editorial

Controlled gambling as a therapeutic option

Some 30 years ago, a number of authors started to consider controlled gambling as an intervention goal (Dickerson & Weeks, 1979; Rankin, 1982; Rosecrance, 1988, 1989). However, advocates of controlled gambling have been few until relatively recently, although it seems that the possibility of establishing controlled gambling as an attainable therapeutic goal for some gamblers is being gradually accepted.

Choosing abstinence or control as a therapeutic goal is not a minor decision. Establishing an inadequate or unattainable goal can entail a great number of risks when dealing with a problem that, as is the case in gambling addiction, can severely damage all areas in the life of an individual. Throughout the years, solid arguments in favor of each option have been raised. It is therefore important to look into the implications of controlled gambling as a therapeutic goal.

Arguments against using controlled gambling as a therapeutic option have been both theoretical and empirical in nature. The first argument is theoretical. The conceptual and theoretical assumptions regarding pathological gambling, be they implicit or explicit, have a continuous impact on therapeutic work and, more specifically, on the objectives considered as part of the psychological intervention. For the clinicians who believe in the existence of an illness — who consider that the illness is latent even before the individual experiences his or her first gambling episode and that it remains active even if the subject never gambles again in the future — the possibility of using controlled gambling techniques as a treatment goal is beyond consideration. These clinicians contend that even one sole gambling episode reactivates the whole disorder. For them, the cases in which gamblers have tried to gamble in a controlled manner and have failed in their effort to do so — and even the cases in which gamblers have relapsed after a long period of time without gambling  — are interpreted as empirical evidence that supports this approach to gambling, thus proving that the only possible way for the gambler to control his or her problem is by quitting gambling altogether.

However, there are empirical data that support the idea that controlled gambling is indeed possible (Dickerson & Weeks, 1979; Rankin, 1982) and that relapse does not necessarily lead to a return to pathological gambling practices (see, for example, the excellent — and classical — studies of Blasczcynski, McConaghy & Frankova, 1991, or Russo, Taber, McCormick & Ramírez, 1984, who showed that some gamblers had relapse experiences without recovering pathological gambling patterns of behavior).

Some gamblers experience periods of gambling in a context marked by abstinence. Furthermore, a positive response to treatment is frequently observed even in gamblers that experience short periods of relapse.  If the gambler suffers a disorder that makes it impossible for him or her to gamble without losing control of the situation, how is it possible for some “pathological” gamblers to gamble in a controlled way? These cases threaten the hypothesis put forward by the medical model.

Perhaps the cases in which gamblers experience relapse or fail in their effort to gamble in a controlled way are instead examples of therapeutic interventions that have not been aimed at the control of gambling, but at the avoidance thereof.

Moreover, by choosing success criteria that are based only on abstinence one can ignore significant improvement indices, such as the decrease in the frequency and intensity of gambling, as well as the urge to gamble, the achievement of self-control once the gambling episode begins, or the potential economic, social, and family improvements.

The second argument against controlled gambling is of a practical nature. It is easier to quit gambling altogether than to gamble in a controlled way. The fact that the gambler frequently exposes him or herself to discriminatory stimuli that enhance gambling practices instead of avoiding them or escaping from them increases the probability of triggering a gambling episode or makes it more difficult for the gambler to control the situation. Furthermore, availability and accessibility of gambling is high, which renders the task even harder. In addition, stopping a gambling episode once it has started entails the deployment of self-control skills that the gambler probably has not developed unless he or she has undergone a previous learning process. 

However true this is, the following consideration can be offered: The goal of controlled gambling can be more enriching for the client than a treatment that is aimed exclusively at abstinence. When considering controlled gambling, it is assumed that the individual can learn how to control his or her behavior, a behavior that has been previously learned. In other words, the treatment not only focuses on showing individuals how to inhibit a specific behavior, but also on teaching them the behavioral mechanisms that enable them to control such behavior voluntarily — that is, showing them how to control what used to be uncontrollable, just as non-problematic gamblers do. It is easy to assume that the acquisition of these skills can benefit individuals in other areas of their lives apart from gambling. The acquisition of these skills would not be possible if the individual had quit gambling instead of learning how to deal with it.

A third argument is also important: No comprehensive body of knowledge regarding the causes of the lack of control and the skills required to regain control exists as of today. Indeed, this gap leads many clinicians to "play it safe" and thus to avoid the risks entailed in a treatment approach that has to be designed to meet the specific characteristics of each gambler.

