community therapy sex difference
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psikiatriTRANSCRIPT
ORIGINAL PAPER
Community Treatment for Problem Gambling:Sex Differences in Outcome and Process
Tony Toneatto Æ Jenny Jing Wang
Received: 6 February 2008 / Accepted: 2 September 2009 / Published online: 20 September 2009
� Springer Science+Business Media, LLC 2009
Abstract This study compared sex differences in related
treatment outcomes and processes in a community sample
of outpatient problem gambling treatment-seekers. Partic-
ipants attended approximately seven sessions of cognitive-
behavioral treatment. Women were more likely to have a
history of psychiatric comorbidity, prefer non-strategic/
non-skill forms of gambling, and have a more rapid pro-
gression towards a gambling problem than did men. At the
6-month post-treatment follow-up, men were found to have
improved to a significantly greater degree on measures of
gambling severity and rates of abstinence in comparison to
women. Moreover, men rated treatment components to be
more helpful, whereas women found specific gambling-
related treatment interventions (e.g., identification of high-
risk situations, gambling beliefs and attitudes) to be less
helpful. Implications for identifying treatment needs of
women seeking problem gambling treatment are discussed.
Keywords Pathological gambling � Sex differences �Treatment outcome � Treatment process
Women have tended to be historically under-represented in
gambling treatment programs (Lesieur and Blume 1991;
Crisp et al. 2000; Volberg 1994, 2003) although this gap is
rapidly narrowing (Petry 2005). Reviews of sex differences
in gambling behavior (e.g., Petry 2005) suggest that the
variables that lead to the initiation, maintenance, and res-
olution of problematic gambling patterns can be affected
by gender. Crisp et al. (2000, 2004) have suggested that the
lower prevalence of female gamblers in treatment may lead
to forms of treatment based on the clinical needs of men
thus potentially neglecting the specific treatment needs of
women. For example, gender differences in the progression
towards pathological gambling (i.e., more rapid among
women), gambling preferences (i.e., for chance-related
forms of gambling among women), predictors of gambling
behavior (i.e., childhood abuse), and history of addiction
and psychiatric comorbidity (i.e., higher rates among
women) have been observed (Petry 2005; Toneatto and
Nguyen 2007; Hraba and Lee 1996). Such differences
might be expected to have an impact on treatment out-
comes and might be expected to influence the nature of the
treatment intervention since the specific content of treat-
ment should match the issues and concerns most relevant to
women.
Despite the call for greater attention to be paid to gender
effects in treatment (Mark and Lesieur 1992) relatively few
outcome studies have reported such data. The few studies
that have examined sex differences include several phar-
macological (e.g., Pallanti et al. 2002; Blanco et al. 2002;
Kim and Grant 2001) and non-pharmacological (e.g.,
Hodgins et al. 2001; Robson et al. 2002) studies but did not
find any differences in treatment outcome. No study to date
has examined cognitive-behavioral treatment outcomes for
problem gambling by gender despite the widespread
availability and effectiveness of this modality in the
treatment of problem gambling (National Centre for Edu-
cation and Training on Addiction 2000; Petry 2005;
The views expressed in this article are those of the authors and do not
reflect those of the Center for Addiction and Mental Health.
T. Toneatto (&) � J. J. Wang
Clinical Research Department, Center for Addiction and Mental
Health, 33 Russell St, Toronto, ON M5S 2S1, Canada
e-mail: [email protected]
T. Toneatto
Department of Psychiatry, University of Toronto, Toronto,
ON, Canada
123
Community Ment Health J (2009) 45:468–475
DOI 10.1007/s10597-009-9244-1
Toneatto and Ladouceur 2003; Toneatto and Millar 2004).
A greater understanding of sex differences in psychosocial
treatment outcomes is important in order to facilitate the
development of optimally effective treatments for problem
gambling and to avoid generalizing treatment outcomes
from studies that consist primarily of male gamblers.
In addition to identifying gender differences in treatment
outcomes it is also important to understand the basis of
such differences. The Banff consensus (Walker et al. 2006)
recently set out a framework for reporting outcomes in
problem gambling treatment research that strongly
encouraged gambling treatment researchers to place greater
emphasis on understanding the process variables that may
mediate gambling treatment outcomes. That is, it is
important to identify the elements of treatment, which
generally tend to be multimodal, that are most associated
with beneficial treatment outcomes. Differences in out-
comes may be mediated by treatment-specific process
variables (e.g., specific variables) as well as by variables
that may be common to all treatments that characterize the
therapeutic environment and therapist-related factors (i.e.,
non-specific variables) (e.g., Walker et al. 2006; Frank and
Frank 1991; Toneatto 2005). Specific process variables are
related to the ostensible theoretical basis of the treatment
and are critical to examine in order to validly attribute
treatment outcomes to the treatment itself, especially in an
era of empirically supported treatments (Deegear and
Lawson 2003).
