J Gambl Stud (2006) 22:355–372

DOI 10.1007/s10899-006-9027-3

ORIGINAL PAPER

Treatment of Female Pathological Gambling:

The Efficacy of a Cognitive-Behavioural Approach

Nicki Dowling Æ David Smith Æ Trang Thomas

Published online: 22 August 2006

Springer Science+Business Media, Inc. 2006

Abstract Given that a substantial proportion of current pathological gamblers are

female, it is evident that women are underrepresented in the treatment outcome
literature. The current study was designed to redress the limited information on the
treatment of female pathological gambling. Although the use of cognitive-
behavioural therapy is the most highly recommended approach as ‘best practice’ for
the treatment of pathological gambling, no attempt to date has been made to
evaluate the efficacy of this approach for female pathological gambling. Nineteen
female pathological gamblers with electronic gaming machine problems were trea-
ted with a cognitive-behavioural program. While pathological gamblers placed on a
waiting list did not show significant improvement on gambling behaviour and psy-
chological functioning measures, the female pathological gamblers showed signifi-
cant improvement on these measures over the treatment period, and maintained this
improvement at the 6-month follow-up evaluation. By the completion of the follow-
up period, 89% of participants no longer met diagnostic criteria for pathological
gambling. Although further scientific demonstration and replication are required,
the outcomes of this study indicate that the therapy that is considered ‘best practice’
in the treatment of pathological gambling is effective for female pathological
gambling.

N. Dowling (&)
School of Psychiatry, Psychology and Psychological Medicine, Monash University, Building 17,
Clayton, VIC 3800, Australia
e-mail: nicki.dowling@med.monash.edu.au

D. Smith
School of Health Sciences, RMIT University, PO Box 71, Bundoora, VIC 3083, Australia

T. Thomas
School of Health Sciences, RMIT University, GPO Box 2476V, Melbourne, VIC 3001,
Australia
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Keywords Pathological gambling Æ Treatment Æ Female Æ Cognitive-behavioural

therapy Æ Gambling

Introduction

Recent legislative changes in most western countries have lead to an unprecedented

expansion of legalised gambling opportunities and the stimulation of higher rates of
gambling participation and problematic gambling in the general population (Pro-
ductivity Commission, 1999; Volberg, 1996). Pathological gambling, which is defined
in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text
Revision) (DSM-IV-TR) as ‘‘a persistent and recurrent maladaptive gambling
behaviour that disrupts personal, family or vocational pursuits’’ (American Psychi-
atric Association [APA], 2000, p. 671), is increasingly becoming recognised as a
significant public and mental health problem.
Various theoretical models attempt to account for the acquisition and mainte-
nance of pathological gambling. While the absence of a unifying theory is reflected in
the plethora of techniques that have been employed in its treatment, the evaluation
of interventions is relatively new and lagging behind practice. Although limited, the
literature investigating the efficacy of treatment for pathological gambling provides
some evidence that this disorder is amenable to intervention, even when a publishing
bias towards successful outcomes is considered. The approximate overall success
rates for psychological treatments have been estimated to be 70% at 6-months fol-
low-up, 50% at 1-year follow-up, and 30% at 2-year follow-up (López Viets &
Miller, 1997). These improvements in gambling behaviour are also often associated
with notable improvements in psychological functioning (López Viets & Miller,
1997).
Caution is required in accepting such conclusions, however, as their validity is
generally compromised by serious methodological limitations (Ladouceur et al.,
2003; National Centre for Education and Training on Addiction [NCETA], 2000).
Indeed, even basic methodologies have yet to be established in this emerging area of
investigation (López Viets & Miller, 1997). It has also been argued that the treat-
ment outcome literature does not provide a strong basis for differentiation of the
available treatment options (NCETA, 2000). Interestingly, however, all of the
available methodologically robust studies have been conducted using cognitive,
behavioural, and cognitive-behavioural techniques. Indeed, randomised and con-
trolled trials have established the efficacy of behavioural (Echeburúa, Báez, &
Fernández-Montalvo, 1996; McConaghy, Armstrong, Blaszczynski, & Allcock, 1983,
1988; McConaghy, Blaszczynski, & Frankova, 1991), cognitive (Ladouceur et al.,
2001, 2003), and cognitive-behavioural (Sylvain, Ladouceur, & Boisvert, 1997)
techniques in the treatment of pathological gambling.
In accordance with learning principles, behavioural approaches have commonly
applied classical and operant conditioning techniques in order to reduce the arousal
and excitement associated with gambling. The use of behavioural interventions in
the treatment of pathological gambling is illustrated by a treatment outcome study
conducted by McConaghy et al. (1991) that compared imaginal desensitisation with
other behavioural procedures, including aversive therapy, imaginal relaxation, brief

