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Node-link-mapping-enhanced group treatment for pathological gambling
Addictive Behaviors 29 (2004) 73 – 87
Node-link-mapping-enhanced group treatment for pathological gambling Cam L. Melville*, Carolyn S. Davis, Dena L. Matzenbacher, Jeremy Clayborne Department of Psychology, McNeese State University, P.O. Box 91895, Lake Charles, LA 70609-1895, USA
Abstract Two experiments evaluated a group treatment for pathological gambling that used node-link mapping techniques to enhance treatment effectiveness. In Experiment 1, 13 (8 female) pathological gamblers were randomly assigned to either a mapping group (n = 4), a nonmapping group (n = 4), or a wait-list control group (n = 5). The treatments were conducted by Master’s level counselors during 90min sessions conducted twice per week for 8 weeks. Participants were assessed pre- and post-8 weeks and then 6 months later on Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) pathological gambling criteria, three self-ratings of control of gambling, gambling expenditure, and gambling bout duration. Experiment 2 replicated the mapping (n = 9; 8 female) and wait-list (n = 10; 8 female) conditions of Experiment 1 and expanded the dependent measures to include assessment of changes in cooccurring depression and anxiety. The node-link-mapping-enhanced group treatment produced improvements in more of the dependent measures of pathological gambling than treatment without maps (Experiment 1) or an equivalent-length waiting period (Experiments 1 and 2). It also produced larger decreases in cooccurring depression and anxiety than an equivalent-length waiting period (Experiment 2). The results are consistent with previous treatment research with substance abusers. D 2003 Elsevier Ltd. All rights reserved. Keywords: Pathological gambling; Treatment; Depression; Anxiety
* Corresponding author. Tel.: +1-337-475-5462; fax: +1-337-475-5467. E-mail address: [email protected] (C.L. Melville). 0306-4603/$ – see front matter D 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0306-4603(03)00091-1
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1. Introduction Pathological gambling is defined by the Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) (APA, 1994) as an impulse control disorder. The description of pathological gambling includes a preoccupation with gambling, reduction in the ability to control gambling, dishonesty about gambling and its consequences, and increasing amounts wagered following losses. While defined as an impulse control disorder, pathological gambling shares many of the characteristics of substance addictions, including tolerance (e.g., Dickerson, 1984; Griffiths, 1993) and withdrawal (e.g., Wray & Dickerson, 1981). In fact, the DSM-IV criteria for pathological gambling borrow heavily from the criteria for alcohol dependence. Pathological gamblers are likely to experience a number of financial, legal, and occupational problems (e.g., Lesieur, 1998). Moreover, a number of studies have shown that pathological gambling is associated with high rates of cooccurring psychiatric disorders (e.g., Crockford & el-Guebaly, 1998; Specker, Carlson, Edmonson, Johnson, & Marcotte, 1996). High rates of depression (e.g., Black & Moyer, 1998; Linden, Pope, & Jonas, 1986), suicide ideation (e.g., McCormick, Russo, Ramirez, & Taber, 1984), substance abuse (e.g., Lesieur, 1998; McCormick et al., 1984), and anxiety (e.g., Black & Moyer, 1998) have been observed among individuals with pathological gambling. Recent treatment outcome studies have demonstrated that symptoms of pathological gambling improve following gambling specific cognitive–behavioral treatment delivered during individual counseling sessions (e.g., Sylvain, Ladouceur, & Boisvert, 1997). However, little information is available about group treatment for pathological gambling. This is surprising because group treatment is often the format for gambling treatment in community settings (e.g., Twelve-Step Facilitation; Gamblers Anonymous). Group treatment is likely to cost less per gambler and pathological gamblers have reported a preference for group-based therapy over individual therapy following exposure to both (Lesieur & Blume, 1991; SaizRuiz, Moreno, & Lopez-Ibor, 1992). Group-based treatment may be an important treatment tool if it can be shown that group treatment for pathological gambling is effective. Recently, Melville, Davis, and Matzenbacher (2000) developed a node-link-mappingenhanced group treatment for pathological gambling. Node-link mapping is a visual representation technique designed to highlight interrelations between thoughts, emotions, actions, and environmental influences. In addictions treatment, these interrelations are complex and difficult to represent with the natural language used in standard counseling. The visual display produced by a node-link map allows for simultaneous representation of multiple relations, modulating influences, along with short- and long-term behavioral outcomes. The map allows for clearer communication and more focused collaborative problem solving between counselor and client than natural language. Node-link mapping was originally developed for use in substance abuse treatment (e.g., Dansereau, Dees, Greener, & Simpson, 1995; Dees, Dansereau, & Simpson, 1997) and has been shown to decrease the number of positive urine screens for both opiate and cocaine addicts (Dansereau, Joe, & Simpson, 1993; Joe, Dansereau, & Simpson, 1994; Simpson, Dansereau, & Joe, 1997). Mapping-enhanced counseling may have particular promise for the treatment of pathological gambling. For example, pathological gambling has high rates of occurrence within
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minority populations (e.g., National Research Council, 1999), is associated with high rates of criminal activity (e.g., National Research Council, 1999), and has high treatment drop-out rates (e.g., Echeburua, Baez, & Fernandez-Montalvo, 1996; Sylvain et al., 1997). Node-linkmapping-enhanced counseling for substance abuse has been shown to decrease racial and cultural communication barriers (e.g., Dansereau, Joe, Dees, & Simpson, 1996), to decrease criminal activity (e.g., Joe, Dansereau, Pitre, & Simpson, 1997), and to decrease treatment drop-out rates (Dansereau et al., 1993) when compared to standard counseling. The group treatment for pathological gambling developed by Melville et al. (2000) uses node-link mapping techniques to focus 24 h of group counseling in the three topic areas (8 h per topic) identified by Sylvain et al. (1997) as important targets for change. The three topic areas include understanding randomness, problem solving, and relapse prevention. In the understanding randomness section, the factual characteristics of randomness are identified and the relations between randomness, games of chance, and the participant’s behavior (e.g., illusion of control, superstition, chasing) are mapped. Instructional maps (with nodes filled in) are used to teach the factual characteristics of each participant’s preferred game along with the most likely outcome of play. In the problem solving section, node-link maps are used to demonstrate a systematic problem solving strategy in six problem categories. Participants identify and solve problems via node-link maps in financial management, relationship, legal, family, employment, and social problem categories. In the relapse prevention section, nodelink maps are used to separately identify situations high-risk for relapse to gambling and develop alternative coping strategies for each situation. Each participant then develops and maps a specific behavior change plan. Fig. 1 presents an example of a node-link map from the understanding randomness section of the treatment manual (Melville et al., 2000). This node-link map is presented to the client with the top and bottom nodes filled in. The client identifies five or more personal superstitions related to his/her gambling behavior. Then the client, counselor, and group collaboratively examine how each superstition interacts with the random characteristics of the game. Specifically, the superstition will be followed by a win often enough to lead to (L) an
Fig. 1. Example of a node-link map with client response. See text for description.
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illusion of control over the outcome of the game. Subsequent node-link maps examine how an illusion of control leads to continued play in spite of losses. In the present study, two experiments examined the efficacy of this node-link-mappingenhanced group treatment. Experiment 1 compared the mapping-enhanced group treatment to the same treatment without maps, and to a wait-list control group on measures of pathological gambling. Experiment 2 replicated the mapping and wait-list conditions of Experiment 1 and extended the dependent measures to include cooccurring depression and anxiety.
2. Experiment 1 2.1. Method 2.1.1. Participants Twenty gamblers responded to a recruitment advertisement displayed on the front page of a local newspaper. The gamblers identified slot machines (62%) or video poker (38%) as their primary gambling activity. The sample was primarily female (69%), white (85%), married (75%), and employed (90%). These demographic characteristics are similar to previous reports of treatment-seeking samples of pathological gamblers (e.g., Wiebe & Cox, 2001). During the intake interview, gamblers were evaluated on DSM-IV criteria and the South Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1987). Each gambler met DSM-IV criteria for pathological gambling as established by the clinical interview and scored in the pathological range (five or more) on the SOGS. Previous treatment for gambling was limited to a single session of Gamblers Anonymous reported by one participant. Seven gamblers (three female, four male) refused to participate following the intake interview. Similar refusal rates have been observed in previous treatment outcome studies of pathological gambling (e.g., Sylvain et al., 1997). Thirteen participants (five male, eight female) were assessed as described below and then randomly assigned to either a node-link mapping group (n = 4), a nonmapping group (same counseling content without maps) (n = 4), or a wait-list control group (n = 5). An additional four pathological gamblers were referred by a residential treatment program for pathological gambling to a local addictions treatment clinic. Following an assessment interview these participants were exposed to the node-link mapping enhanced treatment in the community setting [mapping (referral)] (n = 4). The average age of participants in each of the groups was 68 (range 53–77) for the mapping group, 52 (range 33–67) for the nonmapping group, 53 (range 47–62) for the control group, and 50 (range 34–62) for the mapping (referral) group. 2.1.2. Assessment Individual assessment interviews were conducted at intake prior to the first counseling session (pretreatment) following 8 weeks of treatment or waiting period (posttreatment), and at 6 months after treatment for those participants randomly assigned to a treatment condition (i.e., mapping and nonmapping groups). Pre- and posttreatment interviews were conducted face to face. Six-month follow-up interviews were conducted face to face or by phone.
