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clinical case corner The role of mindfulness in the cognitive-behavioural treatment of problem gamblingTony Toneatto PhD1,
2, 3
1Centre
for Addiction and Mental Health, Toronto. E-mail:
tony_toneatto@camh.net
Recent years have witnessed the emergence of mindfulness meditation as an
important intervention in the alleviation of illness-related disability and
distress. Although originally developed within the context of physical
illnesses such as chronic back pain, recent years have seen mindfulness
meditation effective in the alleviation of emotional distress, especially
anxiety and depression. Mindfulness meditation assists the individual in
learning more adaptive ways of responding to aversive mental states by
encouraging a focus on remaining present, non-judgement, and acceptance
towards all mental states. Unlike cognitive therapy there is no attempt to
directly challenge or restructure cognition. Given the prominence of
distorted thinking among problem gamblers and the difficulty in modifying
them, mindfulness meditation holds promise as an adjunctive intervention to
help problem gamblers learn to cope with gambling-relevant cognitive
distortions. A case study is presented illustrating the integration of
mindfulness meditation into treatment for problem gambling.
Cognitive-behavioural therapy (CBT) is the main evidence-based treatment for
pathological gambling, a condition characterized by difficulty controlling
impulses to engage in repeated, persistent gambling. Primary treatment
targets in CBT are the gamblers' cognitive distortions, or irrational
beliefs regarding the extent to which gambling outcomes can be predicted and
controlled (Kahnemann & Tversky, 1982). Although CBT has been shown to
benefit problem gamblers (for instance, to reduce the frequency of gambling
and to produce better rates of abstinence from gambling than no treatment at
all (Toneatto & Millar, 2004)), rates of relapse and treatment nonresponse
to CBT remain high. Given the limitations of purely cognitive-behavioural
approaches for the treatment of pathological gambling, it is important to
consider alternative therapeutic strategies that could enhance clinical
outcomes (Toneatto & Millar, 2004). Mindfulness is a meditation practice
derived from Eastern spiritual training that has been integrated
increasingly into CBT for a number of mental health and addiction problems.
When integrated into CBT, mindfulness may provide clients with a unique
practice that can assist them in reacting less impulsively to their own
thinking, especially gambling-related cognitive distortions. A substantial body of work has described
the role of cognitive factors in problem gambling (e.g., Petry, 2005;
Toneatto, 1999; Griffiths, 1995). Problem gamblers have been distinguished
from social gamblers on the basis of having a number of cognitive
distortions (e.g., Joukhador, Maccallum, & Blaszczynski, 2003). Two of these
major cognitive distortions are beliefs that gambling outcomes can be (i)
predicted and (ii) controlled (Letarte, Ladouceur, & Mayrand, 1986). Even
games that are ostensibly completely random, such as slot machines and
bingo, elicit irrational beliefs about control and prediction (e.g.,
Toneatto, Blitz-Miller, Calderwood, Dragonetti, & Tsanos, 1997; Langer,
1983). These core beliefs form the basis for a wide array of irrational or
maladaptive beliefs about gambling outcomes that have been well described in
the literature (e.g., Toneatto & Nguyen, in press (a); Petry, 2005). Some
frequently observed cognitive distortions among pathological gamblers are
the following:
Illusions of control:
These are beliefs that the probability of winning is greater than would
be dictated by random chance. Such beliefs may be more apparent in games
where skill or knowledge may operate (e.g., horse racing, cards, sports
lotteries; Ceci & Liker, 1986) but may also be present in nonskill games
(e.g., bingo, lotteries; Griffiths, 1993; Langer, 1983).
Superstitious beliefs/illusory correlations:
Included among these are talismanic superstitions, which are
beliefs that objects (e.g., a hat) or qualities (such as the color
green) increase the probability of winning (Toneatto et al., 1997).
Alternatively, numbers can take on talismanic properties (Rogers, 1998).
Another category, referred to as behavioural superstitions,
includes beliefs that certain actions or rituals increase the
probability of winning (Bersabe & Arias, 2000). One widespread
behavioural superstition is entrapment (Walker, 1992), the belief that
one must continue to gamble or wager in the event that the winning
outcome takes place. A third category, cognitive superstitions,
includes beliefs that mental states such as prayer, hope, and positive
expectations can influence the probability of winning (Gaboury &
Ladouceur, 1989).