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in-vivo exposure, and prolonged in-vivo exposure. The 2–9 year follow-up evalua-
tion provided an indication of gambling behaviour in the month prior to evaluation.
Of the 33 predominantly male pathological gamblers who received imaginal
desensitisation, 30% displayed gambling cessation, and a further 48% displayed
controlled gambling. Of the 30 predominantly male pathological gamblers who re-
ceived other behavioural procedures, 27% displayed gambling cessation, and a
further 27% displayed controlled gambling.
In contrast, cognitive formulations of the development and maintenance of
pathological gambling imply that intervention should identify cognitive distortions
and biases and correct them through cognitive restructuring techniques. For exam-
ple, a randomised and controlled trial conducted by Ladouceur et al. (2001) evalu-
ated a cognitive treatment program conducted with weekly sessions for a maximum
of 20 weeks. At treatment completion, 86% of the 35 predominantly male patho-
logical gamblers no longer met the DSM-IV criteria for pathological gambling, and
follow-up evaluations revealed that this figure was maintained at 73% after
6 months, and at 71% after 12 months. Moreover, diagnostic criteria, perceptions of
control, desire to gamble, and self-efficacy perceptions improved at the follow-up
evaluations.
Although cognitive-behavioural theories for pathological gambling (e.g., Sharpe,
2002; Sharpe & Tarrier, 1993) appear to have a robust and sound empirical basis, the
translation of these formulations into systematic treatment outcome studies is rel-
atively new. While the evidence for the use of cognitive-behavioural treatment for
pathological gambling is predominantly derived from case studies and multiple
baseline design studies, one randomised and controlled study conducted by Sylvain
and colleagues (1997) demonstrated the efficacy of a standardised treatment pro-
gram comprising cognitive correction, with the inclusion of problem solving training
(including financial planning and alternative activity planning), social skills training,
and relapse prevention as necessary. Fourteen male pathological gamblers were
treated on a weekly or biweekly basis until gambling ceased and an ‘adequate’
perception of gambling and chance was developed. At treatment completion, and
six- and 12-month follow-up evaluations, the treatment group displayed improve-
ment on multiple indices of gambling behaviour (e.g., gambling frequency, gambling
duration, diagnostic criteria, perception of control, desire to gamble, and South Oaks
Gambling Screen scores).
Given the infancy of the treatment outcome literature, the improved methodol-
ogy applied to cognitive and behavioural treatments coupled with the consistency of
findings allows for the generation of cautious service delivery recommendations
regarding these approaches. Although rigorous scientific demonstration and repli-
cation are required to establish fully the efficacy of cognitive-behavioural therapy, it
has been the most highly recommended approach as ‘best practice’ for the treatment
of pathological gambling (López Viets & Miller, 1997; NCETA, 2000; Victorian
Government Department of Human Services [VGDHS], 2000).
Despite the promising evidence for the effectiveness of treatment for pathological
gambling, there is currently little sound research investigating the treatment of fe-
male pathological gambling. Only case studies and multiple baseline designs have
detailed background information and specific treatment outcome information for
females experiencing gambling-related problems. Moreover, treatment outcome
studies have focused almost exclusively on male populations or failed to conduct
gender analyses to elicit the specific treatment response of female pathological
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gamblers. To date, no attempt has been made to investigate specifically the efficacy
of treatment for female pathological gambling.
This gender bias has emerged within the context of prevailing cultural views of
gambling as a stereotypically masculine activity (VGDHS, 2000). However, recent
legislative changes resulting in the liberalisation and rapid proliferation of highly
sophisticated electronic gaming machines has led to a dramatic increase in the
accessibility of gambling for women as a group (VGDHS, 2000). While international
epidemiological prevalence surveys have generally estimated that approximately
one-quarter to one-third of pathological gamblers are female (e.g., Ladouceur, 1991;
Volberg, 1996), several recent studies indicate that female pathological gambling is
becoming more prevalent, particularly in terms of current, rather than lifetime,
prevalence rates (e.g., Productivity Commission, 1999; Volberg, 1996). In some
countries, the margin separating the prevalence of pathological gambling among
men and women appears to have narrowed significantly. For example, females now
comprise 40% of Australian problem gamblers and approximately half of clients
accessing Australian problem gambling support services (Productivity Commission,
1999).
The under-representation of women in gambling research has also lead to a
deficiency in knowledge regarding the demographic, gambling, and psychological
characteristics of treatment-seeking female pathological gamblers. The limited
available literature, however, indicates that females presenting to counselling ser-
vices for gambling-related problems have significantly different demographic char-
acteristics from males. They are more likely to be older, to be married, to be living
with others, and to have dependent children (Crisp et al., 2000; Jackson, Thomas,
Ross, & Kearney, 2001; Jackson et al., 1999; Jackson, Thomas, Thomason, Holt, &
McCormack, 2000). In contrast, men are more likely to be never married and to live
alone (Jackson et al., 1999, 2000, 2001). While some research indicates that females
appear to have similar rates of employment to males (Crisp et al., 2000), other
research suggests that females have lower rates of employment than males (Jackson
et al., 1999, 2000, 2001).
Recent gender analyses also reveal differences in the gambling behaviour of fe-
male pathological gamblers compared to their male counterparts. For example, fe-
male pathological gamblers tend to report a later age of onset of regular gambling,
shorter durations of gambling behaviour prior to seeking help, shorter durations of
problem gambling before seeking help, and shorter periods of ‘social gambling’
(Grant & Kim, 2002; Ladd & Petry, 2002; Potenza et al., 2001; Tavares, Zilberman,
Beites, & Gentil, 2001). There is also evidence to suggest that while female patho-
logical gamblers are as likely to develop interpersonal and leisure use problems as
their male counterparts, they may be slightly less likely to develop financial diffi-
culties, employment problems, and legal problems as a consequence of their gam-
bling behaviour (Crisp et al., 2000; Grant & Kim, 2002; Jackson et al., 1999, 2000,
2001; Ladd & Petry, 2002; Potenza et al., 2001).
There may also be gender differences in the rates of comorbidity and psycho-
pathology displayed by pathological gamblers. Direct gender comparisons have re-
vealed similar, or higher, rates of comorbid mood and anxiety disorders in female
pathological gamblers compared with their male counterparts, but similar, or lower,
rates of alcohol and substance dependence (Grant & Kim, 2002; Ladd & Petry, 2002;
Potenza et al., 2001). It is evident that caution is required when generalising across

