Treatment of problem & pathological gambling in the Nordic countries: Where we are now and where do we go next?

Marianne Hansen, Norwegian Institute for Alcohol and Drug Research, SIRUS Oslo, Norway. E-mail: mh@sirus.no

Abstract

Treatment services specifically for pathological gambling are relatively recent in the Nordic countries. Availability and type of treatment offered varies. A common feature of most of the treatment services is that pathological gambling is treated in the same way as other types of addiction. This article is based on a survey on treatment facilities carried out during the fall of 2004. There were differences in the theoretical perspective that treatment services were based on. The most common theoretical basis was cognitive-behavioural therapy with a focus on correction of cognitive fallacies and magical thinking associated with gambling. There were clear ideological differences between the types of treatment in the different countries. There is limited knowledge about the effect of treatment over time. In the future, focus should be directed towards increased cooperation and professional development between the countries and evaluation of the effects of treatment.
Key words: Problem gambling, pathological gambling, therapy, treatment, development of treatment services, Nordic countries.

Introduction

The availability of different forms of slot machine gambling has increased during the last few years in the Nordic countries. Several factors indicate that the prevalence of problem gambling has also increased. One indication of this is that the amount of money spent on gambling and especially slot machine gambling has increased in all the Nordic countries (Lottertilsynet, 2005; Lotteriinspeksjonen, 2005; Peräkylä, 2005; Madsen, 2005). Another indication is that demand for treatment for pathological gambling has also increased. The initiative to provide treatment and professional development in this field varies in the different countries. Treatment of pathological gambling is a relatively new field in the Nordic countries. Assessment of treatment need, counselling for pathological gambling, and development of treatment services are relevant areas for investigation. Many of the professionals who work in this field have a great commitment to gambling dependency, in relation to development of treatment services and stimulation of public debate.

This article is based on a survey of Nordic treatment services, carried out in November and December 2004, and a report written for the Nordic Council for Alcohol and Drug Research (NAD) and the Swedish National Institute of Public Health (SNIPH). Information was collected from treatment institutes in Sweden, Denmark, and Finland, mainly during study visits. Additional information was collected by e-mail and telephone interviews. Publicly available information about the different treatment services was also used.

Availability of slot machines and the prevalence of gambling problems

Regulation and availability of gambling is very different among the Nordic countries. Sports betting and other types of betting are regulated in all the countries and are partly sold by government-controlled companies. In Finland and Sweden, the slot machine market is a monopoly, while in Norway and Denmark the slot machine market is also open to private companies. Sweden, Denmark, and Finland also allow casinos. As shown in Table 1, most of the people who seek treatment, or who contact a helpline in the four countries, report that they have problems with slot machines (Hjelpelinjen 2004; Stödlinjen, 2004; Peluuri, 2004). Next come games such as odds betting, casino gambling, and Internet gambling. The availability of slot machines and the regulation of slot machine speed and size of winnings vary in the Nordic countries. In Norway and Finland, slot machines are widely available in public places, such as shops, convenience stores, petrol stations, and shopping centres. In Sweden and Denmark, availability is restricted to gaming halls and licensed premises with an age limit of 18 years. The age limit for slot machine gambling is 18 years in all the countries, with the exception of Finland, where the age limit is 15 years. Other types of gambling, such as lotto, sports gambling, and horse gambling, are sold through commission agents in shops and convenience stores. The countries vary with respect to whether there is an age limit of 18 years for sports betting and horse betting. For example, in Finland there is no general age limit of 18 years for these types of gambling. In Norway, an age limit of 18 years was introduced in 2004 for odds betting, but there is no age limit for ordinary football betting.

Table 1.
Comparison of the slot machine market and trade (2003) in Nordic countries

* Information not available.
** Applies to 'open places' such as shops, convenience stores, etc. The maximum winnings in a casino is 40 €.
***Net trade (not including winnings).

Interest in gambling and gambling problems is increasing. Recently, the damage caused by pathological gambling has become more evident. This may be connected with the fact that the media have focussed on the problems caused by slot machine gambling, and more and more individuals have come forward and told their stories. Pathological gambling as a serious health and social problem is becoming more and more recognised, and in several of the Nordic countries we see an increasing demand for treatment and for knowledge about pathological gambling.