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The dependent measures assessed during the assessment interviews included the number of DSM-IV criteria met as established by clinical interview and self-ratings of control of gambling measured on 10-point scales as suggested by Sylvain et al. (1997). Participants rated their ability to control gambling from ‘‘no control’’ to ‘‘all control,’’ and their desire to gamble from ‘‘no desire’’ to ‘‘intense desire.’’ Similarly, participants rated their ability to refrain from gambling in two personally relevant situations from ‘‘unable to refrain’’ to ‘‘able to refrain.’’ Participants also reported the number of times gambled, the number of hours spent gambling, and the number of sessions of Gamblers Anonymous attended (or other treatment for problem gambling) in the past 30 days. Participants were asked ‘‘How much have you spent on gambling in the past 30 days?’’ Assessment personnel were Master’s level interns specifically trained and blind to the conditions of the experiment. 2.1.3. Treatment conditions Following the intake assessment, each participant met individually with their counselor for 30 min. During this session the counselor provided a description of the format for the group counseling sessions along with session dates and times. The counselor emphasized the importance of confidentiality and the participant signed a promise to keep information revealed in the group confidential. At the end of this session participants also tape-recorded thoughts that occurred during an episode of imagined gambling (e.g., Sylvain et al., 1997) for use later in treatment. The treatment groups received manual guided treatment based on Melville et al. (2000). The mapping groups received mapping-enhanced counseling and the nonmapping group received the same treatment content without maps (natural language). For the nonmapping group, the treatment manual was modified to exclude node-link maps. Both mapping and nonmapping group sessions were 90 min in length, conducted twice per week for eight consecutive weeks. Counselors completed a checklist of topic maps completed (mapping group) or topics discussed (nonmapping group) at the end of each session. As the manual presents topics in a highly structured format the checklists indicated that topics were mapped or discussed in the order intended. Participants assigned to the control group were informed that because of random assignment they were placed on a waiting list. They were also informed that the treatment group to which they had been assigned would begin in 8 weeks. Each treatment group was conducted by a Master’s level counselor. Counselors were blind to the conditions of the experiment. They were provided 8 h of training in either the mappingbased treatment or the same treatment without mapping. Training was conducted by the first author. 2.2. Results and discussion Table 1 presents the group means for the mapping, nonmapping, control, and mapping (referral) groups on the number of DSM-IV criteria met, self-ratings of ability to control and refrain from gambling, and desire to gamble. Visual examination of Table 1 shows that the pathological gamblers exposed to mapping-enhanced group treatment met fewer DSM-IV
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Table 1 Group means for the number of DSM-IV criteria, self-ratings of ability to control and refrain from gambling, and desire to gamble at each assessment interval DSM-IV
Ability to control
Ability to refrain
Desire to gamble
Pre Post 6 months Pre Post 6 months Pre Post 6 months Pre Post 6 months Treatment Mapping Nonmapping Control Mapping (referral)
7.3 7.8 6.8 7.8
0.25 0.25 2.0 2.8 4.4 – 1.0 –
3.0 2.8 3.8 3.8
9.0 6.8 5.6 7.3
8.75 6.3 – –
2.6 6.1 1.9 4.0
9.3 6.6 3.1 7.1
9.0 6.1 – –
9.5 7.3 6.2 7.3
1.8 5.5 6.4 2.5
2.0 6.0 – –
diagnostic criteria at posttreatment than either the nonmapping group or the control group. The self-rated ability to control gambling and the ability to refrain from gambling increased from pre- to posttreatment for each group. The desire to gamble decreased from pre- to posttreatment for each treatment group, whereas a slight increase was observed for the control group. The size of the changes for these self-ratings was larger for the mapping groups than for either the nonmapping or control groups. These treatment effects were retained at 6-month follow-up. The data were analyzed using a repeated-measures multivariate analysis of variance (MANOVA). The MANOVA allows for a comprehensive analysis of pre- to posttreatment or pretreatment to 6-month follow-up changes on multiple related dependent measures in each group. Examining the changes for each group is important because little is known about the effects of treatment or the effects of wait-list assignment. A MANOVA applied to the four dependent variables in Table 1 pre- and posttreatment revealed a significant Group Time interaction [ F(3,24) = 3.38, P < .05]. Follow-up repeated-measures analysis of variance (ANOVA) revealed significant interactions for DSM-IV [ F(1,10) = 5.63, P < .05], ability to refrain [ F(1,10) = 9.51, P < .05], and desire to gamble [ F(1,10) = 6.93, P < .05]. Such interactions indicate that the groups exhibited different patterns of change from pre- to posttreatment. A significant interaction was not observed for ability to control gambling. For the mapping group, follow-up t tests revealed significant pre- to posttreatment changes on the DSM-IV criteria [t(3) = 29.0, P < .001], ability to control gambling [t(3) = 4.9, P < .05], ability to refrain [t(3) = 5.62, P < .05], and desire to gamble [t(3) = 10.33, P < .01]. For the nonmapping group, follow-up t tests revealed significant pre- to posttreatment changes on the DSM-IV criteria [t(3) = 3.38, P < .05] and change that approached significance on the ability to control gambling [t(3) = 2.95, P=.06]. For the control group, follow-up t tests revealed a single significant pre- to posttreatment change on DSM-IV criteria [t(3) = 3.21, P < .05]. The presence of statistically significant pre- to posttreatment changes for each group obscures the contribution of treatment. Therefore, the posttreatment means were compared using a one-way analysis of covariance (ANCOVA). The ANCOVA was conducted with group as the independent variable, posttreatment score as the dependent variable, and pretreatment score as the covariate. This analysis allowed posttreatment scores to be compared irrespective of any group differences that may have existed prior to treatment. The ANCOVA revealed significant differences in the posttreatment means for DSM-IV
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[ F(2,9) = 4.55, P < .05], ability to control [ F(2,9) = 7.85, P < .05], and desire to gamble [ F(2,9) = 6.93, P < .05]. A significant difference was not observed for ability to control gambling. The t tests revealed significant differences between the mapping and control groups for DSM-IV [t(7) = 3.1, P < .05] and ability to refrain [t(7) = 3.2, P < .05]. The mapping (referral) group was not included in the statistical analyses because its participants were not randomly assigned. A second MANOVA applied to the pretreatment and 6-month follow-up scores for the mapping and nonmapping groups revealed a significant Group Time interaction [ F(2,16) = 35.66, P < .05]. Follow-up repeated-measures ANOVAs revealed significant interactions for the ability to refrain [ F(1,6) = 22.83, P < .01] and desire to gamble [ F(1,6) = 26.41, P < .01], indicating that the two groups exhibited different patterns of change from pretreatment to 6-month follow-up. Significant interactions were not observed for DSMIV criteria or control of gambling. For the mapping group, follow-up t tests revealed significant pre- to 6-month follow-up changes on the DSM-IV criteria [t(3) = 17.15, P < .01], ability to control [t(3) = 5.79, P < .05], ability to refrain [t(3) = 11.36, P < .01], and desire to gamble [t(3) = 11.62, P < .01]. For the nonmapping group, follow-up t tests revealed only one significant difference for number of DSM-IV criteria [t(3) = 3.4, P < .05]. Table 2 presents the group means for gambling bout duration and expenditure for the mapping, nonmapping, and control groups. Gambling bout duration was calculated by dividing the number of hours spent gambling in the 30 days prior to the assessment by the number of gambling bouts during the same period. Posttreatment gambling expenditure was calculated as a percentage of baseline expenditure by dividing the amount spent on gambling during the 30 days prior to the posttreatment assessment by the amount established at pretreatment. Visual examination of Table 2 shows that gambling bout duration decreased from pre- to posttreatment for each group. The size of the decrease was larger for the mapping group than for the nonmapping or control groups. Similarly, expenditure decreased from pre- to posttreatment for each group with larger decreases observed for the mapping group than for the nonmapping or control groups. These treatment effects were retained at 6-month follow-up. The t tests applied to the bout durations in Table 2 revealed significant pre- to posttreatment changes for the mapping group (t = 4.02, P < .05) but not for the nonmapping or control groups. Similarly, a t test also revealed significant pretreatment to 6-month follow-up changes for the mapping group (t = 5.29, P < .05) but not for the nonmapping or control groups. The t tests applied to the expenditures in Table 2 revealed significant pre- to posttreatment changes for the mapping group (t = 5.01, P < .05), nonmapping group (t = 5.13, P < .05), and Table 2 Group means for gambling bout duration and gambling expenditure at each assessment interval Gambling bout duration Treatment Mapping Nonmapping Control
Expenditure (percentage of baseline)
Pre
Post
6 months
Pre (%)
Post (%)
6 months (%)
4.5 5.3 6.5
0.6 2.8 3.6
0.25 2.8 –
100 100 100
18 22 23
1 13 –
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control group (t = 4.44, P < .05). A t test also revealed significant pretreatment to 6-month follow-up changes for both the mapping group (t = 99.0, P < .001) and the nonmapping group (t = 12.64, P < .05) but not for the control group.