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genders given these possible differences in demographic, gambling, and psycholog-

ical characteristics between male and female pathological gamblers.
Given that the population of female pathological gamblers is clearly under-rep-
resented in the treatment outcome literature, the present study was designed to
address the fundamental issue of whether the therapy considered ‘best practice’ in
the treatment of pathological gambling is effective for female pathological gamblers
by evaluating the efficacy of a cognitive-behavioural approach in the treatment of
female pathological gamblers. It was hypothesised that the treatment would signif-
icantly improve the gambling behaviour and psychological functioning of female
pathological gamblers at post-treatment and follow-up evaluations.

Method

Participants

Of the 39 participants presenting for treatment, six (15%) failed to attend the initial
assessment. A further five did not complete the assessment, three declined to par-
ticipate in treatment following a period on the waiting list, and six left treatment
prematurely. The average number of treatment sessions was 4.5 (SD = 2.9) for those
participants leaving treatment prematurely.
The resulting sample comprised 19 female pathological gamblers, ranging in age
between 28 and 70 years, with a mean age of 44.8 years (SD = 9.9). The majority
were in a current relationship, with 37% married, 11% in a cohabiting relationship,
and a further 21% in a non-cohabiting relationship. The majority (74%) were em-
ployed full-time, with 16% employed on a part-time/casual basis, and 11% retired
from the workforce. The most common occupations of those employed were nursing
(29%) and administration (18%). A comparison of this sample to previous Aus-
tralian female pathological gambling samples reveals similarities in terms of age,
cohabiting relationship rates, and part-time employment rates, but lower rates of
marriage and higher levels of full-time employment (Crisp et al., 2000; Jackson et al.,
1999, 2000, 2001).
The participants were recruited from the general community through advertise-
ments, and radio announcements. Given the predominance of electronic gaming
among women with gambling problems (Productivity Commission, 1999), the only
inclusion criteria were a preferred gambling modality of gaming machines and a
gambling problem that satisfied the diagnosis of pathological gambling (APA, 2000).
The average number of diagnostic criteria met was 7.3 (SD = 1.8), and the average
South Oaks Gambling Screen score was 12.4 (SD = 3.3). The average length of the
gaming machine gambling history was 5.4 years (SD = 1.8), and the average length
of gaming machine problem gambling was 5.1 years (SD = 3.0). None of the par-
ticipants was receiving psychosocial or support therapy for pathological gambling.

Measures

Given the multidimensional nature of pathological gambling (López Viets & Miller,
1997), the relative success of the treatment program was evaluated on conceptually
related measures within the areas of gambling behaviour and psychological
functioning.
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Gambling Behaviour Measures

The weekly gambling behaviour (frequency, duration, amount of money inserted

into gaming machines, and amount of money won/lost [expenditure]) of the par-
ticipants during the pre-treatment, waiting list, treatment, and follow-up phases was
evaluated using continuous gambling diary records. These measures have been
employed to assess treatment outcome in previous literature (Echeburúa et al., 1996;
Ladouceur et al., 2001, 2003; Sylvain et al., 1997).

Psychological Functioning Measures

Beck Depression Inventory (BDI-II: Beck, Steer, & Brown, 1996) The BDI-II is
a 21-item self-report inventory for the assessment of the severity of state depression,
and provides classification of depression as minimal, mild, moderate, and severe. The
psychometric properties of the BDI-II, in terms of internal consistency, test–retest
reliability, content validity, construct validity, factorial validity, and discriminant
validity, have been well established (Beck et al., 1996).
State-Trait Anxiety Inventory (STAI: Spielberger, Gorsuch, Lushene, Vagg, &
Jacobs, 1983) The STAI comprises separate self-report scales for measuring
state and trait anxiety, both of which consist of twenty statements. Spielberger et al.
(1983) provides substantial evidence to support the psychometric properties of the
STAI in terms of internal consistency, test–retest reliability, concurrent validity,
convergent validity, divergent reliability, and construct validity.
Coopersmith Self-Esteem Inventory (SEI Adult Form: Coopersmith, 1981) The
Coopersmith SEI is a 25-item self-report inventory that measures the extent to
which individuals customarily maintain a personal evaluation of competence, suc-
cess, significance, and worthiness. The maximum total score possible for this
inventory is 100, which indicates high self-esteem. Cronbach alpha reliabilities
presented by Coopersmith (1981) indicates that the scale exhibits high internal
consistency.