In this study, sex differences in treatment outcomes in a
sample of problem gamblers receiving outpatient cogni-
tive-behavioral treatment. In addition, differences in the
treatment process, including both specific and non-specific
variables, were examined. The study employed a one-
group, pre-post study design with a follow-up at 6 months
post-treatment. As this study was considered primarily
exploratory, firm hypotheses were not specified.
Method
Participants
Participants were recruited from the Problem Gambling
Service (PGS) at the Centre for Addiction and Mental
Health, an outpatient treatment service situated centrally
within a large urban Canadian metropolis. Consecutive
seekers of outpatient treatment were made aware of the study
when they contacted the PGS to make their initial appoint-
ment. Potential participants were asked if they were inter-
ested in participating in a treatment research study.
Interested individuals were asked to arrive 30 min earlier for
their first appointment in order to complete the baseline
assessment. The study was approved by the institutional IRB.
Procedure
Participants interested in the research study were greeted
by research staff who asked the participant to read and sign
the informed consent prior to completing the baseline
assessment. Following the completion of the assessment,
participants met with their therapist. There was no further
contact between research staff and the participant until
6 months following either the consensual termination of
treatment or the 10th session. Participants were paid $40
for completing the assessments at baseline as well as at
follow-up.
Assessment
Outcome Assessment
The baseline assessment consisted of measures of gambling
behavior, psychiatric symptoms, gambling severity, sub-
stance use and abuse, and treatment history. The frequen-
cies and monetary expenditures of the major types of
gambling were assessed with the Canadian Problem
Gambling Index (CPGI; Ferris and Wynne 2001). The
CPGI has been found to show good internal consistency
(a = .84), test–retest reliability (r = .78) and criterion-
related validity (r = .83 with DSM-IV pathological gam-
bling symptoms). The Brief Symptom Inventory-18 (BSI-
18; Derogatis 2000) measured current symptoms of anxi-
ety, depression and somatization. Internal consistency for
the BSI-18 ranged between a = .74 and a = .89 and test–
retest correlations between r = .68 and r = .90. Moreover,
extensive validity in both clinical and non-clinical popu-
lations has been reported as well (Derogatis 2000). Gam-
bling high-risk situations were assessed with a 12-item
short form of the Inventory of Gambling Situations (IGS;
N. Turner and N. Littman-Sharpe, unpublished). The IGS
has received extensive psychometric evaluation (N. Turner
and N. Littman-Sharp, unpublished) and yields scores on
several clinically meaningful sub-scales. Internal consis-
tency for this measure has been shown to be very high
(a = .98) with excellent concurrent validity (e.g., r = .77
with DSM –IV, clinical stress, r = .54, BSI, r = .52)
reported (T. Toneatto, unpublished data). Current sub-
stance use/abuse and lifetime treatment history, gambling
treatment and other psychiatric treatment was assessed
using a checklist routinely administered on the PGS. The
severity of problem gambling was assessed using a
checklist consisting of the ten symptoms of pathological
gambling as described in the DSM-IV (American Psychi-
atric Association 1994). Subjective rating of problem
severity was measured on an 11-point Likert scale ranging
from 0 to 100%. All measures were repeated at the 6-
month follow-up assessment.
Community Ment Health J (2009) 45:468–475 469
123
Process Assessment
A checklist of topics discussed during treatment (e.g., high
risk situations, cognitive distortions, setting goals) was
developed in collaboration with the treatment staff of the
PGS. Participants were asked to rate the helpfulness of
each treatment topic on a 5-point scale ranging from ‘very
unhelpful’ to ‘very helpful’.
Non-specific treatment processes related to the partici-
pants’ relationship with the therapist (e.g., ratings of
respect by therapist, treatment rapport, feeling understood)
and the therapeutic environment (e.g., satisfaction with
treatment, feeling welcome, feeling comfortable) were
evaluated. The non-specific measures were evaluated on
5-point Likert scales ranging from ‘strongly agree’ to
‘strongly disagree’. The process assessment was completed
at the 6-month follow-up.