International studies have shown that the prevalence of pathological gambling lies between 1% and 3% in most countries (Volberg, 1994). In the Nordic countries, population studies have been carried out in Norway, Sweden, and Finland. The Swedish study showed that 2% of the population between 15 and 74 years of age in Sweden had some form of gambling problem (Rönnberg et al., 1999). The prevalence of gambling problems and pathological gambling was highest among adolescents and people born outside Sweden. The Norwegian population survey showed that 1.4% of the population had or have had gambling problems, and that 0.7% of the population have a gambling problem in one form or another (Lund & Nordlund, 2003). A Finnish study has shown that 1.5% of the study participants scored 5 or more on the South Oaks Gambling Screen (SOGS) (Ilkas & Turja, 2003). A large national prevalence study is currently being planned and carried out in Demark. It is expected to be completed in 2007.

During the last few years, there has been an increasing focus on children and adolescents and slot machine gambling. Studies in this field have consistently shown that gambling with money is common among this age group (Griffiths, 1995; Derevensky & Gupta, 2000a, 2000b; Shaffer & Hall, 2001; Derevensky, Gupta, & Winters, 2003). A meta-analysis of studies carried out in North America has shown a low but increasing level of pathological gambling from 1997 to 1999 among adults and a high but stable lifetime prevalence among adolescents and treatment populations (Shaffer & Hall, 2001). A Norwegian study of children and adolescents between the ages of 13 and 19 has shown that 3.2% showed clear signs of gambling problems. This is equivalent to 11,000 young Norwegians (Rossow & Hansen, 2003). No prevalence studies of adolescents have yet been carried out in the other Nordic countries.

Treatment ideology, theoretical perspectives, and treatment of pathological gambling

Pathological gambling has many causes, and development from gambling to pathological gambling can vary from person to person. It is reasonable to suppose that there is a need for different types of treatment. From a clinical perspective, one may assume that there are still not very many therapists who know enough about pathological gambling to be able to offer a specially adapted treatment service. There is no doubt that pathological gambling has many similarities to other types of addiction, but pathological gambling is also very different, demanding specific knowledge of treatment. Currently, there are three dominant models discussed in relation to choice of intervention method: the 'medical' model, the 'behavioural' model, and the 'cognitive' model (Petry, 2002; Petry & Armentano, 1999). Most treatment services in the Nordic countries fall within the spectrum of cognitive-behavioural therapy, often supplemented with elements from solution-focussed therapy (Berg & Briggs, 2002), family therapy, and change-focussed counselling (Miller & Rollnick, 2002).

On the basis of available scientific data, types of treatment within the spectrum of cognitive-behavioural therapy have so far been shown to be effective (Echeburúa, Baez, & Fernandez-Montalvo, 1996; Echeburúa, Fernandez-Montalvo, & Baez, 2000; Sylvain, Ladouceur, & Boisvert, 1997). However, it is not possible to say which types of cognitive-behavioural therapy are the most effective, or whether such interventions are more effective than types of treatment based on other approaches (Toneatto & Ladouceur, 2003).

Today, a relatively broad spectrum of treatment programmes for pathological gambling is available, both in the Nordic countries and internationally. Very few of these programmes are evidence based. The practice in the different countries has been to start treatment without really knowing whether it works and how it works. It seems as though it is not possible to avoid a period of trying and failing in the introductory phase. The main impression gained from talking to therapists was that most of them did not have a developed treatment programme to begin with, but that the programme was developed as they went along.

Therapeutic themes in the treatment of pathological gambling

Pathological gambling causes problems on different levels. The gambler him- or herself can be affected by reduced physical and mental health and ruined economy. The gambler's family and friends often suffer broken relationships. Society as a whole is affected by reduced participation in employment and the cost of treatment and social assistance.