Measures of Clinical Significance

In order to address concerns about the lack of clinical validity of tests of statistical
significance and lack of comparability across studies (Stinchfield & Winters, 2001),
several measures of clinical validity were employed to evaluate the success of the
program.
Diagnostic Criteria The participants were evaluated at the completion of the
treatment program and the 6-month follow-up period to determine the degree to
which the treatment produced a reduction in the proportion of participants meeting
DSM-IV-TR criteria for pathological gambling.
Goal Achievement Scale (GAS) The GAS (Hudson, Jauernig, Wilken, & Ra-
dler, 1995) compares post-treatment to pre-treatment measures in the context of the
goal of treatment to obtain an index of change. Zero success indicates that there is
no change in gambling behaviour following intervention as the gambling behaviour
has remained at pre-treatment levels. Levels of change between zero and 100 per-
cent success are identified based on the final 4 weeks of the follow-up period. Par-
ticipants received a GAS score for three weekly gambling behaviour measures:
frequency, duration, and expenditure.
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Classification of Outcomes Participants were classified into groups according to

their gambling behaviour in the month preceding the 6-month follow-up evaluation,
in the manner adopted by Blaszczynski, Maccallum, and Joukhador (2001). These
categories included abstinence (no gaming machine gambling during the 1-month
period), controlled gambling (spending no more than AUS$20 per week and
spending no more than intended at any one session during the month), lapsed
gambling (one or two uncontrolled sessions of gambling within abstinence or con-
trolled gambling behaviour during the month), and uncontrolled gambling (losing
over AUS$20 per week, repeatedly failing to resist the urge to gamble, spending
more than intended, and chasing losses during the month).

Experimental Design and Procedure

Participants were interviewed individually using a semi-structured interview sche-

dule during a minimum of two assessment sessions. The treatment goal of either
abstinence or controlled gambling was decided through therapist and participant
collaboration. In order to evaluate the efficacy of the treatment without the influence
of different treatment goals, the current paper will report the results derived from
those participants who selected abstinence as their goal of treatment. A comparison
of abstinence and controlled gambling as goals of treatment for female pathological
gambling will be published in a separate paper. Given that gambling activities are
qualitatively different (Blaszczynski & Steel, 1998), abstinence was defined as ‘no
participation in electronic gaming’.
The study employed a 12-week waiting list control group to evaluate the
spontaneous remission of non-treated participants. Initially, each participant was
randomly allocated to either the treatment group or the waiting list control group.
Participants allocated to the control condition were assessed prior to, and fol-
lowing, the waiting list. None of the participants sought alternate treatment while
on the waiting list. Following the waiting list period, the participants originally
allocated to the control condition were assigned to the treatment condition. Sta-
tistical analyses were conducted in order to justify the inclusion of the data from
these participants in the evaluation of the longer-term success of the treatment
program. Given their equivalence, the post-waiting list data for the control group
served as their pre-treatment data for the purpose of determining the treatment
efficacy at 6-month follow-up evaluation. Treated participants (including those
initially assigned to the waiting list control condition) were assessed following
treatment and followed up for a 6 month period following the completion of the
treatment program.
The program was conducted on an outpatient basis at no charge. Although the
primary author conducted the majority of treatment, a treatment manual, training
video, training sessions, and feedback from treatment videos were employed in order
to ensure the integrity and standardisation of treatment delivery in accordance with
recommendations for manual-guided therapies and specification of therapeutic
methods (López Viets & Miller, 1997). The lack of significant difference in GAS
outcomes (gambling frequency, duration, and expenditure) between those treated by
the primary author and other clinicians, Wilks’ L = .953, F (3, 14) = 0.23, P > .05,
g2 = .05, suggests that the program is robust and that the findings are not a result of
the characteristics of one particular clinician.

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Treatment Program Outline

Given the apparent association between pathological gambling and psychopathology

(VGDHS, 2000), the treatment program incorporated a range of empirically vali-
dated cognitive-behavioural components that addressed comorbid conditions in
addition to pathological gambling behaviour. The program consisted of 12 sessions
of 1.5 hours in length. Although every attempt was made to conduct weekly sessions,
cancellations and missed appointments led to an average treatment period of
22 weeks (SD = 12). Each session provided in-session exercises, and homework
exercises were assigned between sessions.
Sessions 1–2: Financial Limit Setting The first two sessions involved setting limits
on gambling behaviour using techniques to control cash flow (e.g., reducing access to
cash cards, cheque-books, and credit cards, paying bills by direct debit, developing
budgets, and developing repayment plans) and self-exclusion. Participants were
encouraged to invite a partner, close friend, or family member to these two initial
sessions as a ‘‘support person’’.
Session 3: Alternative Activity Planning The third session involved identifying
and participating in alternative leisure activities to replace or supplement gambling
behaviours, with an emphasis on inexpensive, pleasurable, and social activities.
Sessions 4–6: Cognitive Correction (gambling) Sessions 4 to 6 provided cognitive
correction specifically addressing fundamental gambling-related cognitive miscon-
ceptions (e.g., Ladouceur et al., 2001, 2003; Sylvain et al., 1997). This component of
the treatment program involved normalising gambling-related cognitive miscon-
ceptions, increasing the client’s awareness of the assumptions underlying their be-
liefs, evaluating their validity on an evidential basis, and modifying and replacing
these beliefs with more appropriate beliefs (Beck, 1995). Cognitive misconceptions
of the basic notions of randomness (e.g., gamblers’ fallacy, chasing losses, dis-
counting losses, overestimation of skill, and the efficacy of systems or superstitious
behaviours) were corrected with evidence generally related to the independence of
play, the inability of strategies or superstitions to control the outcome, and the
negative winning expectancy.
Session 7: Cognitive Correction (general) Session 7 trained participants in cog-
nitive correction techniques (Beck, 1995) in an attempt to provide more adequate
coping skills and to stabilise mood.
Session 8: Problem Solving Participants were trained in traditional five-step
problem solving training (comprising problem identification, problem definition,
generation of alternative solutions, solution identification, and solution implemen-
tation and evaluation).
Sessions 9–10: Communication Training The communication training sessions
were designed to reduce interpersonal conflicts by aiming to develop skills for
communicating assertively, such as learning to refuse requests, make requests, and
respond to criticism.
Sessions 11–12: Relapse Prevention The final two sessions, which were based on
Marlatt and Gordon’s (1985) relapse prevention approach, were designed to address
the issue of avoiding or more effectively coping with high-risk situations, minimising
risk for relapse, and anticipating and coping effectively with relapse. Participants
were required to identify coping strategies in the context of apparently irrelevant
decisions and high-risk situations. Cognitive distortions associated with relapse, such