3. Experiment 2 Experiment 1 demonstrated that a node-link-mapping-based group treatment was effective with a small sample of pathological gamblers. Experiment 2 replicated the node-link mapping and wait-list conditions of Experiment 1 with a larger sample and extended the dependent measures to include measures of cooccurring depression and anxiety. The depression and anxiety measures were included as additional indicators of improved functioning following exposure to treatment. It is important to include these measures of cooccurring disorders for at least two reasons. First, both depression and anxiety have been observed to frequently cooccur with pathological gambling (e.g., Black & Moyer, 1998; Crockford & el-Guebaly, 1998; Linden et al., 1986; Specker et al., 1996). For example, Specker et al. (1996) reported high levels of depression (48%) and anxiety (60%) within their outpatient-treatment-seeking sample. Second, some authors have argued that addictive behavior, including pathological gambling, is triggered by negative mood states such as depression or anxiety (e.g., Cummings, Gordon, & Marlatt, 1980; Marlatt & Gordon, 1985; McCormick, 1994). In fact, Cummings et al. (1980) reported that negative emotion was the most frequent relapse trigger for pathological gambling, accounting for 47% of relapses. To the extent that treatment reduces negative mood states, the number of high-risk situations for relapse should also be reduced. 3.1. Method 3.1.1. Participants The recruitment procedure and participant inclusion criteria used in Experiment 1 were used in Experiment 2. Twenty-eight gamblers responded to the recruitment advertising. Gamblers identified video poker most often as their primary gambling activity (39%), followed by slot machines (36%), black jack (14%), and other casino games (11%). The sample was primarily female (76%), white (89%), married (79%), and employed (93%). As in Experiment 1, these demographics are similar to previous reports of treatment-seeking samples of pathological gamblers (e.g., Wiebe & Cox, 2001). Three gamblers were excluded because they did not meet criteria for pathological gambling. Six gamblers refused to participate following the intake interview. Previous treatment for gambling was reported by only one participant who had attended two sessions of Gamblers Anonymous. Nineteen participants (3 male, 16 female) were assessed and then randomly assigned to either a node-link mapping group (n = 9) or to a wait-list control group (n = 10). The average age of participants in each of the groups was 51 (range 38–68) for the mapping group and 54 (range 35–63) for the control group.
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3.1.2. Assessment The same assessment procedure used in Experiment 1 was used in Experiment 2 except that measures of depression and anxiety were added to the assessment interview and participants were asked to list any prescription medication they were taking. The Beck Depression Inventory-II (BDI-II) was used as a measure of depression. The BDI-II is a 21item self-report instrument based on DSM-IV criteria that provides a reliable and valid measure of depression (e.g., Beck, Steer, & Brown, 1996). The Beck Anxiety Inventory (BAI) was used as a measure of anxiety. The BAI is a 21-item self-report instrument that provides a reliable and valid measure of anxiety (e.g., Beck & Steer, 1993). Experiment 2 included the same counselor training procedures and treatment conditions as those used in Experiment 1 for the mapping group and control group. 3.2. Results and discussion Table 3 presents the group means for DSM-IV criteria, self-ratings of ability to control and ability refrain from gambling, and desire to gamble. Visual examination of Table 3 shows that the pathological gamblers in Experiment 2 exposed to mapping-enhanced group treatment met fewer DSM-IV diagnostic criteria at posttreatment than the control group. As in Experiment 1, the self-rated ability to control gambling and the ability to refrain from gambling increased for both groups. The size of the increase was larger for the mapping group than for the control group. Desire to gamble decreased from pre- to posttreatment for the mapping group but increased pre- to posttreatment for the control group. In general, treatment effects for the mapping group were retained at 6-month follow-up. A MANOVA applied to the four dependent measures in Table 3 at pre- and posttreatment revealed a significant Group Time interaction [ F(2,16) = 5.01, P < .05]. Follow-up ANOVAs revealed significant interactions for DSM-IV criteria [ F(1,17) = 19.87, P < .05], ability to control gambling [ F(1,17) = 6.33, P < .05], ability to refrain [ F(1,17) = 7.73, P < .05], and desire to gamble [ F(1,17) = 9.68, P < .05]. Such interactions indicate that the groups exhibited different patterns of change from pre- to posttreatment. For the mapping group, follow-up t tests revealed significant pre- to posttreatment changes on DSM-IV criteria (t = 5.15, P < .05), ability to control (t = 4.811, P < .05), ability to refrain from gambling (t = 5.32, P < .05), and desire to gamble (t = 2.32, P < .05). Significant pre- to posttreatment changes were not observed for the control group.
Table 3 Group means for the number of DSM-IV criteria met, self-ratings of ability to control and ability to refrain from gambling, and desire to gamble at each assessment interval DSM-IV Pre Treatment Mapping 6.3 Control 5.8
Ability to control
Ability to refrain
Desire to gamble
Post
6 months
Pre
Post
6 months
Pre
Post
6 months
Pre
Post
6 months
1.4 6.6
1.6 –
3.4 3.5
8.9 5.2
7.8 –
3.3 4.2
8.7 4.4
7.5 –
6.6 7.0
2.8 8.7
4.4 –
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Table 4 Group means for gambling bout duration and gambling expenditure at each assessment interval Gambling bout duration Treatment Mapping Control
Expenditure (percentage of pretreatment)
Pre
Post
6 months
Pre (%)
Post (%)
6 months (%)
3.9 4.5
2.0 4.6
1.0 –
100 100
23 98
31 –
For the mapping group, t tests revealed significant pretreatment to 6-month follow-up changes on DSM-IV criteria [t(7) = 5.61, P < .01], ability to control gambling [t(7) = 2.61, P < .05], and ability to refrain [t(7) = 3.74, P < .01]. Differences were not observed for the pretreatment to 6-month follow-up scores on participants’ desire to gamble. Table 4 presents the group means for gambling bout duration and expenditure for the mapping and control groups. Data in Table 4 were calculated and are presented as in Table 2 for Experiment 1. Visual examination of Table 4 shows that gambling bout duration decreased from pre- to posttreatment for the mapping group, whereas bout duration for the control group increased slightly. Expenditure decreased from pre- to posttreatment for each group. The size of the decrease was larger for the mapping group than for the control group. The treatment effects observed for the mapping group were retained at 6-month follow-up. The t tests revealed that the pre- to posttreatment changes in bout duration were not significant for either the mapping or the control group. A t test applied to the pretreatment and 6-month follow-up bout durations for the mapping group approached significance [t(7) = 2.24, P=.06]. One participant did not report bout duration at the 6-month follow-up. The t tests revealed significant reductions from pretreatment expenditure for the mapping group at both posttreatment [t(8) = 8.53, P < .05] and 6-month follow-up [t(7) = 3.58, P < .05]. One participant did not report expenditure at the 6-month follow-up. Statistically significant changes were not observed for the control group. Table 5 presents the mean depression and anxiety scores for the mapping and control groups. Visual examination of Table 5 shows that depression scores decreased pre- to posttreatment for the mapping group, whereas depression scores for the control group did not change. Likewise, anxiety scores decreased for both the mapping and control groups with larger decreases observed for the mapping group. In general, these treatment effects were retained at 6-month follow-up for the mapping group.
Table 5 Group means for depression and anxiety scores at each assessment interval Depression score Treatment Mapping Control
Anxiety score
Pre
Post
6 months
Pre
Post
6 months
23.7 31.4
7.4 30.7
3.3 –
17.4 26.5
6.0 18.6
3.8 –
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Repeated-measures ANOVAs applied to the data in Table 5 revealed significant Group Time interactions for both depression [ F(1,17) = 10.44, P < .05] and anxiety [ F(1,17) = 5.72, P < .05]. For the mapping group, follow-up t tests revealed significant pre- to posttreatment changes in both depression [t(8) = 3.47, P < .01] and anxiety [t(8) = 2.53, P < .05]. Significant pre- to posttreatment changes in depression and anxiety were not observed for the control group. The t tests also revealed significant pretreatment to 6-month follow-up changes on depression [t(6) = 2.84, P < .05]. The pretreatment to 6-month follow-up changes observed for anxiety approached significance [t(6) = 2.19, P=.07]. Two participants were excluded from these analyses because they did not provide 6-month follow-up information on depression and anxiety.