The therapists who were interviewed told about how pathological gambling affected the family and friends of the gambler because of borrowing money, lies, and broken relationships. The damage to third parties could be considerable and not unlike the damage one often finds in the families of alcohol and drug abusers. Pathological gambling leads to reduced productivity in employment, poorer health, and increased sick leave. Many therapists had to deal with crime associated with pathological gambling. The damage caused by pathological gambling over many years could be considerable, and many people sought treatment while they were going through a crisis. Therapists who had experience with treatment of alcohol and drug addicts pointed out the similarity between alcohol and drug addiction and pathological gambling. This similarity is also reflected in the treatment. Therapeutic themes are often related to traditional addiction themes, such as experience of shame, feelings of guilt, and taboos about gambling. Therapists who also worked with the relatives of pathological gamblers described important themes such as communication, trust/mistrust, and role displacement in families. Important issues related to treatment were motivation, ambivalence, risk situations, and relapse. These therapeutic themes were common for all the therapists, independent of their theoretical and professional background. Despite the fact that there is little knowledge about whether treatment is effective and about how it works, therapists were very optimistic about treatment. The general impression was that treatment works and that it is possible to do something about pathological gambling. The definition of successful treatment varied from total abstinence from all gambling to increased control over gambling problems and increased quality of life.

The background for initiating and organizing treatment in Norway, Sweden, Denmark, and Finland

Despite the fact that the Nordic countries are similar in several ways, treatment traditions and demand for treatment for pathological gambling were very different. There were differences in the extent to which pathological gambling was recognised as a problem that can be treated. There is a lot of shame and many taboos associated with pathological gambling, and this has probably prevented many people from contacting treatment services. Another important factor is the availability of adequate treatment services. In the countries where there has been an increase in treatment supply, there has also been an increase in the number of people seeking treatment. Yet another factor is whether pathological gamblers can afford treatment. An investigation of the different treatment services revealed that private institutions that charge for treatment have more difficulty recruiting patients than public institutions. In other words, access to treatment determines the extent to which people seek treatment.

In Norway and Denmark, demand for treatment has been increasing since the first treatment services were initiated. There were no publicly financed treatment services for this group in Sweden until 2003–2004. As a result, demand for treatment has increased slightly, though there are still several institutions that have problems recruiting patients. In Finland, it is surprising that so few people talk about their gambling problems and that there is so little demand for treatment. Finland is different from the other Nordic countries in that gambling problems are not part of the public debate.

In many ways, Denmark can be regarded as an innovator of treatment in the Nordic countries. The established treatment services in Denmark are different from in the other Nordic countries in that special care for pathological gamblers has been established. However, there are no treatment services for pathological gamblers within the public health services. All treatment services and competence in this field are to be found in the private sector. These services have developed from the initiatives and commitment of individuals. At the same time, all treatment is fully funded by the Danish state from the profits from slot machines (1% of gross sales). At present, this is unique in the Nordic countries. A similar scheme is being planned in Norway. Treatment of pathological gambling in Denmark is particularly associated with the Centre for Ludomani in Odense, which was the first place that offered treatment for this group of people. The Centre has provided treatment since the beginning of the 1990s, and it now has clinics in Copenhagen and Aarhus. The Centre for Ludomani currently offers different treatment services, such as individual and group outpatient treatment, and an intensive inpatient treatment programme lasting 12 days. Until 2 years ago, the Centre for Ludomani was the only place that offered this type of treatment in Denmark. The Frederiksberg Centre was granted funding 2 years ago to provide treatment in the Copenhagen area. This centre is a private institution for the treatment of alcohol and drug problems based on the Minnesota model. Outpatient treatment in which patients are given training and group and individual counselling is offered. The Danish treatment institutions have to apply for funding each year. This means that they are uncertain whether they will be granted funding each year, and they do not know in advance how much funding they will receive.