Treatment
The cognitive-behavioral treatment was delivered by 11
therapists (7 women, 4 men) at the PGS, the largest and
oldest gambling treatment agency in Ontario. All thera-
pists were highly experienced in the treatment of problem
gambling. The majority of the participants (45/60) were
treated by female therapists. The treatment modality
delivered at the PGS can be described as short-term
cognitive-behavioral treatment with the goal of both
reducing gambling behavior and alleviating the negative
consequences associated with problem gambling through
the provision of appropriate coping skills. Treatment goals
and interventions were developed in collaboration with
the client. Each session typically consisted of an evalua-
tion of the client’s progress in addressing the gambling
behavior, identification of variables that may have inter-
fered with clinical progress, and the development of
interventions to further facilitate behavior change. Iden-
tification of high-risk triggers for behavior and the
development of effective coping responses were routinely
conducted. Issues unrelated specifically to gambling
behavior but impacting on the resolution of the gambling
problem (e.g., marital issues, emotional factors) were
discussed as needed. The number of treatment sessions
attended was determined consensually between the par-
ticipant and their therapist.
Data Analysis
Two-tailed t-tests (P \ .05) were used to determine the
significance of mean comparisons between men and
women. Chi-square was used to evaluate the association
between gender and categorical variables. Statistical results
approaching conventional significance were reported due
to their heuristic value in elucidating the relationship
between gender in gambling-related treatment outcome and
process. The effect size comparing baseline and follow-up
on key gambling related variables (e.g., reduction in
gambling behavior, reduced severity as measured by
diagnostic measures) was expected to be large (d = .80).
Fixing alpha at 5%, and with the power parameter set at
.80, d = 2.80, a minimal sample size of approximately 15
subjects would be required to adequately power the
analyses.
Results
Sample Description
A total of 60 subjects (44 men, 16 women) completed the
baseline assessment; 46 (76.7%; 32 men, 14 women)
individuals attended the 6-month follow-up assessment.
Rates of attrition for the men and women were similar
(22.8, 25.0%, respectively) with no statistical associa-
tion between availability for follow-up and gender, v2
(1) = 0.03, ns. There were no significant differences on
demographic, gambling-related (i.e., severity, duration,
type) or mental health variables between the 46 individuals
who participated in the follow-up and the 14 individuals
who did not.
The baseline sample was primarily middle aged M
(SD) = 45.37 (12.72), male (73%), married (48%) and
employed (65%). There were no sex differences on any
demographic variable. The primary reasons cited for
seeking treatment, self-motivation and the encouragement
of significant others, were similarly prevalent for both men
(72.7%, 32/44) and women (87.5%, 14/16).
Baseline Description of Gambling Behavior
Men reported a significantly earlier onset of gambling and
problem gambling. Women began gambling in their early
1930s while men reported an onset of gambling over a
decade earlier, in their early 1920s. On average, men
reported a problem gambling duration of approximately
10 years compared to an average of 4.5 years for the
women. This is consistent with the more rapid progression
towards problem gambling that is often reported among
women (i.e., telescoping effect). Non-strategic, chance-
based types of problem gambling (e.g., slots, bingo, lot-
teries) were significantly more common among women
(81.8%), while men mostly (61.4%) preferred strategic,
skill-based types of problem gambling (e.g., cards, track,
sports; v2 (1) = 8.52, P \ .005.
A significantly larger proportion of the women were
completely abstinent from track and sports gambling at
470 Community Ment Health J (2009) 45:468–475
123
the baseline assessment whereas abstinence from slot
machine play was more common among men. Most of the
participants (80%) met DSM-IV diagnostic criteria for
pathological gambling and subjectively rated their gam-
bling problem as relatively severe (*8 on a 10-point
scale).
On the measure of high-risk triggers for heavy gambling
(IGS) a significantly larger proportion of women reported
heavy gambling ‘almost always’ when they were stressed,
depressed or unhappy (68.8 vs. 29.5% of the men, v2
(3) = 7.67, P \ .05, and in conflicted social situations
(43.8 vs. 9.5% of the men, v2 (3) = 9.02, P \ .05.