Interpretive biases:
The problem gambler expends considerable effort to explain gambling
losses in ways that justify continued gambling. Attributional biases
are the tendency to overestimate dispositional factors (e.g., skill,
ability) to explain wins and to underestimate situational factors (e.g.,
luck, probability; Gaboury & Ladouceur, 1989) to explain losses. "Near
misses," in which a gambling outcome falls just short of a win (e.g.,
one number missing from a winning lottery number), are common in many
gambling types (e.g., slot machines, VLTs) and are often reframed as
near wins rather than as losses (Parke & Griffiths, 2004). The
gambler's fallacy refers to another set of beliefs that positive
gambling outcomes are more likely to occur simply because they have not
occurred for a period of time and are therefore "due" (e.g., Rogers,
1998). The gambler's fallacy also includes beliefs that (i) even a brief
sequence of gambling events will express a random process (Spanier,
1994), (ii) chance is self-correcting so that losses and wins balance
over time (Spanier, 1994), and (iii) gambling outcomes are not
independent of each other but can affect each other, such as with coin
tosses and roulette spins (Ladouceur & Dubé, 1997). Finally, chasing
refers to the tendency of gamblers to respond to serious losses by
continuing to gamble based on their belief that this will assist them in
recovering their financial losses (Walker, 1992). Cognitive-behavioural treatments for
problem gambling work directly with the content of cognitions. Thoughts,
beliefs, and attitudes are identified, examined carefully, restructured or
revised, and tested in the natural environment. A variety of techniques are
used to challenge the contents of cognitions, such as questioning the
evidential or formative basis of the irrational belief, modifying
self-dialogue, reframing explanations of gambling outcomes, considering
neglected evidence, detecting occurrences when the expectations did not
match the gambling outcomes, and urging open-minded observation of gambling
outcomes.
While CBT is focused on challenging the content of the cognitive distortions
associated with mental health problems, mindfulness is focused on assisting
clients in examining how they relate to their thoughts. Mindfulness asks
clients to learn to observe their own mental processes openly, without
censure, judgment, or restriction, and without getting caught up in the
actual content of their thoughts. As defined by Segal, Williams, & Teasdale
(2002), the core skill in mindfulness is the capacity to respond to aversive
cognitions, sensations, and emotions with an attitude of nonjudgmental,
accepting, present-moment awareness. In other words, the content of the
thought is less important than how the individual responds to the occurrence
of the thought, as well as other mental content, such as images and
memories. Mindfulness is believed to enhance skills in both recognizing and
disengaging from self-perpetuating mental states characterized by ruminative
and negative thought (see Segal et al., 2002). Mindfulness can best be considered a form
of behavioural, cognitive, and affective self-regulation. Individuals are
asked to maintain a decentred awareness of mental content without "reacting"
to the mental event (e.g., elaborating or becoming preoccupied with the
thought). Instead, mental content is allowed to arise within conscious
awareness and to subside as a natural mental process. As an initial step in
their training in mindfulness, meditators are asked to maintain awareness of
their breathing and to return to this awareness when their attention is
drawn to any thoughts, feelings, or bodily sensations. By repeatedly
returning awareness to the breath, clients are assisted in learning about
the nature of mental activity and in distinguishing mental activity from
responses to such activity. Shifting awareness away from mental content to
the breath also interrupts the flow of ruminative thought processes and has
the effect of reducing the potency of mental events, thereby reducing
impulsive, reactive, or automatic reactions to these events. Individuals are
asked to simply note the occurrence of the event and return their attention
to their breathing. No attention is paid to the specific content, validity,
veridicality, or significance of the mental event itself. With practice,
clients learn to observe sensations, feelings, and thoughts, and the process
of thoughts coming and going. Simply put, thoughts, feelings, and
perceptions (and all other mental events) are viewed as "just thoughts," not
to be believed, judged, suppressed, prolonged, dismissed, manipulated, or,
most importantly, acted upon. Within a mindfulness meditation perspective,
mindfulness interrupts the cognitive chain reaction that usually occurs in
response to spontaneously emerging cognitions, which left unchecked initiate
distressing emotions and behaviours, including pathological gambling (Toneatto,
2002).