In Norway, treatment services for pathological gambling have developed in a similar way to in Denmark. The first treatment services were provided at Renåvangen, an institution for the treatment of people with alcohol and drug problems. The service began as a 3-year project (1997–2000). Treatment was based on experience from alcohol and drug treatment at the therapeutic Community at Renåvangen, and from a therapeutic community institution treating pathological gambling in the Netherlands. Treatment was based on a model in which patients were admitted for two 1-week (7 days) periods, with a break of about 3 to 4 months in the middle. The project provided a lot of useful experience for the outpatient treatment services that were started later. The outpatient treatment services that exist today were established as a result of the commitment and enthusiasm of professionals working in the field of alcohol and drug addiction. In 2000, the Blue Cross Centre in Oslo began an outpatient group therapy service for pathological gamblers. Several professionals have become interested in this area as the number of people seeking treatment has increased. With a few exceptions, most of the clinics that provide treatment for pathological gamblers are clinics for people with alcohol and drug problems. Most people have acquired skills and knowledge in this area partly by visiting, taking courses, or contacting the Blue Cross Centre, and partly from participating in national and Nordic seminars and conferences on pathological gambling. In 2002, the Bergen Clinics were allocated funding from Health and Rehabilitation Foundation for a project. The aim of the project was to develop a form of treatment based on manuals. The project was carried out with 40 people who received treatment. Unfortunately, the project was discontinued, but two manuals were developed, one for clients and one for therapists. Several institutions in Norway use these manuals as the basis for the treatment they provide. A common feature of the existing treatment services currently available in Norway is that they are based on outpatient group treatment, with an emphasis on cognitive-behavioural therapy and correction of cognitive fallacies and prevention of relapse. The specialists in the field of treatment of pathological gambling are a close group who have contact with each other. At present, there are no day-treatment services for pathological gambling in Norway. There are great regional differences in the availability of treatment services. With a few exceptions, there are virtually no treatment services for pathological gamblers in western and northern Norway.

Sweden differs from both Norway and Denmark in that up until now the availability of treatment services for pathological gambling has been very limited. Pathological gambling has been a topic of public debate for several years in Sweden, and research on the prevalence of pathological gambling was carried out at an early stage. However, it has proved to be difficult to develop public treatment services. In Sweden, there is a strong tradition for long-term treatment institutions, providing treatment lasting from several weeks to several months. The Swedish environment consists of many individuals who have a strong commitment to this field, but they appear to be fragmented and it is difficult to obtain an overview of them. However, the commitment of private individuals has been strong, and this has led to the establishment of special interest organizations. In 2001, SNIPH was commissioned by the Swedish government to develop a plan of action and to assess the need for treatment. As a result of the plan of action, SNIPH has been allocated the following tasks: to function as a national resource centre for pathological gambling, to stimulate research and development of knowledge in the field, to disseminate information about pathological gambling, and to work with preventive measures. SNIPH is currently working on developing treatment services to be established in the municipalities. At present, people can apply to social services to have the cost of treatment covered, but in practice such applications are often rejected. SNIPH has established treatment centres in Stockholm, Gothenburg, and Malmö. These centres provide outpatient group therapy, family therapy, courses for relatives, and short-term individual treatment. Experience from these treatment services shall be continuously evaluated during the project period, which lasts until the end of 2006.

In Finland, pathological gambling has so far received little attention in the public arena. There are a few individuals who encounter this problem in their work with dependency problems, and who have a good understanding of pathological gambling, but the public authorities have shown little commitment to the problem. A project was initiated in Finland as early as the beginning of the 1990s. This project was financed by the gambling industry. In particular, professionals from the A-clinics (clinics providing treatment for people with alcohol and drug problems) took part in courses on pathological gambling and treatment. The project was discontinued and little knowledge remains today from that time. While professionals in the field in Norway, Sweden, and Denmark to a certain degree have established contact with each other, this has not happened in Finland. None of the therapists I interviewed during the study had contact with people in the other Nordic countries, or had participated in Nordic seminars or conferences on pathological gambling. Pathological gambling seems to have been given little attention by people in the treatment services, and the availability of treatment is limited because there is so little knowledge about the problem. Consequently, very little specialized treatment is available in Finland today.

Before any other treatment service for pathological gambling was established in the Nordic countries, Gamblers Anonymous offered self-help groups for pathological gamblers. Gamblers Anonymous has meetings in Norway, Sweden, Denmark, and Finland. It varies how geographically accessible the groups are. In Sweden, another kind of self-help group has developed over the last 20 years. Gamblers Foundation (Spelberoendes Riksforbund) has support groups for pathological gamblers over almost all of the country.

