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Clinical research on gambling is quite primitive in comparison with research on other addictions or mental disorders. Almost no controlled clinical outcome studies exist, nor does most research have even a comparison group to give the reader a sense of how problem gamblers differ from other distressed groups. With next to no government research funding and little interest from the academic community, what was learned in the first twenty years came mostly from clinical insights of practitioners or preliminary data collection from clinicians with an empirical bent. However, following the seminal work of Robert Custer (Custer & Milt, 1985), clinicians working in the hospital programs with gamblers published descriptive research on problem gambler characteristics, family environments, spouse relationships, personality patterns, and dual addiction issues (Ciarrocchi, 1987; Ciarrocchi & Hohmann, 1989; Ciarrocchi & Richardson, 1989; Ciarrocchi et al., 1991; Ciarrocchi, 1993; Ciarrocchi & Reinert, 1993; Russo et al., 1984; Taber et al., 1987). Lacking the necessary funding for rigorously controlled studies, gambling research has made slow progress. A recent U.S. congressional initiative to study the impact of problem gambling may change this picture. The commission’s recently released report (National Gambling Impact Study Commission, 1999 [online at http://www.ngisc.gov/]) with its vast literature review (National Academy Press, 1999 [online at http://www.nap.edu]) and new population survey (National Opinion Research Center, 1999 [online at http://www.norc.uchicago.edu/]) may provide an impetus for significant research funding. In the meantime, we need to rely on clinical wisdom to understand problem gambling and how it differs from other addictions and mental disorders. Custer often remarked that problem gambling was about 80% similar to substance abuse, but he always added that understanding the 20% difference was crucial. The empirical literature (Chapter 4), however, has not identified as yet that 20%, so we are left to ponder clinical experience.

C O N T E N T S Acknowledgments xiii List of Worksheets xv CHAPTER 1 The Twenty Percent Difference A Clinician’s Experience 2 The Other Twenty Percent 2 Need for a Comprehensive Clinical Mind 4 The Case for a Pragmatic Approach 5 Countertransference and the Three Ways 6 CHAPTER 2 The Scope of Social and Problem Gambling Social and Recreational Gambling 10 Scope of Problem Gambling 15 vii viii Contents CHAPTER 3 Research on Causes and Treatment of Pathological Gambling Introduction 26 Risk Factors 26 Individual Differences: Models and Research 31 General Personality Characteristics 34 Affective–Motivational Variables 36 Cognitive Distortions 38 Treatment Approaches 43 CHAPTER 4 A Self-Regulation Model for Understanding Pathological Gambling Advantages of Self-Regulation Theory 52 Self-Regulation Theory: General Features 53 Self-Regulation Theory: Specific Mechanisms 55 Risk-Taking: The Missing Ingredient in a Comprehensive Understanding of Pathological Gambling 60 The Downside of Egotism 61 The Psychological Function of Self-Esteem 62 Summary 63 CHAPTER 5 Diagnosis and Assessment of Pathological Gambling Pathological Gambling and the DSM 68 The Clinical Picture 69 DSM Criteria 72 Robert Custer and Stages of Gambling 78 Gambling Assessment Instruments 79 Gambling Subtypes 82 Problem Versus Nonproblem Gambling 84 Contents ix Comorbidity 85 Personality Assessment of Pathological Gamblers 86 Appendix The Lifetime NORC DSM-IV Screen for Gambling Problems 96 The South Oaks Gambling Screen 101 CHAPTER 6 Overview of Clinical Interventions: A Plea for Family Involvement Empirical Basis 106 Treatment