Concurrent Disorders
Rates of current and lifetime substance abuse were similar
for men and women. Moreover, concurrent substance use
was uncommon among the sample with 91.7% of the
women and 71.1% of the men not reporting any substance
use, v2 (1) = 4.41, ns. Rates of contact with the mental
health system, such as treatment by a psychiatrist and
prescription of psychotropic medications, were generally
higher among women. The rates of lifetime prescription of
anti-depressant medication for women (60.0 vs. 32.6% for
men, v2 (1) = 3.90, P \ .05) and current treatment by a
psychiatrist (26.7 vs. 8.8% for men, v2 (1) = 4.22,
P \ .05) reached statistical significance. In addition,
women reported significantly higher baseline scores on the
anxiety sub-scale of the BSI-18, M (SD) = 2.83 (1.29)
when compared to men, M (SD) = 2.14 (0.93), t (55) =
-2.22, P \ .05.
Follow-Up Assessment
Gambling Behavior
At the 6-month follow-up, men were more likely to report
complete abstinence from gambling since treatment ter-
mination (38.2%) than the women (8.3%; v2 (1) = 3.95,
P \ .05 (Table 1). Despite the absence of a sex difference
in the reduction of gambling expenditures between baseline
and follow-up (Tables 1, 2 and 3), a marginally larger
proportion of the men reported spending no gambling
expenditures during the follow-up period (29.5%) com-
pared to 6.3% of the women, v2 (1) = 3.56, P \ .06.
Gambling Severity
A significantly higher proportion of women continued to
meet DSM-IV diagnostic criteria for pathological gambling
at the follow-up (Table 1). The men showed a reduction of
approximately four symptoms on the DSM, while women
reported a reduction of just over one symptom. At follow-
up, 7/12 women (58.3% within gender) continued to meet
diagnostic criteria for pathological gambling, compared to
6/34 men (17.6% within gender).
In an examination of individual DSM pathological
gambling symptoms (Table 4), women were found to have
higher rates for all except two of the ten symptoms. Since
multiple comparisons were conducted for this analysis, the
significant differences reported at P \ .05 must be inter-
preted cautiously. This analysis indicated continued diffi-
culty with problem gambling, in particular the continued
Table 1 Description of
gambling onset, severity and
expenditures, by sex
a t (16.98) = -2.62, P \ .05;b t (57) = 2.36, P = .05;c t(57) = -2.15, P \ .05;d t (45.3) = 2.78, P \ .01;e v2 (1) = 5.97, P \ .05;f t(44) = 2.61, P \ .05;g t (44) = -2.94, P \ .01;h t (44) = -2.91, P \ .01
* 10-point scale ranging from 0
(no problem) to 10 (extremely
serious problem)
Variable Men
(n = 44 at baseline;
n = 32 at follow-up)
Women
(n = 16 at baseline;
n = 14 at follow-up)
Age of first gambling with moneya 20.73 (7.75) 33.33 (17.72)
Years gamblingb 24.02 (12.67) 14.87 (13.98)
Age of problem gambling onsetc 35.09 (13.14) 43.67 (14.04)
Years of problem gamblingd 9.66 (8.96) 4.53 (4.87)
Gambling expenditures-baseline (C$) 5,639 (5,489) 6,588 (9,023)
Gambling expenditures-post treatment (C$) 860 (1,234) 1,470 (11,410)
Change in gambling expenditures-follow-up (C$) -5,372 (5,785) -5,662 (10,716)
%DSM-IV criteria for pathological gambling-baseline 77.3 87.5
%DSM-IV criteria for pathological gambling-follow-upe 20.6 58.3
Change in number of DSM symptoms endorsedf 4.18 (3.33) 1.33 (2.93)
M(SD) pathological gambling symptoms-baseline 6.43 (2.38) 6.25 (2.91)
M(SD) pathological gambling symptoms-follow-upg 2.26 (2.92) 5.33 (3.60)
Self-rating* of problem gambling severity-baseline 7.75 (2.45) 8.56 (2.37)
Self-rating* of problem gambling severity-follow-uph 2.91 (2.31) 5.42 (3.20)
Change in self rating* of problem severity-follow-up 4.71 (2.90) 3.00 (3.49)
Community Ment Health J (2009) 45:468–475 471
123
use of gambling as a coping mechanism for negative and
aversive emotional states.
The subjective rating of problem gambling severity was
higher among women (5.4/10) compared to the men (2.9/
10). Moreover, women continued to report significantly
higher scores on the anxiety sub-scale of the BSI-18, M
(SD) = 2.18 (1.00) in comparison to men, M (SD) = 1.57
(0.76), t (44) = -2.18, P \ .05) at the follow-up.