Two treatment manuals have been developed in the Nordic countries—one in Norway and one in Sweden (Skjerve & Prescott, 2003; Prescott & Skjerve, 2002; Ortiz, 2004). The Norwegian manual is partly based on the treatment programme of Ladouceur, Sylvain, Boutin, and Doucets (2002). The manual has a slightly extended focus, based on the idea that for some pathological gamblers there are important determining factors other than fallacies. The manual includes interventions directed at strengthening motivation, decision-making, and practical mastering strategies. The Swedish manual has a section on psycho education for gambling and pathological gambling, and a section on behavioural therapy with a focus on factors that trigger and maintain pathological gambling, problem solving, and prevention of relapse. Both manuals are intended to be used as practical aids in the treatment of pathological gambling. The manuals have not yet been evaluated.

Two different types of self-help manuals are available in the Nordic countries. The first type is available for participants in a Swedish Internet-based self-help programme, based on cognitive-behavioural therapy (http://www.slutaspela.nu/). Treatment is divided into eight modules with homework after each module. The second self-help manual (Hansen & Skjerve, 2005) is available at http://www.rus-ost.no/. This manual is intended to be a tool for solving the problem oneself or as a source of motivation to seek treatment.

So far, we know little about the effectiveness of treatment manuals and self-help manuals. However, they provide a theoretically based starting point for the further development of treatment services.

Table 2.
An overview of treatment services in the Nordic countries

** The estimates are based on information from the institutions where interviews were carried out and provide an indication of the number of people who have received treatment.

Experience gained from providing treatment for pathological gambling

What kinds of people seek treatment?

The gender distribution of people who seek treatment was skewed. The majority of people who had contacted treatment services were men, mainly between 30 and 40 years old. This was the case in all the Nordic countries. Several of the institutions reported that the proportion of men was between 70% and 90%. Despite the predominance of men, some of the therapists reported that the proportion of women was increasing, and that more and more women were seeking treatment, compared to the situation 2 or 3 years ago. Women who seek treatment tend to be older than men—between 50 and 60 years old. There were very few women in the younger age groups. The age range of people who had sought treatment was 14 to 80 years. Treatment services for adolescents are almost nonexistent in the Nordic countries. Several therapists reported that there were quite a few boys under 18 years old and their parents among those seeking treatment. Some of the treatment centres have accepted adolescents for treatment, as an exception, but other centres have not been able to do so. The few centres that offer treatment to adolescents reported that they always involve parents in the treatment. Adolescents who seek treatment often have other problems, such as learning difficulties, behavioural problems, and criminal behaviour.

Both the Swedish and the Norwegian population surveys (Lund & Nordlund, 2003; Rönnberg et. al., 1997) have shown that there is a higher proportion of pathological gamblers among immigrants with a non-western background than among ethnic Swedes and Norwegians. This was reflected in the people who seek treatment. Several challenges related to this were mentioned. More people in this group had multiple problems. Therefore, they needed a more comprehensive treatment programme that also included treatment of other types of mental illness. Language differences often created problems for group therapy. The dropout rate was higher in this group. Currently, there is no specific experience in designing treatment programmes that are specially adapted for immigrants, but this is an area that several therapists were concerned about and wished to work with.

Most of the people who received treatment were in debt. The size of the debt varied from several thousand to several million kroner. The treatment institutions had slightly different strategies for dealing with financial problems and different attitudes towards the problem. All the institutions agreed that dealing with financial problems in some way or another was important, as well as decisive for attaining an existence free from gambling. Some of the institutions provided financial counselling as part of the treatment programme. They had separate members of staff to help pathological gamblers obtain an overview of their debts and contact their creditors to organize a debt settlement. Other institutions helped by referring clients to a financial adviser outside the institution. On the other hand, some of the therapists I interviewed were concerned about not getting involved in financial problems as part of the treatment, because the practical issues related to money and debt could easily dominate the treatment programme.