Modalities 106 Format 108 CHAPTER 7 Motivational Enhancement, Stages of Change, and Goal-Setting The Context of Motivational Enhancement 110 Origins of Motivational Enhancement 111 Stages-of-Change Model 112 Strategies Used to Change 116 Motivational Enhancement Approach 116 Motivational Enhancement and Goal-Setting 124 Worksheet 7.1: Consequences of Gambling Checklist 129 Worksheet 7.2: Decisional Balance 130 Worksheet 7.3: Abstinence/Recovery Goal-Setting 131 Worksheet 7.4: Occupational Goal-Setting 132 Worksheet 7.5: Family Goal-Setting 133 Worksheet 7.6: Relationship Goal-Setting 134 Worksheet 7.7: Health Goal-Setting 135 Worksheet 7.8: Financial Goal-Setting 136 Worksheet 7.9: Recreational/Entertainment Goal-Setting 137 Worksheet 7.10: Spiritual/Religious/Personal Character Goal-Setting 138 Worksheet 7.11: Goals-Summary 139 Worksheet 7.12: Goal-Planning 140 Worksheet 7.13: Resolving Goal Conflicts 141 x Contents CHAPTER 8 Abstinence Control and Relapse Prevention Building a Fence Around Temptation 144 Defining Abstinence Control 145 Stimulus Control Assessment 147 Stimulus Control and Environmental Management 149 Summary 154 Worksheet 8.1: Gambling Triggers 155 Worksheet 8.2: Coping with Relapse: Lapse/Slip Analysis 156 Worksheet 8.3: Gambling Behavior Warning Signs 157 Worksheet 8.4: Coping with Relapse: Containing a Slip by Stopping Snowballing 158 CHAPTER 9 Managing Urges Through Acceptance Cravings and Self-Regulation Theory 160 Acceptance Rationale 161 Rehearsal 163 Implementing Acceptance and Urge Surfing 165 Worksheet 9.1: Emotion Regulation: Introduction to Urge Surfing: Rehearsal 167 Worksheet 9.2: Emotion Regulation: Acceptance—Urge Surfing 168 CHAPTER 10 Depression, Anxiety, and Guilt: Cognitive Strategies Anxiety Management 170 Managing Depression 173 Managing Guilt Feelings 176 Summary 180 Worksheet 10.1: Challenging Beliefs Leading to Negative Feelings 181 CHAPTER 11 Changing Beliefs About Gambling: The Downside of Hope Introduction 184 Application 184 Evaluating Client Beliefs 185 Challenging Gambling Beliefs 186 Worksheet 11.1: List of Beliefs About Gambling and Reasons for Gambling 192 Worksheet 11.2: Gambling Beliefs and Reasons 193 Worksheet 11.3: Gambling Timeline 194 CHAPTER 12 Problem-Solving and Overcoming Procrastination Introduction 196 Problem-Solving 196 Format 197 Description of the Current Problem 197 Generating Solutions 199 Implementing the Solution 201 Evaluate the Solution 201 Overcoming Procrastination 202 Summary 206 Worksheet 12.1: Problem-Solving 207 Worksheet 12.2: Changing Behavior: Procrastination Analysis 209 Worksheet 12.3: Procrastination Change 210 CHAPTER 13 Financial and Legal Issues Overview 214 Managing Financial Issues 214 Legal and Forensic Issues 219 Contents xi CHAPTER 14 Couples and Family Treatment Family Scenarios 226 Pathological Gambling Patients and Families: Different Perspectives 227 Couples Therapy for Pathological Gambling 232 Model Overview 234 Working with Family Members Alone 240 Countertransference Issues 245 CHAPTER 15 Spirituality, Virtue, and Character: A Model for Therapist Collaboration in Long-Term Growth Rationale for Chapter 248 Religion and Spirituality: Model and Definition 250 Therapeutic Interface with Spirituality 254 Interventions for Building Character–Virtue 266 Worksheet 15.1: Truthfulness 268 Worksheet 15.2: Responsible Conscience 269 Worksheet 15.3: Humility 270 Worksheet 15.4: Justice 271 Worksheet 15.5: Courage 272 Worksheet 15.6: Temperance 273 Worksheet 15.7: Implementing Goals Assessment 274 Worksheet 15.8: Virtue Diary 275 References 277 APPENDIX A National Council on Problem Gambling Affiliate List 293 APPENDIX B Worksheets 301 Index 339

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