4. General discussion The node-link-mapping-enhanced group treatment for pathological gambling used in the present study (e.g., Melville et al., 2000) produced improvements in more of the dependent measures of pathological gambling than treatment without maps (natural language) (Experiment 1) or an equivalent-length waiting period (Experiments 1 and 2). The mappingenhanced treatment also produced larger decreases in cooccurring depression and anxiety than an equivalent-length waiting period. In fact, 71% of those in this treatment group had depression and anxiety scores that were reduced to subclinical levels. From a clinical perspective, all 17 of the pathological gamblers in Experiments 1 and 2 exposed to the mapping-enhanced group treatment improved by at least 67% on the DSM-IV criteria compared to only 2 of 15 in the control groups. The improvements observed likely reflect the effect of the current treatment because participants reported they did not participate in any other forms of treatment during the study. It is important to note that the mapping group in Experiment 1 was older than the other groups. It is possible that the improvement observed for this group was due to nonspecific factors related to age (e.g., natural recovery). However, this explanation is highly speculative given the paucity of research on the effects of age on treatment seeking or treatment outcome with pathological gamblers. These results are consistent with previous research on node-link mapping with substance abusers. Previous research on mapping-enhanced counseling in substance abuse treatment has demonstrated that mapping results in improvements that are often dramatic. For example, Dees et al. (1997) observed larger reductions in drug use among clients exposed to node-link mapping than among clients exposed to standard counseling. Similarly, in the present study, large reductions in gambling bout duration and expenditure were more consistently observed following exposure to the mapping-enhanced group treatment than following exposure to group treatment without maps or 8-week waiting period. For example, in Experiment 1, the reduction in gambling bout duration following exposure to mapping-enhanced group treatment was nearly twice as large as the reductions observed for the nonmapping group (at posttreatment and 6-month follow-up) and the control group (at posttreatment). For the mapping-enhanced group in Experiment 2, gambling bout duration had decreased by 49% at the posttreatment assessment and by 74% at the 6-month follow-up.
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Large reductions in gambling expenditure were also observed following exposure to the mapping-enhanced group treatment. For example, expenditure decreased by 97% and 89% for the mapping groups in Experiments 1 and 2, respectively. Smaller, but notable, decreases in expenditure were also observed for the nonmapping and control groups in Experiment 1 and control group in Experiment 2, with decreases of 89%, 78%, and 28%, respectively. The reductions observed in the control group suggest that gambling expenditure may also decrease following assessment of gambling behaviors and/or commitment to treatment. One possibility is that the inquiry into personal gambling history highlights the amount lost to gambling, thus increasing motivation to reduce gambling expenditure. In addition, clinical observation during assessments suggested that some participants may have difficulty with accurate recall of dollar amounts spent on gambling during the preceding 30 days. Future studies in this area may consider the use of a more structured assessment of previous expenditure, such as the time-line follow-back method (e.g., Sobell & Sobell, 1992). The present results are also consistent with previous research on the treatment of pathological gambling that used gambling-specific cognitive–behavioral therapy during individual counseling sessions. For example, Sylvain et al. (1997) used individual counseling procedures to expose pathological gamblers to cognitive correction and skill building in the same three target areas as in the present group treatment. For their treatment group at posttreatment, DSM-IV criteria were below pathological levels, the ability to control and refrain from gambling had significantly increased, and desire to gamble had significantly decreased, compared to the wait-list control group. Likewise, in both Experiments 1 and 2 of the present study, each of the four measures of control over gambling (i.e., DSM-IV criteria, ability to control, ability to refrain, desire to gamble) showed significant improvement following exposure to the mapping-enhanced group treatment. By comparison, change was observed in only one measure (DSM-IV criteria) for the nonmapping and control groups in Experiment 1. While speculative, it is possible that the mapping techniques used in the present study serve to individualize the sessions even though the topics are presented in a group context. Clients are taught these mapping strategies as a group, and are encouraged to have open discussion of the maps; however, each client completes maps that are specific to their own situation. Thus, counselors (or clients) can capitalize on the individualized problem solving focus of individual counseling in the context of a supportive group environment. However, this explanation may be simplistic because the maps used in the present study provide unique opportunities for pathological gamblers to examine clinically relevant information. For example, the mapping-enhanced group treatment used instructional maps (with nodes filled in) to expose the odds of particular outcomes given a particular strategy of play for each participant’s preferred game (e.g., Toneatto & Sobell, 1990). Future research will need to examine the contribution of specific components of the treatment approach to treatment outcome. Previous research has also demonstrated high rates of cooccurring depression and anxiety in treatment-seeking samples of pathological gamblers (e.g., Specker et al., 1996). Similarly, high rates of depression and anxiety were observed in Experiment 2 of the present study.
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Seventy-six percent of the pathological gamblers in Experiment 2 had pretreatment depression scores in the moderate to severe range, and eighty-eight percent had pretreatment anxiety scores in the moderate to severe range. Previous research has demonstrated improvement in cooccurring depression (e.g., Echeburua et al., 1996) and anxiety (e.g., Echeburua et al., 1996; Sharpe & Tarrier, 1992) following treatment for pathological gambling. The results of the present study suggest that measures of depression and anxiety are sensitive to improved functioning produced by mapping-enhanced treatment. For example, Table 5 shows that depression scores at posttreatment decreased significantly to minimal levels following exposure to the mapping-enhanced group treatment and remained at minimal levels at the 6-month follow-up. Depression scores for the pathological gamblers in the wait-list condition did not change. Table 5 also shows that anxiety scores at posttreatment decreased significantly following exposure to the mapping-enhanced group treatment. Anxiety scores for the pathological gamblers in the wait-list condition did not change. The present study does not isolate the treatment factors that produced the decreases in depression and anxiety. However, the decreases cannot be attributed to pharmacological effects of prescribed medication. None of the participants reported the use of anti-anxiety or antidepressant medication at posttreatment or 6-month follow-up. Future studies will need to determine the mechanism by which treatment produced these improvements. Finally, the present study included a group of pathological gamblers referred for after-care to a community clinic following completion of a 36-day residential treatment program for pathological gambling. Despite completion of the residential treatment program, these participants met DSM-IV criteria for pathological gambling at pretreatment for the current study and were exposed to the mapping-enhanced group treatment. Table 1 shows that the results for this group were strikingly similar to the results for the mapping-enhanced group conducted in the experimental condition. The improvements observed among referral participants who had already completed a state-sponsored treatment program further indicate that mapping-enhanced group treatment may produce outcomes that are superior to standard treatment approaches. Further research will be needed to compare mapping-enhanced treatment to more traditional, 12-step approaches.
Acknowledgements The authors would like to thank Melinda J. Henderson for her comments on an earlier version of this manuscript and the American Press Foundation for assistance with recruitment advertising.
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Beck, A. T., & Steer, R. A. (1993). Beck Anxiety Inventory manual. San Antonio, TX: The Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II manual. San Antonio, TX: The Psychological Corporation. Black, D. W., & Moyer, T. (1998). Clinical features and psychiatric comorbidity of subjects with pathological gambling behavior. Psychiatric Services, 49, 1434 – 1439. Crockford, D. N., & el-Guebaly, N. (1998). Psychiatric comorbidity in pathological gambling: A critical review. Canadian Journal of Psychiatry, 43, 43 – 50. Cummings, C., Gordon, J., & Marlatt, G. A. (1980). Relapse: Strategies of prevention and prediction. In W. R. Miller (Ed.), The addictive behaviors. Oxford, UK: Pergamon. Dansereau, D. F., Dees, S. M., Greener, J. M., & Simpson, D. D. (1995). Node-link mapping and the evaluation of drug abuse counseling sessions. Psychology of Addictive Behaviors, 9, 195 – 203. Dansereau, D. F., Joe, G. W., Dees, S. M., & Simpson, D. D. (1996). Ethnicity and the effects of mappingenhanced drug abuse counseling. Addictive Behaviors, 21, 363 – 376. Dansereau, D. F., Joe, G. W., & Simpson, D. D. (1993). Node-link mapping: A visual representation strategy for enhancing drug abuse counseling. Journal of Counseling Psychology, 40, 385 – 395. Dees, S. M., Dansereau, D. F., & Simpson, D. D. (1997). Mapping-enhanced drug abuse counseling: Urinalysis results in the first year of methadone treatment. Journal of Substance Abuse Treatment, 14, 45 – 54. Dickerson, M. G. (1984). Compulsive gamblers. London: Longman. Echeburua, E., Baez, C., & Fernandez-Montalvo, J. (1996). Comparative effectiveness of three therapeutic modalities in the psychological treatment of pathological gambling: Long-term outcome. Behavioural and Cognitive Psychotherapy, 24, 51 – 72. Griffiths, M. D. (1993). Tolerance in gambling: An objective measure using the psychophysiological analysis of male fruit machine gamblers. Addictive Behaviors, 18, 365 – 372. Joe, G. W., Dansereau, D. F., Pitre, U., & Simpson, D. D. (1997). Effectiveness of node-link mapping enhanced counseling for opiate addicts: A 12-month post-treatment follow-up. The Journal of Nervous and Mental Disease, 185, 306 – 313. Joe, G. W., Dansereau, D. F., & Simpson, D. D. (1994). Node-link mapping for counseling cocaine users in methadone treatment. Journal of Substance Abuse, 6, 393 – 406. Lesieur, H. R. (1998). Costs and treatment of pathological gambling. Annals - AAPSS, 556, 153 – 171. Lesieur, H. R., & Blume, S. B. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184 – 1188. Lesieur, H. R., & Blume, S. B. (1991). Evaluation of patients treated for pathological gambling in a combined alcohol, substance abuse, and pathological gambling unit using the Addiction Severity Index. British Journal of Addiction, 86, 1017 – 1028. Linden, R. D., Pope, H. G., & Jonas, J. M. (1986). Pathological gambling and major affective preliminary findings. Journal of Clinical Psychiatry, 47, 201 – 203. Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford. McCormick, R. A. (1994). The importance of coping skill enhancement in the treatment of the pathological gambler. Journal of Gambling Studies, 10, 77 – 86. McCormick, R. A., Russo, A. M., Ramirez, I. F., & Taber, J. I. (1984). Affective disorders among pathological gamblers seeking treatment. American Journal of Psychiatry, 141, 215 – 218. Melville, C. L., Davis, C. S., & Matzenbacher, D. (2000). Three-step treatment for pathological gambling using node-link mapping. Lake Charles, LA: McNeese State University. National Research Council (1999). Pathological gambling: A critical review. Washington, DC, National Academy Press: Author. Saiz-Ruiz, J., Moreno, I., & Lopez-Ibor, J. J. (1992). Ludopatia: Estudio clinico y terapeutico-evolutivo de un grupo de jugadores patologicos. Actas Luso-Espanolas de Neurlogia y Psiquiatria, 20, 189 – 197. Sharpe, L., & Tarrier, N. (1992). A cognitive – behavioral treatment approach for problem gambling. Journal of Cognitive Psychotherapy: An International Quarterly, 6, 193 – 203.