Dropouts

Most of the therapists reported that the dropout rate from treatment was high, especially at the beginning of treatment. It was pointed out that many of the people who sought treatment were in a crisis situation when they contacted the institution, and that this was a contributing factor to the high dropout rate. Several of the therapists reported dropout rates of between 30% and 50%. In all the Nordic countries, the dropout rate was highest between the first contact and the first appointment. The dropout rate also seems to be higher for outpatient treatment than for inpatient treatment. The Centre for Ludomani in Denmark provides both types of treatment, and here there was a difference between inpatient and outpatient treatment programmes. The treatment institutions in Norway that had fewer places had lower dropout rates. The dropout rate was also lower in Finland, where it was difficult to get a place for treatment.

People who complete treatment

Not surprisingly, the people who completed treatment and managed best afterwards were the people with the least complex problems. A good network, employment, and high motivation were factors that increased the probability that treatment would be successful. All the therapists had this experience.

Feedback from the participants

Feedback was collected from the participants in a nonsystematic way. Some institutions obtained a written evaluation from participants at the end of treatment. Other institutions obtained no feedback from participants. Participants reported that it was important for them to be treated with understanding and not condemnation. Several participants reported that they had gained much from receiving treatment and that taking part in group therapy had been educational and had given them a greater understanding of their problem. One of the most frequent responses was that it had been very useful to meet other people in the same situation. Recognizing that others were in the same situation was very important. This is probably because pathological gambling is a problem that has found little acceptance in society, and many people experience a great sense of relief when they become part of a group where they can 'be themselves' and 'avoid having to explain themselves all the time'. Some of the participants also stressed how important it was to include their family in the treatment. Some of them expressed the wish for a longer-lasting and more comprehensive treatment programme. There is little information from the people who drop out of treatment or from those who do not find the treatment useful. Thus, the feedback presented here is only from the people who completed treatment.

The desire to expand treatment services in the Nordic countries

The need to increase the level of competence

Most therapists expressed a clear desire to have contact with other people who work in this field. Several of them said that they felt that they were alone in the field and that they wanted to have contact with colleagues and to receive guidance from them. They also wished that there were more courses on pathological gambling. Several of them wished that they could participate in national and Nordic seminars on this topic. There was large variation in the level of participation in courses and seminars. Therapists from Norway and Denmark had participated more than others in national and Nordic seminars. The situation was more variable for the Swedish therapists. Some of them had close contact with professionals in Norway and Denmark. But many of the therapists from private treatment services in particular had little or no contact with colleagues. The Finnish therapists were in a similar situation. The therapists in Finland had little contact with each other, they had no contact with others in the Nordic countries, and they did not participate in Nordic seminars.

A greater variety of treatment services

At present, several of the treatment institutions offer a limited range of treatment services, either short-term group therapy lasting from 6 to 12 weeks, or a course of individual counselling sessions. All the institutions wished to be able to offer a greater variety of treatment services, better adapted to each individual. The institutions also varied in the follow-up treatment they offered. Follow-up varied from two to three follow-up consultations to weekly follow-up, according to need. The institutions that had no resources to follow up clients regretted this and expressed the view that a course of treatment lasting from 6 to 8 weeks was too short to bring about lasting change. Other institutions had experienced that a short course of treatment was adequate for some people. This highlights the need for a greater variety of treatment services.

A focus on relatives

The majority of therapists regarded relatives as an important resource in treatment. Several of them had established programmes for the relatives of pathological gamblers, in the same way as clinics for people with alcohol and drug problems have programmes for relatives. This provides the possibility for individual treatment on the relatives' own terms. Several of the therapists wished to be able to offer a programme that is better adapted to relatives, including support groups, courses, and treatment.

The economic framework for maintaining and developing treatment services

Funding of treatment services varies. All the institutions, independent of how they were funded, wished to have more resources to extend and develop the services they offered. The Danish treatment institutions receive funding for 1 year at a time. Even though the treatment services in Denmark are well established, this provides a challenge with regard to long-term planning. Staff is appointed for 1 year at a time and each year the institutions have to apply for funding for the next year. The economic situation for the Norwegian institutions is somewhat different. Some of them described treatment of pathological gambling as a service that is separate from the regular services. Some of them had a limited number of places each year allocated for treatment of pathological gambling. Others could offer treatment of pathological gambling as part of their regular service. Several of the clinics had a waiting list for treatment. The private institutions in Sweden depended on patients who pay for their treatment in order to continue to offer treatment services.