Mindfulness practices, as described in Kabat-Zinn (1990), include
systematic, guided meditations practised daily for approximately an hour,
and also during sessions with a therapist. During these practices, the
client learns to bring present-moment, nonjudgmental awareness to bodily
sensations, feelings, and thought contents and processes. Specific
mindfulness meditation practices include
sitting meditation, which involves bringing awareness back to the breath
each time attention drifts to other sensations, feelings, and thoughts;
the body scan, which involves scanning for physical sensations from the
toes, up through the body to the head, and gently guiding awareness back
to sensations when attention drifts to other aspects of experience;
mindful yoga, which involves attending fully to gentle yoga postures and
movements;
everyday mindfulness, which involves bringing awareness to everyday
activities, such as eating, walking, washing the dishes, and having a
shower, and to the full range of sensations, thoughts, and feelings as
they arise.
Gradually, awareness is expanded so that it encompasses all aspects of
experience. For instance, while doing the sitting meditation, meditators
will note where their attention goes and observe how sensations, feelings,
and thoughts arise and pass. By observing and noting these everyday aspects
of experience, clients gain skills in knowing and noting experience without
impulsivity or reactivity. Clients who gain the skill of observing and
noting experience without getting caught up in reactions gradually become
less reactive to more emotionally laden sensations, feelings, and
cognitions, including those sensations, feelings, and cognitions in the
chain of events that lead to discrete episodes of problem gambling.
In sum, rather than reacting to thoughts and attempting to control them
directly, for instance by altering their content as in standard CBT,
individuals are encouraged to passively but alertly observe their mental
activity. Individuals are guided in observing that the process of cognition
is automatic, conditioned, and autonomous (Toneatto, 2002). Through the
cultivation of mindful attention the links between thinking and impulsive
acting out, which are usually automatic and out of awareness, are gradually
deconditioned. With sustained practice, the mindful meditator learns that
the content and process of mental activity is:
(i) incessant, insofar as the conscious mind is always producing some kind
of mental activity;
(ii) unpredictable, given that it is impossible to predict what kinds of
cognitive events will emerge within consciousness;
(iii) uncontrollable, insofar as efforts to suppress or eliminate cognitive
activities will only be met with failure; and, finally,
(iv) impermanent and transient, as they arise, abide, and cease within
awareness without any apparent conscious involvement of the individual.
Distinguishing mental events from the responses to them provides a choice to
the gambler regarding how to best respond, rather than react, to
gambling-related cognition. Learning to relate differently to gambling
cognitions may be as important as, if not more important than, challenging
the specific contents of the thoughts. In a sample of video lottery players,
Ladouceur (2004) showed that the raw frequency of erroneous perceptions
related to gambling did not distinguish problem from non-problem gamblers.
Instead, problem gamblers were more convinced of, or attached to, the
seeming truth of their erroneous gambling-related perceptions than
non-problem gamblers. Thus, whereas the problem and non-problem gamblers
were similar with respect to the number of cognitive distortions they
endorsed, only the problem gamblers responded in a way that indicated an
investment in, or attachment to, these thoughts. Ladouceur's findings
suggest that it is not the thoughts themselves, but rather the gamblers'
relationship to gambling-related thoughts and tendency to fixate or
ruminate on these cognitions, that contribute most significantly to the
thoughts' maladaptive behavioural consequences.
Although it is unlikely that mindfulness meditation is sufficient as a
standalone intervention for treating problem gambling, it may have utility
as a component of cognitive-behavioural treatment as has been found in the
treatment of severe mental health problems involving disordered emotion
regulation (such as self-harm and borderline personality disorder; Linehan,
1993), or as a relapse prevention strategy following standard CBT (as in the
treatment of depression; see Segal et al., 2002). In considering a
mindfulness meditation intervention for problem gambling, it is critical to
continue to provide treatments that have been shown to be effective. The
benefits of mindfulness training might best be realized when delivered
concurrently with other therapies, or when delivered as an adjunct to help
clients better cope with persisting urges and cravings and prevent the risk
of relapses.