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Simpson, D. D., Dansereau, D. F., & Joe, G. W. (1997). The DATAR project: Cognitive and behavioral enhancements to community-based treatments. In F. M. Tims, J. A. Inciardi, B. W. Fletcher, & A. M. Horton Jr. (Eds.), The effectiveness of innovative approaches in the treatment of drug abuse ( pp. 182 – 203). Westport, CT: Greenwood Press. Sobell, L. C., & Sobell, M. B. (1992). Timeline follow-back: A technique for assessing self-reported alcohol consumption. In R. Litten, & J. Allen (Eds.), Measuring alcohol consumption. Totowa, NJ: The Humana Press. Specker, S. M., Carlson, G. A., Edmonson, K. M., Johnson, P. E., & Marcotte, M. (1996). Psychopathology in pathological gamblers seeking treatment. Journal of Gambling Studies, 12, 67 – 81. Sylvain, C., Ladouceur, R., & Boisvert, J. M. (1997). Cognitive and behavioral treatment of pathological gambling: A controlled study. Journal of Consulting and Clinical Psychology, 65, 727 – 732. Toneatto, T., & Sobell, L. C. (1990). Pathological gambling treated with cognitive behavioral therapy: A case report. Addictive Behaviors, 15, 497 – 501. Wiebe, J., & Cox, B. J. (2001). A profile of Canadian adults seeking treatment for gambling problems and comparisons with adults entering an alcohol treatment program. Canadian Journal of Psychiatry, 46, 418 – 421. Wray, I., & Dickerson, M. G. (1981). Cessation of high frequency gambling and ‘‘withdrawal’’ symptoms. British Journal of Addiction, 76, 401 – 440.
Node-link-mapping-enhanced group treatment for pathological gambling Cam L. Melville*, Carolyn S. Davis, Dena L. Matzenbacher, Jeremy Clayborne Department of Psychology, McNeese State University, P.O. Box 91895, Lake Charles, LA 70609-1895, USA
Abstract Two experiments evaluated a group treatment for pathological gambling that used node-link mapping techniques to enhance treatment effectiveness. In Experiment 1, 13 (8 female) pathological gamblers were randomly assigned to either a mapping group (n = 4), a nonmapping group (n = 4), or a wait-list control group (n = 5). The treatments were conducted by Master’s level counselors during 90min sessions conducted twice per week for 8 weeks. Participants were assessed pre- and post-8 weeks and then 6 months later on Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) pathological gambling criteria, three self-ratings of control of gambling, gambling expenditure, and gambling bout duration. Experiment 2 replicated the mapping (n = 9; 8 female) and wait-list (n = 10; 8 female) conditions of Experiment 1 and expanded the dependent measures to include assessment of changes in cooccurring depression and anxiety. The node-link-mapping-enhanced group treatment produced improvements in more of the dependent measures of pathological gambling than treatment without maps (Experiment 1) or an equivalent-length waiting period (Experiments 1 and 2). It also produced larger decreases in cooccurring depression and anxiety than an equivalent-length waiting period (Experiment 2). The results are consistent with previous treatment research with substance abusers. D 2003 Elsevier Ltd. All rights reserved. Keywords: Pathological gambling; Treatment; Depression; Anxiety
* Corresponding author. Tel.: +1-337-475-5462; fax: +1-337-475-5467. E-mail address: [email protected] (C.L. Melville). 0306-4603/$ – see front matter D 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0306-4603(03)00091-1
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1. Introduction Pathological gambling is defined by the Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) (APA, 1994) as an impulse control disorder. The description of pathological gambling includes a preoccupation with gambling, reduction in the ability to control gambling, dishonesty about gambling and its consequences, and increasing amounts wagered following losses. While defined as an impulse control disorder, pathological gambling shares many of the characteristics of substance addictions, including tolerance (e.g., Dickerson, 1984; Griffiths, 1993) and withdrawal (e.g., Wray & Dickerson, 1981). In fact, the DSM-IV criteria for pathological gambling borrow heavily from the criteria for alcohol dependence. Pathological gamblers are likely to experience a number of financial, legal, and occupational problems (e.g., Lesieur, 1998). Moreover, a number of studies have shown that pathological gambling is associated with high rates of cooccurring psychiatric disorders (e.g., Crockford & el-Guebaly, 1998; Specker, Carlson, Edmonson, Johnson, & Marcotte, 1996). High rates of depression (e.g., Black & Moyer, 1998; Linden, Pope, & Jonas, 1986), suicide ideation (e.g., McCormick, Russo, Ramirez, & Taber, 1984), substance abuse (e.g., Lesieur, 1998; McCormick et al., 1984), and anxiety (e.g., Black & Moyer, 1998) have been observed among individuals with pathological gambling. Recent treatment outcome studies have demonstrated that symptoms of pathological gambling improve following gambling specific cognitive–behavioral treatment delivered during individual counseling sessions (e.g., Sylvain, Ladouceur, & Boisvert, 1997). However, little information is available about group treatment for pathological gambling. This is surprising because group treatment is often the format for gambling treatment in community settings (e.g., Twelve-Step Facilitation; Gamblers Anonymous). Group treatment is likely to cost less per gambler and pathological gamblers have reported a preference for group-based therapy over individual therapy following exposure to both (Lesieur & Blume, 1991; SaizRuiz, Moreno, & Lopez-Ibor, 1992). Group-based treatment may be an important treatment tool if it can be shown that group treatment for pathological gambling is effective. Recently, Melville, Davis, and Matzenbacher (2000) developed a node-link-mappingenhanced group treatment for pathological gambling. Node-link mapping is a visual representation technique designed to highlight interrelations between thoughts, emotions, actions, and environmental influences. In addictions treatment, these interrelations are complex and difficult to represent with the natural language used in standard counseling. The visual display produced by a node-link map allows for simultaneous representation of multiple relations, modulating influences, along with short- and long-term behavioral outcomes. The map allows for clearer communication and more focused collaborative problem solving between counselor and client than natural language. Node-link mapping was originally developed for use in substance abuse treatment (e.g., Dansereau, Dees, Greener, & Simpson, 1995; Dees, Dansereau, & Simpson, 1997) and has been shown to decrease the number of positive urine screens for both opiate and cocaine addicts (Dansereau, Joe, & Simpson, 1993; Joe, Dansereau, & Simpson, 1994; Simpson, Dansereau, & Joe, 1997). Mapping-enhanced counseling may have particular promise for the treatment of pathological gambling. For example, pathological gambling has high rates of occurrence within
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minority populations (e.g., National Research Council, 1999), is associated with high rates of criminal activity (e.g., National Research Council, 1999), and has high treatment drop-out rates (e.g., Echeburua, Baez, & Fernandez-Montalvo, 1996; Sylvain et al., 1997). Node-linkmapping-enhanced counseling for substance abuse has been shown to decrease racial and cultural communication barriers (e.g., Dansereau, Joe, Dees, & Simpson, 1996), to decrease criminal activity (e.g., Joe, Dansereau, Pitre, & Simpson, 1997), and to decrease treatment drop-out rates (Dansereau et al., 1993) when compared to standard counseling. The group treatment for pathological gambling developed by Melville et al. (2000) uses node-link mapping techniques to focus 24 h of group counseling in the three topic areas (8 h per topic) identified by Sylvain et al. (1997) as important targets for change. The three topic areas include understanding randomness, problem solving, and relapse prevention. In the understanding randomness section, the factual characteristics of randomness are identified and the relations between randomness, games of chance, and the participant’s behavior (e.g., illusion of control, superstition, chasing) are mapped. Instructional maps (with nodes filled in) are used to teach the factual characteristics of each participant’s preferred game along with the most likely outcome of play. In the problem solving section, node-link maps are used to demonstrate a systematic problem solving strategy in six problem categories. Participants identify and solve problems via node-link maps in financial management, relationship, legal, family, employment, and social problem categories. In the relapse prevention section, nodelink maps are used to separately identify situations high-risk for relapse to gambling and develop alternative coping strategies for each situation. Each participant then develops and maps a specific behavior change plan. Fig. 1 presents an example of a node-link map from the understanding randomness section of the treatment manual (Melville et al., 2000). This node-link map is presented to the client with the top and bottom nodes filled in. The client identifies five or more personal superstitions related to his/her gambling behavior. Then the client, counselor, and group collaboratively examine how each superstition interacts with the random characteristics of the game. Specifically, the superstition will be followed by a win often enough to lead to (L) an
Fig. 1. Example of a node-link map with client response. See text for description.