Assessment of patients and evaluation of the effect of treatment

Few of the treatment institutions carried out systematic assessments of patients and evaluation of treatment. If patients were assessed, this was done during the preparatory consultation or on admittance before treatment was started. Some of the institutions use the SOGS as a diagnostic tool (Lesieur & Blume, 1987). The institutions that assessed their patients more systematically did this partly in order to evaluate their own practice and partly in order to collect data for planned research projects. Several of the therapists who were interviewed expressed a wish to be able to set aside more time to carry out a more thorough assessment of their patients, in order to be able to improve their evaluation of the effect of treatment. Some of the therapists believe that it is problematic that treatment services are now being developed when no evidence-based knowledge about the effect of treatment is available. Evidence-based knowledge is also needed in order to improve the quality control of treatment.

Summary

Treatment of pathological gambling is a new and rapidly developing professional field in the Nordic countries. The existing treatment services are inadequate to cover the need for treatment of pathological gambling. The established clinics have many applicants and several of them have waiting lists. Newly established clinics often experience that it takes time before their services are known and patients apply for treatment. Recruitment can go slowly to begin with. Whether people seek treatment or not seems to depend on existing norms in society in relation to pathological gambling. During the last few years, in both Norway and Denmark, pathological gambling has been put on the agenda, and to a greater extent it has been recognised as a problem in society. Norway and Denmark are also the countries with the most people seeking treatment. Finland is the country with the least treatment services and the least number of people seeking treatment. In Sweden, public treatment services have only been available during the last 2 to 3 years, but the private sector has a long tradition of offering treatment. Whether treatment is free or not also seems to influence recruitment. It is difficult to recruit patients if they have to pay for treatment themselves

Probably only a small proportion of people with gambling problems seek treatment. It is reasonable to assume that some pathological gamblers manage to stop gambling by themselves, that some of them join self-help groups, and that some get help from available information and self-help material.

The availability of treatment varied. It was easier to obtain treatment in large towns than in small places. Services are most easily available in Denmark, which has to do with geographical factors. In the other three countries, there are large regional differences in availability of treatment, particularly in the northern areas. If outpatient treatment is the main type of treatment offered, it is appropriate for services to be available close to where people live and work. There are large differences between the countries in availability of treatment and the type of treatment offered, but there are also some common features in the way treatment is organised. Cognitive therapy, often in groups, with a focus on prevention of relapse and correction of cognitive fallacies, was often used, sometimes in combination with a relational focus. This study can contribute to closer cooperation between treatment institutions in the Nordic countries. Contact between professionals is useful for developing methods of treatment and for assessing clients and evaluating treatment. Even though this study of treatment services in the Nordic countries does not include all the treatment services, there is reason to believe that it provides a good overview of the situation in this area.

Up until now, very little evaluation has been carried out of treatment services for pathological gambling. This is not just in the Nordic countries, but also internationally. In order to evaluate treatment, treatment services must be established. An aim for the future should be to develop treatment services and increase the number of treatment institutions. Therapists and researchers in the field should be given the opportunity to document and systematize their work and their experience, so that knowledge about pathological gambling can be made available for everyone. It can also be useful to try out different treatment methods for pathological gambling and to find out which treatment methods are more effective.

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Manuscript history: Submitted February 8, 2006; accepted September 25, 2006. All URLs were active at the time of submission. This article was peer-reviewed.

For correspondence: Marianne Hansen, Norwegian Institute for Alcohol and Drug Research, POB 565 Sentrum, 0105 Oslo, Norway. Phone: +47 2234 0420, fax: +47 2234 0401,
e-mail: mh@sirus.no

Competing interests: None declared.

Ethical approval: None required.

Funding: MH is employed by the Norwegian Institute for Alcohol and Drug Research. This project was financed by the Swedish National Institute of Public Health.

Marianne Hansen is a research fellow at the Norwegian Institute for Alcohol and Drug Research. She is a clinical psychologist and has 6 years of experience treating pathological gambling. She is currently preparing a PhD thesis on pathological gambling. E-mail: mh@sirus.no