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as beliefs relating to testing personal control and the ‘‘abstinence violation effect’’,
were reviewed. Finally, decision consequences matrices were created, and partici-
pants were provided with a reminder card.
Imaginal Desensitisation In the final 20 minutes of the first six sessions, partic-
ipants were required to participate in imaginal desensitisation in the manner out-
lined by McConaghy and colleagues (1983, 1988). This procedure required
participants to maintain a state of relaxation while visualising themselves performing
the behaviours in scenes in which they are stimulated to gamble, but in which they
leave without gambling.

Data Analyses

A series of multivariate analyses of variance (MANOVAs) were employed to

evaluate the relative success of the treatment program on conceptually related
measures within the areas of gambling behaviour and psychological functioning. In
order to confirm that the two randomly allocated groups (i.e., treatment and control
groups) were equivalent prior to the waiting list or treatment phases, the gambling
behaviour and psychological functioning measures for the groups prior to the waiting
list/treatment phases were compared. The success of the treatment group relative to
the control group was then evaluated by comparing the pre- and post-treatment
measures for the treatment group with the pre- and post-waiting list measures for the
control group. In order to justify including the treatment outcome information from
the participants initially allocated to the waiting list control group in the long-term
treatment outcome analyses, the post-waiting-list measures of these participants
were compared to the pre-treatment measures of the treatment group. Given their
equivalence, the post-waiting list data for the control group served as their pre-
treatment data for the purpose of determining the treatment efficacy at the 6-month
follow-up evaluation. Finally, the longer-term success of the treatment program was
evaluated by comparing measures of gambling behaviour, psychological functioning,
and clinical significance across the pre-treatment, treatment, and follow-up phases
for all participants who completed treatment. Because complete follow-up infor-
mation was not available from one participant and MANOVA analyses exclude
follow-up dropouts, the majority of these analyses were based on the results from 18
participants.

Results

Comparison of Treatment and Control Groups

Pre-Waiting List and Pre-Treatment Measures

In order to confirm the equivalence of the two randomly allocated groups

(i.e., treatment and control groups), the gambling behaviour (Table 1) and psy-
chological functioning (Table 2) of the groups prior to the waiting list/treatment
phases were compared. MANOVAs for independent samples confirmed no signifi-
cant multivariate differences between the two groups for the gambling behaviour
measures, Wilks’ L = .829, F (4, 20) = 1.03, P = .41, g2 = .17; or psychological
functioning measures, Wilks’ L = .812, F (4, 16) = 0.92, P = .47, g2 = .19.
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Table 1 Comparison of gambling behaviour measures for treatment condition (pre- and post-
treatment phase) and control condition (pre- and post-waiting list)

Group Pre-treatment/ Post-treatment/

waiting list waiting list
M SD M SD

Gambling frequency
Waiting list control 1.70 1.65 1.94 1.70
Treatment 1.48 1.54 0.37 0.52
Gambling duration (mins)
Waiting list control 210 196 237 181
Treatment 175 187 45 83
Money inserted ($)
Waiting list control $260 318 $360 408
Treatment $204 241 $32 50
Expenditure ($)
Waiting list control $98 229 $260 304
Treatment $166 224 $6 36

Table 2 Comparison of psychological functioning measures for treatment condition (pre- and post-
treatment phase) and control condition (pre- and post-waiting list)

Group Pre-treatment/ Post-treatment/

waiting list waiting list
M SD M SD

BDI-II
Waiting list control 16.7 12.5 18.9 12.5
Treatment 24.3 12.7 9.3 7.9
STAI state anxiety standard scores
Waiting list control 64.1 14.4 64.6 16.4
Treatment 68.8 18.0 52.1 14.1
STAI trait anxiety standard scores
Waiting list control 66.6 14.1 67.8 15.1
Treatment 71.8 17.7 54.7 15.0
Coopersmith SEI
Waiting list control 52.0 27.9 50.2 23.6
Treatment 54.0 23.0 73.7 25.0

Post-Treatment Outcomes

In order to evaluate the success of the treatment group relative to that of the control
group, the pre- and post-treatment measures for the treatment group were compared
with the pre- and post-waiting list measures for the control group.
Gambling Behaviour The gambling behaviour measures for the pre-waiting list
and waiting list phases for the control group and the pre-treatment and treatment
phases for the treatment group are displayed in Table 1. Examination of Table 1
reveals that the gambling behaviour of the control group increased across the
waiting list phase, while that of the treatment group substantially improved across
the treatment phase. A MANOVA with repeated measures revealed a significant
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interaction (group x phase) effect, Wilks’ L = .541, F (4, 20) = 4.24,