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illusion of control over the outcome of the game. Subsequent node-link maps examine how an illusion of control leads to continued play in spite of losses. In the present study, two experiments examined the efficacy of this node-link-mappingenhanced group treatment. Experiment 1 compared the mapping-enhanced group treatment to the same treatment without maps, and to a wait-list control group on measures of pathological gambling. Experiment 2 replicated the mapping and wait-list conditions of Experiment 1 and extended the dependent measures to include cooccurring depression and anxiety.
2. Experiment 1 2.1. Method 2.1.1. Participants Twenty gamblers responded to a recruitment advertisement displayed on the front page of a local newspaper. The gamblers identified slot machines (62%) or video poker (38%) as their primary gambling activity. The sample was primarily female (69%), white (85%), married (75%), and employed (90%). These demographic characteristics are similar to previous reports of treatment-seeking samples of pathological gamblers (e.g., Wiebe & Cox, 2001). During the intake interview, gamblers were evaluated on DSM-IV criteria and the South Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1987). Each gambler met DSM-IV criteria for pathological gambling as established by the clinical interview and scored in the pathological range (five or more) on the SOGS. Previous treatment for gambling was limited to a single session of Gamblers Anonymous reported by one participant. Seven gamblers (three female, four male) refused to participate following the intake interview. Similar refusal rates have been observed in previous treatment outcome studies of pathological gambling (e.g., Sylvain et al., 1997). Thirteen participants (five male, eight female) were assessed as described below and then randomly assigned to either a node-link mapping group (n = 4), a nonmapping group (same counseling content without maps) (n = 4), or a wait-list control group (n = 5). An additional four pathological gamblers were referred by a residential treatment program for pathological gambling to a local addictions treatment clinic. Following an assessment interview these participants were exposed to the node-link mapping enhanced treatment in the community setting [mapping (referral)] (n = 4). The average age of participants in each of the groups was 68 (range 53–77) for the mapping group, 52 (range 33–67) for the nonmapping group, 53 (range 47–62) for the control group, and 50 (range 34–62) for the mapping (referral) group. 2.1.2. Assessment Individual assessment interviews were conducted at intake prior to the first counseling session (pretreatment) following 8 weeks of treatment or waiting period (posttreatment), and at 6 months after treatment for those participants randomly assigned to a treatment condition (i.e., mapping and nonmapping groups). Pre- and posttreatment interviews were conducted face to face. Six-month follow-up interviews were conducted face to face or by phone.
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The dependent measures assessed during the assessment interviews included the number of DSM-IV criteria met as established by clinical interview and self-ratings of control of gambling measured on 10-point scales as suggested by Sylvain et al. (1997). Participants rated their ability to control gambling from ‘‘no control’’ to ‘‘all control,’’ and their desire to gamble from ‘‘no desire’’ to ‘‘intense desire.’’ Similarly, participants rated their ability to refrain from gambling in two personally relevant situations from ‘‘unable to refrain’’ to ‘‘able to refrain.’’ Participants also reported the number of times gambled, the number of hours spent gambling, and the number of sessions of Gamblers Anonymous attended (or other treatment for problem gambling) in the past 30 days. Participants were asked ‘‘How much have you spent on gambling in the past 30 days?’’ Assessment personnel were Master’s level interns specifically trained and blind to the conditions of the experiment. 2.1.3. Treatment conditions Following the intake assessment, each participant met individually with their counselor for 30 min. During this session the counselor provided a description of the format for the group counseling sessions along with session dates and times. The counselor emphasized the importance of confidentiality and the participant signed a promise to keep information revealed in the group confidential. At the end of this session participants also tape-recorded thoughts that occurred during an episode of imagined gambling (e.g., Sylvain et al., 1997) for use later in treatment. The treatment groups received manual guided treatment based on Melville et al. (2000). The mapping groups received mapping-enhanced counseling and the nonmapping group received the same treatment content without maps (natural language). For the nonmapping group, the treatment manual was modified to exclude node-link maps. Both mapping and nonmapping group sessions were 90 min in length, conducted twice per week for eight consecutive weeks. Counselors completed a checklist of topic maps completed (mapping group) or topics discussed (nonmapping group) at the end of each session. As the manual presents topics in a highly structured format the checklists indicated that topics were mapped or discussed in the order intended. Participants assigned to the control group were informed that because of random assignment they were placed on a waiting list. They were also informed that the treatment group to which they had been assigned would begin in 8 weeks. Each treatment group was conducted by a Master’s level counselor. Counselors were blind to the conditions of the experiment. They were provided 8 h of training in either the mappingbased treatment or the same treatment without mapping. Training was conducted by the first author. 2.2. Results and discussion Table 1 presents the group means for the mapping, nonmapping, control, and mapping (referral) groups on the number of DSM-IV criteria met, self-ratings of ability to control and refrain from gambling, and desire to gamble. Visual examination of Table 1 shows that the pathological gamblers exposed to mapping-enhanced group treatment met fewer DSM-IV
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Table 1 Group means for the number of DSM-IV criteria, self-ratings of ability to control and refrain from gambling, and desire to gamble at each assessment interval DSM-IV
Ability to control
Ability to refrain
Desire to gamble
Pre Post 6 months Pre Post 6 months Pre Post 6 months Pre Post 6 months Treatment Mapping Nonmapping Control Mapping (referral)
7.3 7.8 6.8 7.8
0.25 0.25 2.0 2.8 4.4 – 1.0 –
3.0 2.8 3.8 3.8
9.0 6.8 5.6 7.3
8.75 6.3 – –
2.6 6.1 1.9 4.0
9.3 6.6 3.1 7.1
9.0 6.1 – –
9.5 7.3 6.2 7.3
1.8 5.5 6.4 2.5
2.0 6.0 – –
diagnostic criteria at posttreatment than either the nonmapping group or the control group. The self-rated ability to control gambling and the ability to refrain from gambling increased from pre- to posttreatment for each group. The desire to gamble decreased from pre- to posttreatment for each treatment group, whereas a slight increase was observed for the control group. The size of the changes for these self-ratings was larger for the mapping groups than for either the nonmapping or control groups. These treatment effects were retained at 6-month follow-up. The data were analyzed using a repeated-measures multivariate analysis of variance (MANOVA). The MANOVA allows for a comprehensive analysis of pre- to posttreatment or pretreatment to 6-month follow-up changes on multiple related dependent measures in each group. Examining the changes for each group is important because little is known about the effects of treatment or the effects of wait-list assignment. A MANOVA applied to the four dependent variables in Table 1 pre- and posttreatment revealed a significant Group Time interaction [ F(3,24) = 3.38, P < .05]. Follow-up repeated-measures analysis of variance (ANOVA) revealed significant interactions for DSM-IV [ F(1,10) = 5.63, P < .05], ability to refrain [ F(1,10) = 9.51, P < .05], and desire to gamble [ F(1,10) = 6.93, P < .05]. Such interactions indicate that the groups exhibited different patterns of change from pre- to posttreatment. A significant interaction was not observed for ability to control gambling. For the mapping group, follow-up t tests revealed significant pre- to posttreatment changes on the DSM-IV criteria [t(3) = 29.0, P < .001], ability to control gambling [t(3) = 4.9, P < .05], ability to refrain [t(3) = 5.62, P < .05], and desire to gamble [t(3) = 10.33, P < .01]. For the nonmapping group, follow-up t tests revealed significant pre- to posttreatment changes on the DSM-IV criteria [t(3) = 3.38, P < .05] and change that approached significance on the ability to control gambling [t(3) = 2.95, P=.06]. For the control group, follow-up t tests revealed a single significant pre- to posttreatment change on DSM-IV criteria [t(3) = 3.21, P < .05]. The presence of statistically significant pre- to posttreatment changes for each group obscures the contribution of treatment. Therefore, the posttreatment means were compared using a one-way analysis of covariance (ANCOVA). The ANCOVA was conducted with group as the independent variable, posttreatment score as the dependent variable, and pretreatment score as the covariate. This analysis allowed posttreatment scores to be compared irrespective of any group differences that may have existed prior to treatment. The ANCOVA revealed significant differences in the posttreatment means for DSM-IV