Since gamblers may initially be unaware of the degree to which their
gambling behaviour is associated with irrational beliefs, many of the
standard intake assessment and self-monitoring processes used in CBT are
important as a component of a mindfulness-based approach to working
clinically with the problem gambler. To increase clients' awareness of
gambling-related cognitions and beliefs, several methods are utilized:
(i) A detailed lifetime history of the gambling behaviour is obtained to
highlight key gambling-related automatic thoughts. As part of this
assessment, information is obtained on the onset of problem gambling, basis
of gambling preferences, motivation for gambling, adoption of special
rituals or strategies to increase the chance of winning, the way losses are
accounted for, and so on.
(ii) Clients can be taught to self-monitor their gambling cognitions. To
elicit cognitive distortions prior to gambling episodes, gamblers can be
asked for thoughts pertaining to the probability of winning, how lucky they
believe they are, specific cues or signs that might predict their success,
how the decision of how much money to wager was made, specific rituals or
superstitious behaviours, and so on. Following gambling episodes, gamblers
can be asked to explain why they think they won or lost, the impact of the
outcome on the next episode of gambling, how they would have bet or gambled
differently, why the special ritual or superstitious behaviour did not
succeed, and so on.
(iii) Many of the distorted cognitive processes common in gambling can often
be elicited in the office by asking clients to imagine a characteristic
gambling episode and, with the prompting of the therapist, describe the
cognitive processes guiding gambling-related behaviours, decisions, and
consequences.
Mr. S is married, in his sixties, and the father of four adult children, and
has gambled most of his life. His game of choice has been roulette. When
casinos arrived in his community 5 years ago, he began gambling more
compulsively. Over the past 5 years, he had been visiting the nearest casino
upon the monthly arrival of his pension cheque, which he immediately spent
on gambling. While waiting for his cheque, he experienced a pattern of
preoccupation with gambling consisting of fantasies of winning large sums of
money, feeling "like a winner," and paying off his debts. He believed that,
unlike other patrons, he had a special skill at playing roulette and was
able to control the outcome of a game that he otherwise saw as influenced by
random chance. While playing, his conviction that he could win strengthened
and overwhelmed any incompatible beliefs. When he gambled, he inevitably
lost the money he brought with him (approximately $2,000) within an hour of
his arrival, prompting him to chase his losses by immediately withdrawing
funds from the ATM on-site. During the course of a 24-hour period he
typically lost $10,000. Physically and emotionally exhausted and full of
self-loathing and guilt he would return home to face the anger of his
family. A month later, the cycle would repeat itself. When he finally
presented for treatment he was highly motivated to resolve this problem.
Based on a detailed examination of his gambling episodes, several cognitive
distortions were identified: illusions of control, in which he believed that
he could improve his chances at winning and that he could identify or
develop unique "systems" to win; assumptions that discrete plays of roulette
were connected and that losses would be diluted with wins if he persisted in
playing; and pervasive feelings of superiority to other gamblers. Through a
cognitive analysis Mr. S was able to clearly recognize these beliefs about
gambling and to benefit from straightforward cognitive techniques that
undermined the confidence with which he held these beliefs. He was able to
entertain doubt about each of these beliefs and rationally understand their
fallibility. Furthermore, Mr. S also became acutely aware of the
consequences of his chronic gambling on the mental and physical health of
his wife and children. Instead of dismissing their concerns, he felt guilty
and remorseful that their wellbeing was being so severely affected by his
gambling behaviour.
Despite these cognitive insights and understanding, Mr. S nevertheless found
it difficult to refrain from gambling and had barely reduced his involvement
after several months of treatment. He reported that he was able to
circumvent his clinical understanding by entertaining beliefs that the "next
time" he would win, or that "one more time won't hurt." He continued to
fantasize about winning, generating very intense urges and leaving him
vulnerable to returning to the casino once his cheque arrived. His awareness
of the psychosocial consequences of his gambling diminished during these
periods, especially when his cravings to gamble were intense and compelling.