P = .01, g2 = .46. Significant univariate differences for all gambling measures were
found: gambling frequency, F (1, 23) = 11.22, P = .003, g2 = .33; gambling duration,
F (1, 23) = 13.39, P = .001, g2 = .37; money inserted, F (1, 23) = 13.14, P = .001,
g2 = .36; and expenditure, F (1, 23) = 10.89, P = .003, g2 = .32.
Psychological Functioning The psychological functioning measures at the pre-
and post-waiting list evaluations for the control group and the pre- and post-treat-
ment evaluations for the treatment group are displayed in Table 2. Examination of
Table 2 reveals that the psychological functioning of the control group deteriorated
slightly from pre- to post-waiting list evaluations, while that of the treatment group
substantially improved from pre- to post-treatment evaluations. A MANOVA with
repeated measures revealed a significant interaction (group x phase) effect, Wilks’
L = .478, F (4, 16) = 4.37, P = .01, g2 = .52. Significant univariate differences for all
psychological functioning measures were found: BDI-II scores, F (1, 19) = 15.84,
P = .001, g2 = .46; STAI state anxiety standard scores, F (1, 19) = 6.67, P = .02,
g2 = .26; STAI trait anxiety standard scores, F (1, 19) = 14.20, P = .001, g2 = .43; and
Coopersmith SEI scores, F (1, 19) = 9.71, P = .006, g2 = .34.

Post-Waiting List and Pre-Treatment Measures

Participants initially allocated to the waiting list control group were treated after
completing the waiting list phase. In order to justify including these participants in
the treatment outcome analyses, the post-waiting-list measures of these participants
were compared to the pre-treatment measures of the treatment group. MANOVAs
for independent samples revealed no significant multivariate differences between
these two groups for the gambling behaviour measures, Wilks’ L = .912, F (4,
14) = 0.34, P = .85, g2 = .09; or psychological functioning measures, Wilks’ L = .910,
F (4, 14) = 0.35, P = .84, g2 = .09. Thus, the post-waiting list data for the control
group served as pre-treatment data for the purpose of examining treatment outcome
at 6-month follow-up.

Six-Month Follow-up Outcomes

Treatment outcome for all participants who completed treatment (including those
who were initially allocated to the waiting list control group) was evaluated across
the pre-treatment, treatment, and follow-up phases. Treatment outcome was
evaluated on measures of gambling behaviour, psychological functioning, and
clinical significance.

Gambling Behaviour

The collection of continuous gambling behaviour data allowed weekly means to be

calculated over each phase. Due to the variability in the length of the treatment
phase, however, session-to-session means are displayed in preference to weekly
means (Fig. 1). Examination of Fig. 1 reveals an immediate reduction for all
gambling behaviour measures at the beginning of treatment. Progressive improve-
ment across the treatment phase is evident, with these gains maintained across the
follow-up period. The weekly gambling behaviour measures collated over the phases
are displayed in Table 3.
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Pre-
Treatment Treatment Follow-Up
2 Pre-
Tx
1.5
Frequency

0.5

2 00

1 50
Duration (mins)

1 00

50

2 50

2 00
Money inserted ($)

1 50

1 00

50

150
100
Expenditure ($)

50
0
-50
-100
-150
-200
10-11
11-12
9-10
1-2
2-3
3-4
4-5
5-6
6-7
7-8
8-9

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
1
2

1
2
3
4
5
6
7
8
9

Week/Session Number
Fig. 1 Weekly/sessional gambling behaviour measures during treatment phases

Inspection of Table 3 reveals that all measures improved from the pre-treatment
phase to the treatment phase, and were maintained in the follow-up period. A
MANOVA with repeated measures revealed a significant multivariate effect, Wilks’
L = .268, F (8, 10) = 3.41, P = .04, g2 = .73. In order to adjust for the violation of the
sphericity assumption by all four gambling behaviour measures: gambling frequency
(Mauchley’s W = .231, v2 = 23.46, P < .001); gambling duration (Mauchley’s
W = .260, v2 = 21.54, P < .001); money inserted (Mauchley’s W = .255, v2 = 21.84,
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J Gambl Stud (2006) 22:355–372 367

Table 3 Weekly gambling behaviour measures during treatment phases

Measure (n = 18) Pre-treatment Treatment phase Follow-up phase

phase
M SD M SD M SD

Frequency 1.56 1.41 0.39 0.45 0.27 0.28

Duration (mins) 170 171 45 69 28 36
Money inserted $197 224 $50 59 $58 76
Expenditure $178 216 $25 49 $50 75

P < .001); and expenditure (Mauchley’s W = .210, v2 = 24.99, P < .001), the Huynh-
Feldt statistic was applied to subsequent univariate analyses. Significant univariate
differences for all gambling behaviour measures were found: gambling frequency,
F (1.16, 19.66) = 14.63, P = .001, g2 = .46; gambling duration, F (1.18, 20.05) = 14.97,
P = .001, g2 = .47; money inserted, F (1.18, 19.98) = 7.82, P = .009, g2 = .32; and
expenditure, F (1.14, 19.38) = 7.91, P = .009, g2 = .32. Post-hoc pairwise compari-
sons for main effects with Bonferroni adjustments for multiple comparisons revealed
a significant reduction in all measures from the pre-treatment phase to the treatment
phase: gambling frequency (P = .004); gambling duration (P = .003); money inserted
(P = .02); and expenditure (P = .02); and no significant changes in any of the
measures from the treatment phase to the follow-up phase (P > .05).