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[ F(2,9) = 4.55, P < .05], ability to control [ F(2,9) = 7.85, P < .05], and desire to gamble [ F(2,9) = 6.93, P < .05]. A significant difference was not observed for ability to control gambling. The t tests revealed significant differences between the mapping and control groups for DSM-IV [t(7) = 3.1, P < .05] and ability to refrain [t(7) = 3.2, P < .05]. The mapping (referral) group was not included in the statistical analyses because its participants were not randomly assigned. A second MANOVA applied to the pretreatment and 6-month follow-up scores for the mapping and nonmapping groups revealed a significant Group Time interaction [ F(2,16) = 35.66, P < .05]. Follow-up repeated-measures ANOVAs revealed significant interactions for the ability to refrain [ F(1,6) = 22.83, P < .01] and desire to gamble [ F(1,6) = 26.41, P < .01], indicating that the two groups exhibited different patterns of change from pretreatment to 6-month follow-up. Significant interactions were not observed for DSMIV criteria or control of gambling. For the mapping group, follow-up t tests revealed significant pre- to 6-month follow-up changes on the DSM-IV criteria [t(3) = 17.15, P < .01], ability to control [t(3) = 5.79, P < .05], ability to refrain [t(3) = 11.36, P < .01], and desire to gamble [t(3) = 11.62, P < .01]. For the nonmapping group, follow-up t tests revealed only one significant difference for number of DSM-IV criteria [t(3) = 3.4, P < .05]. Table 2 presents the group means for gambling bout duration and expenditure for the mapping, nonmapping, and control groups. Gambling bout duration was calculated by dividing the number of hours spent gambling in the 30 days prior to the assessment by the number of gambling bouts during the same period. Posttreatment gambling expenditure was calculated as a percentage of baseline expenditure by dividing the amount spent on gambling during the 30 days prior to the posttreatment assessment by the amount established at pretreatment. Visual examination of Table 2 shows that gambling bout duration decreased from pre- to posttreatment for each group. The size of the decrease was larger for the mapping group than for the nonmapping or control groups. Similarly, expenditure decreased from pre- to posttreatment for each group with larger decreases observed for the mapping group than for the nonmapping or control groups. These treatment effects were retained at 6-month follow-up. The t tests applied to the bout durations in Table 2 revealed significant pre- to posttreatment changes for the mapping group (t = 4.02, P < .05) but not for the nonmapping or control groups. Similarly, a t test also revealed significant pretreatment to 6-month follow-up changes for the mapping group (t = 5.29, P < .05) but not for the nonmapping or control groups. The t tests applied to the expenditures in Table 2 revealed significant pre- to posttreatment changes for the mapping group (t = 5.01, P < .05), nonmapping group (t = 5.13, P < .05), and Table 2 Group means for gambling bout duration and gambling expenditure at each assessment interval Gambling bout duration Treatment Mapping Nonmapping Control
Expenditure (percentage of baseline)
Pre
Post
6 months
Pre (%)
Post (%)
6 months (%)
4.5 5.3 6.5
0.6 2.8 3.6
0.25 2.8 –
100 100 100
18 22 23
1 13 –
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control group (t = 4.44, P < .05). A t test also revealed significant pretreatment to 6-month follow-up changes for both the mapping group (t = 99.0, P < .001) and the nonmapping group (t = 12.64, P < .05) but not for the control group.
3. Experiment 2 Experiment 1 demonstrated that a node-link-mapping-based group treatment was effective with a small sample of pathological gamblers. Experiment 2 replicated the node-link mapping and wait-list conditions of Experiment 1 with a larger sample and extended the dependent measures to include measures of cooccurring depression and anxiety. The depression and anxiety measures were included as additional indicators of improved functioning following exposure to treatment. It is important to include these measures of cooccurring disorders for at least two reasons. First, both depression and anxiety have been observed to frequently cooccur with pathological gambling (e.g., Black & Moyer, 1998; Crockford & el-Guebaly, 1998; Linden et al., 1986; Specker et al., 1996). For example, Specker et al. (1996) reported high levels of depression (48%) and anxiety (60%) within their outpatient-treatment-seeking sample. Second, some authors have argued that addictive behavior, including pathological gambling, is triggered by negative mood states such as depression or anxiety (e.g., Cummings, Gordon, & Marlatt, 1980; Marlatt & Gordon, 1985; McCormick, 1994). In fact, Cummings et al. (1980) reported that negative emotion was the most frequent relapse trigger for pathological gambling, accounting for 47% of relapses. To the extent that treatment reduces negative mood states, the number of high-risk situations for relapse should also be reduced. 3.1. Method 3.1.1. Participants The recruitment procedure and participant inclusion criteria used in Experiment 1 were used in Experiment 2. Twenty-eight gamblers responded to the recruitment advertising. Gamblers identified video poker most often as their primary gambling activity (39%), followed by slot machines (36%), black jack (14%), and other casino games (11%). The sample was primarily female (76%), white (89%), married (79%), and employed (93%). As in Experiment 1, these demographics are similar to previous reports of treatment-seeking samples of pathological gamblers (e.g., Wiebe & Cox, 2001). Three gamblers were excluded because they did not meet criteria for pathological gambling. Six gamblers refused to participate following the intake interview. Previous treatment for gambling was reported by only one participant who had attended two sessions of Gamblers Anonymous. Nineteen participants (3 male, 16 female) were assessed and then randomly assigned to either a node-link mapping group (n = 9) or to a wait-list control group (n = 10). The average age of participants in each of the groups was 51 (range 38–68) for the mapping group and 54 (range 35–63) for the control group.
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3.1.2. Assessment The same assessment procedure used in Experiment 1 was used in Experiment 2 except that measures of depression and anxiety were added to the assessment interview and participants were asked to list any prescription medication they were taking. The Beck Depression Inventory-II (BDI-II) was used as a measure of depression. The BDI-II is a 21item self-report instrument based on DSM-IV criteria that provides a reliable and valid measure of depression (e.g., Beck, Steer, & Brown, 1996). The Beck Anxiety Inventory (BAI) was used as a measure of anxiety. The BAI is a 21-item self-report instrument that provides a reliable and valid measure of anxiety (e.g., Beck & Steer, 1993). Experiment 2 included the same counselor training procedures and treatment conditions as those used in Experiment 1 for the mapping group and control group. 3.2. Results and discussion Table 3 presents the group means for DSM-IV criteria, self-ratings of ability to control and ability refrain from gambling, and desire to gamble. Visual examination of Table 3 shows that the pathological gamblers in Experiment 2 exposed to mapping-enhanced group treatment met fewer DSM-IV diagnostic criteria at posttreatment than the control group. As in Experiment 1, the self-rated ability to control gambling and the ability to refrain from gambling increased for both groups. The size of the increase was larger for the mapping group than for the control group. Desire to gamble decreased from pre- to posttreatment for the mapping group but increased pre- to posttreatment for the control group. In general, treatment effects for the mapping group were retained at 6-month follow-up. A MANOVA applied to the four dependent measures in Table 3 at pre- and posttreatment revealed a significant Group Time interaction [ F(2,16) = 5.01, P < .05]. Follow-up ANOVAs revealed significant interactions for DSM-IV criteria [ F(1,17) = 19.87, P < .05], ability to control gambling [ F(1,17) = 6.33, P < .05], ability to refrain [ F(1,17) = 7.73, P < .05], and desire to gamble [ F(1,17) = 9.68, P < .05]. Such interactions indicate that the groups exhibited different patterns of change from pre- to posttreatment. For the mapping group, follow-up t tests revealed significant pre- to posttreatment changes on DSM-IV criteria (t = 5.15, P < .05), ability to control (t = 4.811, P < .05), ability to refrain from gambling (t = 5.32, P < .05), and desire to gamble (t = 2.32, P < .05). Significant pre- to posttreatment changes were not observed for the control group.
Table 3 Group means for the number of DSM-IV criteria met, self-ratings of ability to control and ability to refrain from gambling, and desire to gamble at each assessment interval DSM-IV Pre Treatment Mapping 6.3 Control 5.8
Ability to control
Ability to refrain
Desire to gamble
Post
6 months
Pre
Post
6 months
Pre
Post
6 months
Pre
Post
6 months
1.4 6.6
1.6 –
3.4 3.5
8.9 5.2
7.8 –
3.3 4.2
8.7 4.4
7.5 –
6.6 7.0
2.8 8.7
4.4 –
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Table 4 Group means for gambling bout duration and gambling expenditure at each assessment interval Gambling bout duration Treatment Mapping Control
Expenditure (percentage of pretreatment)
Pre
Post
6 months
Pre (%)
Post (%)
6 months (%)
3.9 4.5
2.0 4.6
1.0 –
100 100
23 98
31 –
For the mapping group, t tests revealed significant pretreatment to 6-month follow-up changes on DSM-IV criteria [t(7) = 5.61, P < .01], ability to control gambling [t(7) = 2.61, P < .05], and ability to refrain [t(7) = 3.74, P < .01]. Differences were not observed for the pretreatment to 6-month follow-up scores on participants’ desire to gamble. Table 4 presents the group means for gambling bout duration and expenditure for the mapping and control groups. Data in Table 4 were calculated and are presented as in Table 2 for Experiment 1. Visual examination of Table 4 shows that gambling bout duration decreased from pre- to posttreatment for the mapping group, whereas bout duration for the control group increased slightly. Expenditure decreased from pre- to posttreatment for each group. The size of the decrease was larger for the mapping group than for the control group. The treatment effects observed for the mapping group were retained at 6-month follow-up. The t tests revealed that the pre- to posttreatment changes in bout duration were not significant for either the mapping or the control group. A t test applied to the pretreatment and 6-month follow-up bout durations for the mapping group approached significance [t(7) = 2.24, P=.06]. One participant did not report bout duration at the 6-month follow-up. The t tests revealed significant reductions from pretreatment expenditure for the mapping group at both posttreatment [t(8) = 8.53, P < .05] and 6-month follow-up [t(7) = 3.58, P < .05]. One participant did not report expenditure at the 6-month follow-up. Statistically significant changes were not observed for the control group. Table 5 presents the mean depression and anxiety scores for the mapping and control groups. Visual examination of Table 5 shows that depression scores decreased pre- to posttreatment for the mapping group, whereas depression scores for the control group did not change. Likewise, anxiety scores decreased for both the mapping and control groups with larger decreases observed for the mapping group. In general, these treatment effects were retained at 6-month follow-up for the mapping group.