Men were marginally more likely to indicate at the
follow-up assessment that additional treatment was not
required (44.1%) following termination compared to
women (16.7%; v2 (1) = 5.43, P \ .07). However, as
Tables 5 and 6 shows, the reasons for discontinuing treat-
ment were similar for men and women.
Treatment Process and Program Satisfaction
There was no sex difference in the number of treatment
sessions attended (men: M (SD) = 6.16 (5.07), women: M
(SD) = 8.31 (7.93), t (19.6) = -1.01, ns). Twenty per-
cent of the sample attended greater than ten sessions. Few
Table 2 Gambling abstinent rates at baseline and follow-up, by sex
% Abstinent Men
(n = 44 at
baseline;
n = 32 at
follow-up)
Women
(n = 16 at
baseline;
n = 14 at
follow-up)
Cards-baseline 43.2 68.8
Cards-followupa 52.4 90.9
Racetrack-baselineb 63.6 100
Racetrack-follow-up 81.0 90.9
Sports-baselinec 70.5 100
Sports-follow-upd 66.7 100
Lotteries-baseline 38.6 37.5
Lotteries-follow-up 42.9 27.3
Bingo-baseline 86.4 68.8
Bingo-follow-up 81.0 72.7
Slot machines-baselinee 50.0 12.5
Slot machines-follow-upf 61.9 9.1
a v2 (1) = 4.75, P \ .05; b v2 (1) = 7.93, P \ .01; c v2 (1) = 6.04,
P \ .05; d v2 (1) = 4.69, P \ .05; e v2 (1) = 6.88, P \ .01; f v2
(1) = 8.18, P \ .05
Table 3 Mental health, substance abuse and gambling treatment
history, by sex
Variable Men
(n = 44)
Women
(n = 16)
Substance abuse treatment
Ever treated for an alcohol problem 11.4 13.3
Currently have an alcohol problem 6.8 13.3
Ever treated for other drug problems 9.1 13.3
Currently have a drug problem 9.1 6.7
Ever been treated by a psychiatrist 34.9 60.0
Currently being treated by a
psychiatrista6.8 26.7
Gambling treatment
Ever attended gamblers anonymous 29.5 50
Ever attended other treatment for
gambling problem
22.7 25
Mental health treatment
Ever prescribed medication for anxiety 18.2 35.7
Currently taking medication for anxiety 9.1 7.7
Ever been prescribed medication for
depressionb32.6 60.0
Currently taking medication for
depression
18.6 26.7
a v2 (1) = 4.22, P \ .05; b v2 (1) = 3.50, P \ .06
Table 4 DSM-IV symptoms of pathological gambling at follow-up,
by sex
Symptom Men
(n = 34)
Women
(n = 12)
Preoccupied with gamblinga 23.5 58.3
Need to increase gamblingb 20.6 58.3
Repeated unsuccessful efforts to controlc 20.6 58.3
Restless/irritable when cutting downd 23.5 58.3
Gambling to escape problemse 29.4 75.0
Chasing lossesf 23.5 58.3
Lying to others about gamblingg 23.5 58.3
Committing illegal acts 17.6 8.3
Jeopardizing relationshipsh 29.4 58.3
Rely on others to relieve desperate
financial situationi14.7 41.7
a v2 (1) = 4.89, P \ .05; b v2 (1) = 5.97, P \ .05; c v2 (1) = 5.97,
P \ .05; d v2 (1) = 4.89, P \ .05; e v2 (1) = 7.60, P \ .01; f v2
(1) = 4.89, P \ .05; g v2 (1) = 4.89, P \ .05; h v2 (1) = 3.18,
P \ .07; i v2 (1) = 3.79, P \ .05
Table 5 Reasons for termination of treatment, by sex
Reason Men
(n = 44)
Women
(n = 16)
My therapist and I decided treatment
completed
14.7 (5) 8.3 (1)
Decided I was doing okay 41.2 (14) 41.7 (5)
Did not like my therapist 0 (0) 8.3 (1)
Missed a session and no follow-up 8.8 (3) 8.3 (1)
Attending other treatment program 5.9 (2) 0 (0)
Difficulty attending appointments 0 (0) 8.3 (1)
Still in treatmenta 29.4 (10) 25 (3)
a This question was asked following session 10; several participants
continued to attend treatment
472 Community Ment Health J (2009) 45:468–475
123
sex differences in the rating of the treatment program
overall, the therapist or the components of treatment were
observed. Since multiple comparisons were conducted, the
few significant differences reported at P \ .05 must be
interpreted cautiously. Where differences were found they
were consistent with a theme of general dissatisfaction on
the part of the women. Compared to the men, the women
were significantly less likely to state that they would
re-contact the treatment agency for additional treatment.