Psychological Functioning

The average psychological functioning scores measured prior to treatment, following

treatment, and following completion of the follow-up phase are displayed in Table 4.
Examination of Table 4 reveals that all measures of psychological functioning im-
proved from the pre-treatment to post-treatment evaluations, and were maintained at
the post-follow-up evaluation. Average BDI-II scores improved from the moderate
range of depression at the pre-treatment evaluation to the minimal range of depres-
sion at both post-treatment and post-follow-up evaluations. Compared to normative
standardisation data, state anxiety improved from the 80th percentile rank at the pre-
treatment evaluation to the 53rd percentile rank at the post-treatment evaluation, and
was maintained at the 47th percentile rank at the post-follow-up evaluation. Similarly,
trait anxiety improved from the 87th percentile rank at the pre-treatment evaluation
to the 63rd percentile rank at the post-treatment evaluation, stabilising at the 54th
percentile rank at the post-follow-up evaluation. Coopersmith SEI scores improved
from the 14th percentile rank at the pre-treatment evaluation to the 40th percentile
rank at the post-treatment evaluation, and further improved to the 48th percentile at

Table 4 Psychological functioning measures at treatment evaluations

Measure (n = 18) Pre-treatment Post-treatment Post-follow-up

M SD M SD M SD

BDI-II 24.0 11.5 10.3 8.1 8.9 10.9

STAI state anxiety standard scores 67.8 17.5 52.7 14.8 50.2 15.4
STAI trait anxiety standard scores 71.3 15.3 55.9 14.1 53.3 16.7
Coopersmith SEI 49.8 22.6 69.6 26.3 74.9 22.5

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the post-follow-up evaluation. A MANOVA with repeated measures revealed a sig-

nificant multivariate effect for the treatment phase, Wilks’ L = .233, F (8, 10) = 4.13,
P = .02, g2 = .77. In order to adjust for the violation of the sphericity assumption by
the STAI state anxiety standard scores (Mauchley’s W = .630, v2 = 7.40, P = .03), the
Huynh-Feldt statistic was applied in subsequent univariate analyses involving STAI
state anxiety standard scores. Significant univariate differences were found across the
three evaluation periods for all measures: BDI-II scores, F (2, 34) = 22.23, P < .001,
g2 = .57; STAI state anxiety standard scores, F (1.56, 26.55) = 15.09, P < .001,
g2 = .47; STAI trait anxiety standard scores, F (2, 34) = 20.08, P < .001, g2 = .54; and
Coopersmith SEI scores, F (2, 34) = 19.72, P < .001, g2 = .54. Post-hoc pairwise
comparisons for main effects with Bonferroni adjustments for multiple comparisons
revealed a significant reduction in all four measures from pre-treatment to post-
treatment evaluations: BDI-II scores (P < .001); STAI state anxiety standard scores
(P = .004); STAI trait anxiety standard scores (P < .001); and Coopersmith SEI scores
(P < .001); and no significant changes in any of the measures from post-treatment to
post-follow-up evaluations (P > .05).

Clinically Significant Change

Diagnostic Criteria Of the 19 participants completing the treatment program, 16

(84%) no longer met diagnostic criteria for pathological gambling at completion of
the program. Of the 18 participants for whom complete follow-up information was
available, 16 (89%) no longer met diagnostic criteria at the completion of the follow-
up period.
Goal Achievement Scale (GAS) The GAS (Hudson et al., 1995) was employed
to determine the clinical significance of the change during the last 4 weeks of the
follow-up period (n = 18). The average GAS scores were 83% for gambling fre-
quency, 74% for gambling duration, and 81% for expenditure.
Classification of Outcomes Participants (n = 18) were classified into groups
according to their gambling behaviour in the month preceding the 6-month follow-
up evaluation (Blaszczynski et al., 2001). Abstinence was displayed by 61% of
participants, controlled gambling was displayed by 11% of participants, lapsed
gambling was displayed by 17% of participants, and uncontrolled gambling was
displayed by 11% of participants.

Discussion

The present study aimed to evaluate the efficacy of a cognitive-behavioural inter-

vention in the treatment of female pathological gambling. The results indicate that
this program was effective in improving gambling behaviour (gambling frequency,
duration, money inserted, and expenditure) and psychological functioning (depres-
sion, state anxiety, trait anxiety, and self-esteem) from the pre-treatment to the
post-treatment evaluations, and that these gains were maintained at the 6-month
follow-up evaluation. By the completion of the 6-month follow-up period, 89% of
participants no longer met diagnostic criteria for pathological gambling, the average
rate of improvement for gambling-related measures from pre-treatment ranged from
74 to 83%, and 72% of female pathological gamblers were classified as abstinent or
controlled gamblers. In addition, evaluation with self-report measures revealed that
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depression, anxiety, and self-esteem improved to normal or near-normal levels at