Table 5 Group means for depression and anxiety scores at each assessment interval Depression score Treatment Mapping Control
Anxiety score
Pre
Post
6 months
Pre
Post
6 months
23.7 31.4
7.4 30.7
3.3 –
17.4 26.5
6.0 18.6
3.8 –
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Repeated-measures ANOVAs applied to the data in Table 5 revealed significant Group Time interactions for both depression [ F(1,17) = 10.44, P < .05] and anxiety [ F(1,17) = 5.72, P < .05]. For the mapping group, follow-up t tests revealed significant pre- to posttreatment changes in both depression [t(8) = 3.47, P < .01] and anxiety [t(8) = 2.53, P < .05]. Significant pre- to posttreatment changes in depression and anxiety were not observed for the control group. The t tests also revealed significant pretreatment to 6-month follow-up changes on depression [t(6) = 2.84, P < .05]. The pretreatment to 6-month follow-up changes observed for anxiety approached significance [t(6) = 2.19, P=.07]. Two participants were excluded from these analyses because they did not provide 6-month follow-up information on depression and anxiety.
4. General discussion The node-link-mapping-enhanced group treatment for pathological gambling used in the present study (e.g., Melville et al., 2000) produced improvements in more of the dependent measures of pathological gambling than treatment without maps (natural language) (Experiment 1) or an equivalent-length waiting period (Experiments 1 and 2). The mappingenhanced treatment also produced larger decreases in cooccurring depression and anxiety than an equivalent-length waiting period. In fact, 71% of those in this treatment group had depression and anxiety scores that were reduced to subclinical levels. From a clinical perspective, all 17 of the pathological gamblers in Experiments 1 and 2 exposed to the mapping-enhanced group treatment improved by at least 67% on the DSM-IV criteria compared to only 2 of 15 in the control groups. The improvements observed likely reflect the effect of the current treatment because participants reported they did not participate in any other forms of treatment during the study. It is important to note that the mapping group in Experiment 1 was older than the other groups. It is possible that the improvement observed for this group was due to nonspecific factors related to age (e.g., natural recovery). However, this explanation is highly speculative given the paucity of research on the effects of age on treatment seeking or treatment outcome with pathological gamblers. These results are consistent with previous research on node-link mapping with substance abusers. Previous research on mapping-enhanced counseling in substance abuse treatment has demonstrated that mapping results in improvements that are often dramatic. For example, Dees et al. (1997) observed larger reductions in drug use among clients exposed to node-link mapping than among clients exposed to standard counseling. Similarly, in the present study, large reductions in gambling bout duration and expenditure were more consistently observed following exposure to the mapping-enhanced group treatment than following exposure to group treatment without maps or 8-week waiting period. For example, in Experiment 1, the reduction in gambling bout duration following exposure to mapping-enhanced group treatment was nearly twice as large as the reductions observed for the nonmapping group (at posttreatment and 6-month follow-up) and the control group (at posttreatment). For the mapping-enhanced group in Experiment 2, gambling bout duration had decreased by 49% at the posttreatment assessment and by 74% at the 6-month follow-up.
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Large reductions in gambling expenditure were also observed following exposure to the mapping-enhanced group treatment. For example, expenditure decreased by 97% and 89% for the mapping groups in Experiments 1 and 2, respectively. Smaller, but notable, decreases in expenditure were also observed for the nonmapping and control groups in Experiment 1 and control group in Experiment 2, with decreases of 89%, 78%, and 28%, respectively. The reductions observed in the control group suggest that gambling expenditure may also decrease following assessment of gambling behaviors and/or commitment to treatment. One possibility is that the inquiry into personal gambling history highlights the amount lost to gambling, thus increasing motivation to reduce gambling expenditure. In addition, clinical observation during assessments suggested that some participants may have difficulty with accurate recall of dollar amounts spent on gambling during the preceding 30 days. Future studies in this area may consider the use of a more structured assessment of previous expenditure, such as the time-line follow-back method (e.g., Sobell & Sobell, 1992). The present results are also consistent with previous research on the treatment of pathological gambling that used gambling-specific cognitive–behavioral therapy during individual counseling sessions. For example, Sylvain et al. (1997) used individual counseling procedures to expose pathological gamblers to cognitive correction and skill building in the same three target areas as in the present group treatment. For their treatment group at posttreatment, DSM-IV criteria were below pathological levels, the ability to control and refrain from gambling had significantly increased, and desire to gamble had significantly decreased, compared to the wait-list control group. Likewise, in both Experiments 1 and 2 of the present study, each of the four measures of control over gambling (i.e., DSM-IV criteria, ability to control, ability to refrain, desire to gamble) showed significant improvement following exposure to the mapping-enhanced group treatment. By comparison, change was observed in only one measure (DSM-IV criteria) for the nonmapping and control groups in Experiment 1. While speculative, it is possible that the mapping techniques used in the present study serve to individualize the sessions even though the topics are presented in a group context. Clients are taught these mapping strategies as a group, and are encouraged to have open discussion of the maps; however, each client completes maps that are specific to their own situation. Thus, counselors (or clients) can capitalize on the individualized problem solving focus of individual counseling in the context of a supportive group environment. However, this explanation may be simplistic because the maps used in the present study provide unique opportunities for pathological gamblers to examine clinically relevant information. For example, the mapping-enhanced group treatment used instructional maps (with nodes filled in) to expose the odds of particular outcomes given a particular strategy of play for each participant’s preferred game (e.g., Toneatto & Sobell, 1990). Future research will need to examine the contribution of specific components of the treatment approach to treatment outcome. Previous research has also demonstrated high rates of cooccurring depression and anxiety in treatment-seeking samples of pathological gamblers (e.g., Specker et al., 1996). Similarly, high rates of depression and anxiety were observed in Experiment 2 of the present study.
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Seventy-six percent of the pathological gamblers in Experiment 2 had pretreatment depression scores in the moderate to severe range, and eighty-eight percent had pretreatment anxiety scores in the moderate to severe range. Previous research has demonstrated improvement in cooccurring depression (e.g., Echeburua et al., 1996) and anxiety (e.g., Echeburua et al., 1996; Sharpe & Tarrier, 1992) following treatment for pathological gambling. The results of the present study suggest that measures of depression and anxiety are sensitive to improved functioning produced by mapping-enhanced treatment. For example, Table 5 shows that depression scores at posttreatment decreased significantly to minimal levels following exposure to the mapping-enhanced group treatment and remained at minimal levels at the 6-month follow-up. Depression scores for the pathological gamblers in the wait-list condition did not change. Table 5 also shows that anxiety scores at posttreatment decreased significantly following exposure to the mapping-enhanced group treatment. Anxiety scores for the pathological gamblers in the wait-list condition did not change. The present study does not isolate the treatment factors that produced the decreases in depression and anxiety. However, the decreases cannot be attributed to pharmacological effects of prescribed medication. None of the participants reported the use of anti-anxiety or antidepressant medication at posttreatment or 6-month follow-up. Future studies will need to determine the mechanism by which treatment produced these improvements. Finally, the present study included a group of pathological gamblers referred for after-care to a community clinic following completion of a 36-day residential treatment program for pathological gambling. Despite completion of the residential treatment program, these participants met DSM-IV criteria for pathological gambling at pretreatment for the current study and were exposed to the mapping-enhanced group treatment. Table 1 shows that the results for this group were strikingly similar to the results for the mapping-enhanced group conducted in the experimental condition. The improvements observed among referral participants who had already completed a state-sponsored treatment program further indicate that mapping-enhanced group treatment may produce outcomes that are superior to standard treatment approaches. Further research will be needed to compare mapping-enhanced treatment to more traditional, 12-step approaches.
Acknowledgements The authors would like to thank Melinda J. Henderson for her comments on an earlier version of this manuscript and the American Press Foundation for assistance with recruitment advertising.
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