However, the search for controlled gambling would necessarily boost research on the factors that influence gambling behavior and that enhance or protect a harmful gambling pattern. For example, if failures are not considered to be evidence of the existence of a disorder, then we must focus our efforts on studying the reasons that led to treatment failures in gamblers who drop out of treatment or who do not benefit from it. It is important that we look into the skills that the pathological gambler is lacking, the personal components that enhance gambling addiction, and the specific differences that exist between the gamblers who are able to control their gambling activities and those who are unable to do so. Furthermore, we must perform a comprehensive study of adequate explanatory models that can be verified empirically: Only if we know why the gambler cannot control him or herself will it be possible to prevent this lack of control. Although significant progress has been made in this regard during the past years by leaving aside the approach that considers problematic gamblers to be a homogenous group and promoting the study of the different functions that gambling can play in different subgroups of gamblers, we are still unfortunately far from having a large and empirically consolidated body of knowledge.

A fourth argument is methodological in nature: There is no consolidated treatment with enough empirical evidence to support its efficacy in the achievement of controlled gambling. This is still unfortunately true, although progress is being made. However, it is not possible to gather data if the starting point or initial approach is not accepted. Nevertheless, we are not working from scratch; there are indeed therapeutic interventions that have proved their efficacy in the control of other excessive behaviors that can help us (see, for example, the special issue on controlled drinking, Coldwell & Heather, 2006).

Having mentioned the arguments against this therapeutic goal, it is important to describe arguments that support the use of controlled gambling as a therapeutic option. In the first place, we must not forget the high dropout rate that exists in treatment for pathological gambling. It seems reasonable to think that the high dropout rate in gambling therapies can be linked to the assumption that the solution to the problem is the interruption of all forms of gambling. In this regard, programs aimed at a controlled use of gambling offer certain advantages, given that the goal of the treatment is the reduction, and not the total suppression, of a socially accepted behavior.

It must also be considered that the percentage of problem gamblers who seek treatment is still low. It is likely that gamblers who feel unable to control their gambling and want help, but reject the idea of being sick or of quitting gambling, will forever oppose treatment. Furthermore, our experience is that nowadays there are more people requesting treatment with less severe levels of gambling than in the past. Fortunately, an increasing number of individuals seek help because they are starting to worry about their gambling behavior but have not yet reached their maximum level of decline. The motivation that leads these people to seek treatment differs greatly from that of individuals whose lives have been destroyed by gambling, and thus, the goals of treatment must be adapted to meet the characteristics of each gambler.

An increasingly common response to these issues is to propose the restrictions of a controlled gambling option for those gamblers that are "at risk" and that have not yet reached the disordered level. Even the recent and interesting perspective of harm reduction shares this preventive characteristic: It practically proposes a secondary prevention, accepting the existence of a minimum and persistent level of damage. It has, therefore, a different goal than the one sought by the controlled-gambling-objective: a harm-free level of controlled gambling.

I want to finish with the following questions: "Is controlled gambling possible only with gamblers who do not meet the clinical criteria for disorder?" "Can controlled gambling be considered a goal of therapeutic intervention, and not only a preventive one?" In other words, “Is controlled and non-harmful gambling possible for those who have been previously addicted to gambling?”

María Prieto Ursúa, PhD, Department of Psychology, Universidad Pontificia Comillas, Madrid, Spain. E-mail: mprieto@chs.upcomillas.es

References

Coldwell, B. & Heather, N. (2006). Introduction to the special issue. Addiction Research and Theory, 14(1). Special issue: Controlled drinking: Thirty years on. Pp. 1-5.

Dickerson, M. & Weeks, D. (1979). Controlled gambling as a therapeutic technique for compulsive gamblers. Journal of Therapy and Behavioural Psychiatry, 10, 139-141.

Rankin, H. (1982). Control rather than abstinence as a goal in the treatment of excessive gambling. Behavior Research and Therapy, 20, 185-187.

Rosecrance, J. (1988). Active gamblers as peer counsellors. International Journal of the Addictions, 23(7), 751-766.

Rosecrance, J. (1989). Controlled gambling: A promising future. In H.J. Shaffer & S.A. Stein (Eds.), Compulsive gambling: Theory, research, and practice (pp. 147-160). Lexington, MA: D.C. Heath.

Russo, A.M., Taber, J.I., McCormick, R.A. & Ramírez, L.F. (1984). An outcome study of an inpatient treatment program for pathological gamblers. Hospital and Community Psychiatry, 35(8), 823-827.

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