As an additional component of treatment, Mr. S was agreeable to learning
mindfulness meditation. He was presented with a rationale for this technique
that focused on learning to attend to gambling-related thoughts and feelings
with an attitude of discovery, observation, and dispassionate awareness.
Over the course of several weeks Mr. S mastered the basic techniques of
mindful meditation and breath control and committed himself to a daily
practice routine of 45 minutes. Specifically, he was taught to permit
thoughts related to gambling to arise and subside, initially only while
meditating but eventually throughout the day. He was instructed neither to
"cling" to a thought nor to elaborate it (e.g., fantasize) but to simply
observe that the thought had occurred and to become aware of his breathing.
He was encouraged to note that all thoughts, gambling-related or not, were
very brief, transient, and impermanent, rather than to "react" by
fantasizing, distorting, suppressing, or dismissing. Instead, he was
encouraged to observe his thoughts in the same way he might observe waves
crashing on a shore or clouds drifting across the sky. Mr. S was instructed
to refrain from judging any specific thought or feeling as desirable or not,
watching all of his mental events emerge into his conscious awareness and as
rapidly disappear. Through such practice, he was able to clearly distinguish
himself as the "observer" from the activity of his consciousness, the
"observed."
Equally importantly, his mindfulness skills led him to be more aware of the
thoughts and feelings he had about the consequences of his gambling. These
tended to be dismissed or rationalized away when he was caught in a strong
urge to gamble and would completely disappear while at the casino. By
applying mindfulness skills, he became and remained aware of the harms his
gambling had caused for his significant others. Mr. S also found that as he
diligently practised his mindfulness skills, he was able to apply his
attitude of uninvolved observation of his gambling-related cognitive
processes throughout the day. He found himself responding to gambling
thoughts with amusement, curiosity, and amazement but with reduced
conviction in their validity or, most importantly, the need for a
behavioural reaction on his part. He noted that this attitude generally led
to a rapid dissolution of these thoughts and the elimination of any strong
urges or temptations to gamble. He acknowledged that the gambling thoughts
continued to occur at approximately the same frequency as before treatment
but their intensity or salience in his awareness was much diminished
(analogous to reducing the volume on the radio), and as a result he was able
to make more adaptive decisions (i.e., not gamble). The case of Mr. S was presented to
illustrate the utility and limitations of a cognitive approach. Although
intellectually able to restructure his cognitive distortions related to
gambling, during standard CBT, Mr. S found it difficult to actually modify
his gambling behaviour. This is not an uncommon occurrence in the treatment
of gambling. Recently, Williams and Connolly (2006) found that educating
university students on probability theory (e.g., odds) through the use of
gambling examples produced differences in the ability to calculate gambling
odds and resistance to irrational gambling-related mathematical beliefs
compared to those who were instructed on probability theory generically
(i.e., without the aid of gambling-related examples). However, there was no
effect on gambling behaviour, leading Williams and Connolly (2006) to
conclude that learning mathematical knowledge related to gambling was
unrelated to gambling behaviour.
A missing element of the traditional cognitive therapy approach supplied by
mindfulness training is the practice of a critical metacognitive skill. The
metacognitive skill imparted to Mr. S is an experientially based mindfulness
practice, which demonstrated to Mr. S that his gambling-related cognitions,
which appeared to emerge independently and spontaneously, were distinct from
his mental responses to them. Mr. S was taught a series of skills, including
body scan, mindful yoga postures, sitting meditation, and mindful eating and
walking. He was taught to expand these skills to specific gambling-related
sensations, feelings, and cognitions. Over the course of the therapy, he
learned to replace reacting as he normally would (with excessive
preoccupation and engagement in feelings, sensations, and cognitive
distortions about gambling) with allowing cognitive events to rapidly arise
and subside as they normally do when they are observed, but not interfered
with. The development of this metacognitive skill essentially liberated Mr.
S from the "compulsion" to react to his distortions with actual gambling
behaviour. It also simultaneously allowed him to remain aware of the
negative consequences of his gambling to a greater degree than he would have
otherwise.