Women were less likely to rate the following treatment
specific components as helpful: the identification of high-
risk situations and triggers for their gambling, the devel-
opment of effective coping responses and action plans and
the discussion of gambling-related cognitive distortions.
Gender differences for several other treatment aspects
approached significance (i.e., setting short and long-term
goals), with women generally rating all aspects of the
gambling treatment they received to be relatively less
helpful.
Discussion
With the growing number of women seeking treatment for
problem gambling and the accumulation of a considerable
body of research showing many sex differences in gam-
bling and problem gambling, it is important to investigate
whether such differences are also obtained in treatment
outcomes. Very little is currently known about sex differ-
ences in gambling treatment outcomes. Brief cognitive-
behavioral treatments commonly offered in most outpatient
settings may be unintentionally geared towards male-spe-
cific treatment needs (Crisp et al. 2000, 2004), given the
traditionally disproportionate number of men within the
treatment seeking population (e.g., Volberg 1994). This
may contribute to higher rates of early treatment termina-
tion and dissatisfaction with therapeutic interventions
within treatment-seeking females (Dowling et al. 2006).
With the increasing number of women seeking treatment, a
better understanding of women-specific treatment needs
and interventions will be critical to effectively treat prob-
lem gambling within this growing demographic (Mark and
Lesieur 1992). The primary goal of this study was to
examine sex differences in outcomes following cognitive-
behavioral therapy and the therapeutic processes that may
mediate such differences.
The results of this study were consistent with previous
research in demonstrating gender differences in gambling
behavior and history, such as the rapid progression towards
problem gambling among women, men’s preferences for
strategic/’skill-based’ gambling and the tendency to gam-
ble heavily under conditions of negative affect and inter-
personal conflict among women (Grant and Kim 2002;
Ladd and Petry 2003; Potenza et al. 2001; Trevorrow and
Moore 1998). Moreover, in the current study, contact with
the mental health treatment system and concurrent
comorbidity, especially anxiety and depression, were ele-
vated among female problem gamblers, also consistent
with previous research (e.g., Potenza et al. 2001; Ibanez
et al. 2003).
Unlike previous treatment gambling studies (none of
which examined cognitive-behavioral treatments) that
found no gender differences in outcome (e.g., Hodgins
et al. 2001; Pallanti et al. 2002; Blanco et al. 2002; Kim
and Grant 2001), several significant gender-influenced
differences in treatment outcome, process and satisfaction
were identified in the current study. In general, men
reported significantly more positive treatment outcomes
and reduced severity of their gambling problem compared
Table 6 Evaluation of therapeutic environment, therapist and treat-
ment, by sex
Variable Men
(n = 34)
Women
(n = 12)
Therapeutic environment, rating of agreement/strong agreement
Welcoming treatment atmosphere 91.2 83.3
Positive initial contact with agency 90.9 100
Comfortable in re-contacting agencya 97.1 80.0
Culture respected 96.6 88.9
Therapist factors, ratings of agreement/strong agreement
Understood by therapist 84.8 91.7
Felt respected by therapist 97.0 83.3
Knowledgeable therapist 84.8 72.7
Mutually agreed goals and tasks 80.6 54.5
Free and honest communication
with therapist
97.1 83.3
Therapist helped accomplish my goals 76.7 58.3
Treatment factors, ratings of helpful/very helpful
Counselling effective 76.7 58.3
Helpful treatment content 97.1 83.3
Coping with high-risk situationsb 80.0 41.7
Examine positives and negatives
of gambling
84.4 91.7
Review of gambling behavior since last
session
78.6 58.3
Identify high risk situations and triggersc 93.5 66.7
Setting short-term goals 70.0 45.5
Setting long-term goals 64.3 36.4
Discuss gambling distortionsd 87.5 58.3
Discuss issues regarding family/
friends
75.0 90.9
Discuss financial issues 56.7 80.0
Discuss leisure activities 75.9 63.6
a v2 (1) = 3.54, P \ .06; b v2 (1) = 5.89, P \ .05; c v2 (1) = 5.21,
P \ .05; d v2 (1) = 4.56, P \ .05
Community Ment Health J (2009) 45:468–475 473
123
to women. Men also reported a higher abstinence rate at the
6-month follow-up. Women continued to rate their gam-
bling problem as more severe than did the men, both at
baseline and at the follow-up. Overall, the women in this
study seemed to have had a more severe gambling problem
at baseline but did not benefit from treatment to the degree
that the men did, despite having a much shorter duration of
problem gambling than the men.