post-treatment and follow-up evaluations. The hypothesis that cognitive-behavioural
treatment would significantly improve gambling behaviour and psychological func-
tioning outcomes at post-treatment and post-follow-up evaluations was therefore
supported. These findings compare favourably to recent studies evaluating cognitive,
behavioural, and cognitive-behavioural treatments for predominantly male or mixed
gender pathological gamblers (Blaszczynski et al., 2001; Echeburúa et al., 1996;
Ladouceur et al., 2001, 2003; McConaghy et al., 1983, 1988, 1991; Sylvain et al.,
1997).
The outcomes of this research program are consistent with the view that cogni-
tive-behavioural techniques are effective in the treatment of female pathological
gambling (López Viets & Miller, 1997, NCETA, 2000; VGDHS, 2000). While
interventions that are comprised of a combination of therapeutic components make
it difficult to elucidate their relative contribution (Blaszczynski et al., 2001; López
Viets & Miller, 1997, NCETA, 2000; VGDHS, 2000), the general aim of this study
was not to determine the specific efficacy of particular therapeutic techniques, but to
address the fundamental issue of whether the therapy considered ‘best practice’ is
effective for female pathological gamblers. Further research will be required to
determine which single technique or combination of techniques is most effective in
treating pathological gamblers of both genders using measures that directly evaluate
change in each area. Given the apparent multi-causal nature of pathological gam-
bling, it may be that the most effective treatment for both genders involves the
combination of therapeutic techniques rather than any single technique (VGDHS,
2000).
When considering the practical implications of the findings of this study, it is
important to note several methodological limitations. While the apparent differences
between male and female pathological gamblers in previous research raise the pos-
sibility of gender-specific treatment needs, the absence of a male comparison group in
this study precludes forming conclusions regarding gender differences in treatment
outcome. Future research is therefore required to evaluate the influence of gender on
treatment outcomes and the potential impact of gender differences in demographic,
gambling, and psychological characteristics on treatment outcome. It would also be of
interest to examine the preferential response of males and females to different
treatment interventions. Secondly, given the relatively small sample size of female
pathological gamblers employed in this study, it is acknowledged that further scientific
demonstration and replication with larger samples is required in order to fully
establish the efficacy of cognitive-behavioural techniques and programs for female
pathological gamblers. Finally, it is acknowledged that it is desirable for treatment
outcome studies to include follow-up durations of 1–2 years (López Viets & Miller,
1997). While the results of this study suggest that the intervention was effective in the
short- and medium-term, it is recommended that future outcome studies continue
follow-up for at least 1 year after the completion of treatment.
Despite the success of this treatment program, the findings were moderated by the
treatment attrition rate (expressed as the proportion of pathological gamblers
commencing treatment who did not complete treatment) of 24% and treatment
refusal rate (expressed as the proportion of pathological gamblers contacting the
treatment agency but not presenting for treatment) of 15%. High attrition rates
before the completion of treatment were not unexpected given the high rates
reported by other studies in the pathological gambling treatment outcome literature.
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In fact, these rates compare favourably with previous treatment attrition rates of
15% to 53% and treatment refusal rates of 6 to 19% (e.g., Blaszczynski et al., 2001;
Echeburúa et al., 1996; Sylvain et al., 1997). These relatively low rates may indicate
that this program was attractive to female pathological gamblers, or that female
pathological gamblers are less likely to drop out once they have initiated treatment.
While the attrition rates in this study are comparatively low, it is evident that
clinicians should generally expect high rates of drop-out in the treatment of path-
ological gambling, particularly early in the treatment process (Echeburúa et al.,
1996; Ladouceur et al., 2003). High attrition rates in the treatment of pathological
gamblers are generally attributed to the low or ambivalent motivation that is
inherent in a substantial proportion of pathological gamblers (Blaszczynski & Steel,
1998). It is generally agreed that many pathological gamblers initiate contact with
treatment agencies in response to financial, legal, and emotional crises, and external
pressure from others, and that they tend to terminate treatment prematurely fol-
lowing crisis resolution or a reduction in external pressure (Blaszczynski, Walker,
Sagris, & Dickerson, 1997). It is therefore possible that those remaining in the
treatment program are more motivated and committed to succeed than those who
drop out (VGDHS, 2000). It is evident that future research is required to address the
issue of reducing the incidence of treatment refusal and attrition. It is important for
future research to identify and address the barriers to participating in, and contin-
uing treatment, for pathological gambling. The findings of this study suggest that
strategies are required to develop strong internal motivation early in the referral and
treatment process in order to facilitate treatment participation and completion. The
effect of motivation for change and motivational interviewing strategies on attrition
rates have yet to be explored with regard to their potential applicability to patho-
logical gambling and will provide an interesting direction for future research.
Despite numerous attempts, complete follow-up information was not available
from one participant during the follow-up period. The 6-month follow-up rate, ex-
pressed as the proportion of treated pathological gamblers follow-up, of 95%
compares favourably to previous 6-month follow-up rates of 71–90% (e.g.,
Ladouceur et al., 2001, 2003; Sylvain et al., 1997). There does not seem to be a
consensus regarding whether the individuals who could not be located at follow-up
evaluations should be included or excluded from the statistical analysis of treatment
outcome results. It has been suggested that while those pathological gamblers who
were unavailable for follow-up evaluations are likely to have poorer outcomes than
the contacted sample, it is overly stringent to classify them all as treatment failures
(Stinchfield & Winters, 2001). However, the overall rate of uncontrolled gambling at
the 6-month follow-up evaluation increases from 11 to 16% when the participant
who was not followed-up is classified as a treatment failure.
In conclusion, the current study provides the first treatment outcome study of
female pathological gambling. The findings revealed that a cognitive-behavioural
program employed to treat female pathological gamblers was capable of producing
statistically and clinically significant improvements in gambling behaviour and psy-
chological functioning. The outcomes of this study compare favourably to recent
studies evaluating cognitive-behavioural treatments for predominantly male patho-
logical gamblers (Blaszczynski et al., 2001; Echeburúa et al., 1996; Ladouceur et al.,
2001, 2003; McConaghy et al., 1983, 1988, 1991; Sylvain et al., 1997). Although further
scientific demonstration and replication with larger samples are required, the
finding that cognitive-behavioural therapy is effective in the treatment of female
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pathological gambling is consistent with the recommendation that cognitive-

behavioural therapy is ‘best practice’ for the treatment of pathological gambling
(López Viets & Miller, 1997; NCETA, 2000; VGDHS, 2000).

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