The most significant limitation in advocating for the inclusion of a
mindfulness meditation component in treatment for problem gambling is the
lack of empirical evidence. There is considerable research demonstrating the
benefits of mindfulness meditation for other emotional disorders, such as
anxiety, depression, and stress (Toneatto & Nguyen, in press (b)). There are
also a number of treatment programs for more severe mental health issues,
including self-harm and personality disorders, that make cogent arguments
for mindfulness as a clinically potent tool for enhancing self-awareness and
emotion regulation (e.g., Linehan, 1993). Given the potential benefits of
mindfulness for reducing distress and maladaptive engagement in other
impulsive, maladaptive behaviours, mindfulness could conceivably provide
similar benefits to patients engaging in pathological gambling, a group for
whom problem gambling is usually one of a number of mental health or
addiction concerns.
Another important consideration is that for it to be effective, the
instructor must have considerable personal experience with, and maintain an
active practice in, mindfulness meditation. Not all clinicians and,
likewise, not all problem gamblers, can be expected to find the techniques
of mindfulness meditation, which include sitting meditation and the practice
of an attitude of dispassionate observation, desirable or easy to learn.
Such challenges may be particularly evident when working with highly
impulsive or comorbidly diagnosed problem gamblers. To be effective,
mindfulness meditation needs to be practised regularly, on a daily basis if
possible, and over an extended period of time. The problem gambler needs to
be willing to maintain consistent practice to gain the potential benefits of
mindfulness meditation.
In conclusion, mindfulness meditation interventions are compatible with
other psychotherapies, especially the cognitive-behavioural approaches, with
which they share many similarities. Mindfulness also introduces unique
strategies that might serve to enhance the benefits provided by standard
CBT. Mindfulness interventions are likely to continue to attract clinical
and scientific interest and become an additional therapeutic option for the
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& Nguyen, L. (in press (a)). Individual characteristics and problem gambling
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& Nguyen, L. (in press (b)). Mindfulness interventions: Are they indicated
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change gambling behaviour? Psychology of Addictive Behaviors, 20,
62–68. Manuscript
history: submitted: September 13, 2006; accepted: November 1, 2006. This
article was peer-reviewed. For
correspondence: Tony Toneatto, PhD, Clinical Research Department, Center for
Addiction and Mental Health, 33 Russell St., Toronto, Canada M5S 2S1. Phone
416-535-8501 ext. 6828, fax 416-595-6399, e-mail
tony_toneatto@camh.net Contributors:
TT reviewed the literature of cognitive distortions in problem gamblers. LV
developed the case study. LN helped write the section on mindfulness
meditation. All three authors assisted in the writing of the article. Competing
interests: None declared for any of the three authors.
Funding: The
writing of this article was not funded. Tony Toneatto is employeed by CAMH.
Lisa Vettese holds a CIHR-funded post-doctoral fellowship. Linda Nguyen is a
full-time student in the Faculty of Nursing at the University of Toronto. Tony Toneatto
(PhD, clinical psychology, McGill University) is a senior scientist in the
Clinical Research Department at CAMH. He holds a cross-appointment in the
Departments of Psychiatry and Public Health Sciences at the University of
Toronto and is also a registered clinical psychologist in Ontario. His
research interests include the psychology and treatment of problem gambling,
psychiatric comorbidity and addictions, and mindfulness meditation.
Lisa Vettese (PhD, clinical
psychology, York University) is a registered clinical psychologist. She
completed a postdoctoral fellowship focused on mindfulness and addictions,
sponsored by the Canadian Institutes for Health Research, and trainings
through the Centre for Mindfulness Studies at University of Massachusetts
Medical School. Her interests include the integration of
mindfulness into psychotherapy for chronic pain, psychological trauma, and
concurrent mental health and addiction issues. She conducts research at the
Centre for Addiction and Mental Health, and has a private practice
incorporating cognitive-behavioural and mindfulness-based treatment
approaches.
Linda Nguyen (BSc., zoology, University of Toronto) is currently in her
first year in the Faculty of Nursing at the University of Toronto. She is
interested in mindfulness meditation and its application to medical and
emotional disorders, especially anxiety and depression. |
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