Several sex differences in treatment process variables
were also found which may help explain the differences
found in treatment outcome. More female gamblers rated
therapeutic tasks that are considered central to cognitive-
behavioral therapy (i.e., identifying high-risk situations,
discussing gambling-related cognitive distortions, develop
coping response) to be less helpful in reducing their gam-
bling behavior in comparison to men. While these thera-
peutic elements are central to the cognitive-behavioral
approaches to problem gambling, they may be insufficient
in addressing women-specific treatment needs.
In addition, emotional dysfunction was elevated among
the women as indicated by the higher rates of psychiatric
treatment, past treatment for depression, and higher anxi-
ety. Negative affect may act as an important obstacle to
treatment progress, especially if it is functionally related to
gambling and therefore may require a more specific inter-
vention (Hodgins and Holub 2007; Hodgins et al. 2005;
Petry 2005). Moreover, the DSM symptom patterns at
follow-up not only indicated a stronger functional rela-
tionship between gambling and negative affect among
women, but also suggested that women were more likely to
use gambling as a form of negative affect regulation and a
coping mechanism for gambling-related withdrawal
symptoms. This is consistent with Getty, Watson and
Frisch’s (2000) report that depression in women attending
GA was associated with poorer (i.e., reactive) coping
styles. Furthermore, Blanco et al. (2006) also found women
pathological gamblers to be more likely to report gambling
as a form of alleviation from depression compared to men.
In terms of treatment outcome, Daughters et al. (2003) also
identified negative affect and cognitive distortions as likely
predictors of poor treatment outcome. The current study
suggested that these predictors may be more problematic
for women.
While psychiatric co-morbidity would normally be
identified and assessed in any comprehensive gambling
treatment approach, such symptoms may not always be
effectively addressed during the brief interventions com-
monly delivered in outpatient settings. In addition to
gambling-specific approach, treatment interventions for
women may require additional skill training in emotional
regulation and coping in order to maximize positive out-
comes (Getty et al. 2000). More specifically, by identifying
the functional relationship between gambling behavior and
emotional regulation, the coping skill deficits that may
interfere with establishing control over gambling behavior
can be better understood. Specifically, this might include
the treatment of depression and anxiety, emotions that are
the target of gambling behavior among women. A more
closely integrated intervention combining cognitive-
behavioral treatment and pharmacological management
might also be indicated based on the presence of dys-
functional emotional syndromes among the woman
gamblers.
It is noteworthy that men and women did not differ with
respect to the non-specific aspects of treatment (e.g., rela-
tionship with therapist, perceptions of respect), which
suggests that the differential outcomes may be more
associated with the specific treatment interventions rather
than extra-therapeutic variables. Men and women were
equally satisfied with the therapeutic environment and their
therapist.
Several methodological limitations weakened the find-
ings of this study and thus serve as a caution against pre-
mature generalization of the findings. The small sample size
at the follow-up, especially of the women, limits the power
of the results reported. In addition, details about additional
treatment(s) that may have been sought between treatment
and the 6-month follow-up was not assessed. Moreover, the
relatively short follow-up period may not have permitted
the assessment of stable treatment outcomes. The fact that
self-report in this study was not corroborated, weakened the
internal validity of the study. Finally, since multiple com-
parisons were conducted for several of the statistical anal-
yses, the significant differences reported at P \ .05 must be
interpreted cautiously and within the context of this study as
a pilot investigation. Thus, the results are best considered
preliminary and suggestive. Future research should strive to
rectify these weaknesses and validate the major findings of
this study in a larger sample.
With the increasing prevalence of women in gambling
treatment it is important that sex differences in treatment
needs and modalities be better understood. This study
demonstrated that women attending an outpatient gambling
program did not fare as well as their male counterparts at a
6-month follow-up and appeared to value less the inter-
ventions common to a cognitive-behavioral approach.
There are also suggestions that an effective CBT for
women gamblers may need to place a greater emphasis on
the role of emotional variables and concurrent disorders
that may mediate excessive gambling.
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