would be made available through mail by phone request. References Hodgins, D. C., Currie, S. R., & el-Guebaly, N. (2001). Motivational enhancement and self-help treatments for problem gambling. Journal of Consulting and Clinical Psychology, 69 (1), 50-57. Martins, S. S. (2003). Pathological gambling and female gender: personality and clinical characteristics. Unpublished doctoral dissertation, University of São Paulo, State of São Paulo, Brazil. SMART ® Recovery (2004). Available: http://www.smartrecovery.org Tavares, H. (2000). Pathological gambling and its relation to the impulsive-compulsive spectrum of disorders. Unpublished doctoral dissertation, University of São Paulo, State of São Paulo, Brazil. Tavares, H., Zilberman, M. L., & el-Guebaly, N. (2003). Are there cognitive and behavioural approaches specific to the treatment of pathological gambling? Canadian Journal of Psychiatry, 48 (1), 22-27. This article was not peer reviewed. Submitted: April 14, 2004. All URLs were active at the time of submission. For correspondence: Hermano Tavares, Ambulatório do Jogo Patológico e Outros Transtornos do Impulso, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Rua Ovídio Pires de Campos s/n, São Paulo - SP, Brazil, CEP 05403-010, phone/fax: 55-11-30837816, e-mail: hermanot@uol.com.br. Competing interests: None declared. Hermano Tavares is a psychiatrist who completed his training at the Institute of Psychiatry-Hospital Clinics, São Paulo, where in 1997 he founded the Gambling and Other Impulse Control Disorders Outpatient Unit. He completed his doctorate in 2000 with research on pathological gambling and the impulsive-compulsive spectrum of disorders. His doctoral dissertation received the Doctoral Dissertation Award from the National Council on Problem Gambling in Dallas, Texas. Dr. Tavares was a postdoctoral fellow at the University of Calgary (2001-2002), with shared funding by the Alberta Gaming Research Institute (AGRI) and the National Council on Research and Development, Brazil. He recently returned to São Paulo and is a supervisor of the postgraduation program of the Department of Psychiatry, University of São Paulo.
		issue 11 — july 2004