Betting on change: An analysis of cognitive motivational behavior therapy versus referral to gamblers anonymous for gambling disorder.

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Published in final edited form as: Psychol Addict Behav. 2025 Mar 20;39(4):375–388. doi: 10.1037/adb0001063 Betting on Change: An Analysis of Cognitive Motivational Behavior Therapy vs. Referral to Gamblers Anonymous for Gambling Disorder Edelgard Wulfert 1 , Stephanie Wemm 2 , James Broussard 3 Author information Article notes Copyright and License information 1 Department of Psychology, University at Albany, State University of New York 2 Department of Psychiatry, Yale University Medical School 3 Department of Psychology, Jackson State University ✉ Correspondence concerning this article should be addressed to Edelgard Wulfert, Department of Psychology, University at Albany, State University of New York, Albany, NY 12222. ewulfert@albany.edu Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12140906  NIHMSID: NIHMS2055301  PMID: 40111861 The publisher's version of this article is available at Psychol Addict Behav Abstract Objective: Many existing treatments for gambling disorder grapple with the challenge of losing participants from treatment. Thus, treatments designed to increase adherence and retention would contribute significantly to the existing gambling treatment efficacy literature. Our study steps into the arena with an innovative approach. Method: We tested the effectiveness of Cognitive Motivational Behavior Therapy (CMBT), a treatment for gambling disorder designed not only to address symptoms but also to anchor participants throughout the treatment journey. We enrolled 46 individuals seeking treatment for gambling problems, all meeting criteria for gambling disorder, and randomly assigned them to undergo 12 sessions of CMBT or to attend at least 12 sessions of Gamblers Anonymous (GA) meetings. Results: Zero-inflated poisson regression showed that individuals in CMBT had a 94% probability of completing treatment, with 95.7% attending all 12 treatment sessions and 91.3% completing the 6-month follow-up. Overall, individuals in CMBT gambled less money during follow-up periods relative to baseline than those in GA, F (3, 116.81)=3.72, p =0.01. A secondary moderator analysis revealed that of those participants who were low in readiness to change, only those randomized to CMBT gambled less money, F (3, 110.29)=3.96, p =0.01. Conclusions: Compared to GA, CMBT was more effective at retaining participants in treatment and reducing the amount of money gambled. For those who began treatment with low readiness to change, CMBT also decreased the severity of problem gambling, which was not the case for those referred to GA. Keywords: cognitive motivational behavior therapy, motivational interviewing, cognitive behavior therapy, gambling disorder, Gamblers Anonymous, randomized control trial A major cross-national meta-analysis ( Tran et al., 2024 ) showed that gambling is a global phenomenon, with 46% of adults and 28% of adolescents having gambled in the past year. The prevalence of gambling in the United States matches these data. According to the American Gaming Association (2023) , 102 million adults, or 41% of the population, visited a casino for gambling or other entertainment in the past year and 20% bet on some sport. Almost three quarters of Americans perceive the casino industry to benefit local communities due to their entertainment value, job creation and tax revenues. These perceived benefits notwithstanding, research highlights the detrimental societal, social, and personal effects of gambling. Globally, nearly 2% of adults are engaging in problematic gambling ( Tran et al., 2024 ). Similarly, up to 2% of the U.S. population develop a gambling disorder at some point in their lives, and an additional 5% engage in risky forms of gambling that cause harm but do not warrant a psychiatric diagnosis ( Welte et al., 2015 ). For these individuals, the surge in physical and online betting opportunities has been associated with increased social costs and multiple adverse personal consequences of excessive gambling ( Blaszczynski et al., 2011 ; Camp, Hartley, & Kelly, 2018 ). Addressing the harmful consequences of recurrent excessive gambling requires effective treatments ( Potenza et al., 2019 ). However, this urgent need faces significant challenges. First, only about 10% of individuals with a lifetime diagnosis of gambling disorder ever seek treatment ( Cunningham-Williams et al., 2005 ; Volberg et al., 2006). A Canadian survey found treatment-seeking rates varying from 3% for problem gamblers to 25% with severe gambling disorder ( Suurvali et al., 2008 ). These data underscore the widespread reluctance of individuals to pursue psychological treatment. Second, the development of effective treatments for gambling disorder remains in its early stages ( Petry, Ginley, & Rash, 2017 ). Reviews and meta-analyses have reported promising results for different variants of cognitive behavioral therapies (CBT) and motivational enhancement techniques when compared to minimum interventions or waitlist controls (e.g., Petry et al., 2017 ; Yakovenko et al., 2015 ). However, recent findings suggest caution. In a meta-analysis, Pfund and colleagues (2023) found that CBT interventions significantly reduced gambling severity, frequency and intensity at post-treatment, but the evidence for lasting effects at follow-up was inconclusive. Caution is also warranted due to the heterogeneity of the studies in meta-analyses and the predominance of small-sample studies that tend to report the largest treatment effects ( Gooding & Tarrier, 2009 ; Pfund et al., 2023 ). A third challenge in the gambling treatment literature is high attrition. Individuals with gambling problems are not only reluctant to seek treatment, but approximately 31–39% are estimated to drop out prematurely (e.g., Melville et al., 2007 ; Pfund et al., 2018 , 2021 ). This high rate of attrition is particularly concerning in light of recent meta-analytic findings that attending more sessions in face-to-face gambling-focused treatments is linked to better outcomes ( Pfund et al., 2020 ). In essence then, while cognitive and behavioral interventions for gambling disorder have received substantial empirical support, the challenges described above also highlight that enhancing treatment efficacy and improving retention are critical areas for future research. A Case for Motivational Enhancement Many individuals grappling with gambling disorder lack intrinsic motivation to pursue treatment ( Pulford et al., 2009 ). Rather than being self-driven, seeking help is influenced by external factors such as a partner, family, job-related or legal circumstances. The reason for this hesitancy is the gambler’s ambivalence arising from the dual nature of gambling. Akin to other addictive behaviors, gambling is simultaneously intensely rewarding and detrimental, thereby creating a motivational conflict. The individual is faced with a choice between two equally undesirable alternatives: continuing to gamble at the risk of losing family, friends, employment, and self-respect; or renouncing a potent source of reinforcement. Therapists who are inattentive to this motivational conflict may inadvertently promote dropout by prematurely implementing change strategies. To mitigate dropout, gamblers’ ambivalence may be decreased through a Motivational Interviewing (MI) approach ( Miller & Rollnick, 2013 ). This is a widely used client-centered approach that uses a collaborative, goal-oriented style of communication to increase clients’ motivation to change. When the therapist adopts an empathic, non-judgmental style, often coupled with personalized feedback, a condition is created that may enable patients to evaluate their situation without defensiveness, which in turn might increase their motivation for action and a commitment to change. Brief MI interventions have demonstrated moderate to large effects in treating substance use disorders, both in individual ( Burke et al., 2003 ) and group settings (Santa Ana et al., 2005), and they have also have been used to address gambling problems. For example, Hodgins and colleagues showed that problem gamblers fared better with a self-help CBT workbook when they received a brief MI telephone call than the workbook alone, although these effects dissipated over a 12-month follow-up ( Hodgins et al., 2001 ). Additional reports of beneficial effects of brief MI exist ( Hodgins et al., 2004 ; 2009; Pfund, Whelan, Peter & Meyers, 2020 ), but other studies have found few benefits of a single MI session compared to brief advice ( Petry et al., 2008 ) or comparable effects of MI, MI+CBT, and brief advice ( Petry et al., 2009 ). The efficacy of MI-enhanced Internet-based CBT for disordered gambling has also been investigated. Although brief weekly MI telephone calls improved outcomes compared to a waitlist, non-compliance with completing the assigned CBT modules was high ( Carlbring et al., 2008 , 2012 ). Similarly, four individual MI sessions versus eight CBT group sessions led to equivalent improvements in gambling frequency and expenditures, but not more than a waitlist condition ( Carlbring et al, 2010 ). In addition, compliance with session attendance was low. An additional evaluation of the efficacy of brief MI in treating gambling problems comes from a systematic review and meta-analysis ( Yakovenko et al., 2015 ). In all but one study, MI was delivered in a single session face-to-face or via telephone. Compared to controls, MI was associated with modest reductions in gambling frequency and money lost from pre- to post-treatment, with only gambling frequency remaining lower during longer-term follow-up. The authors concluded that MI is efficacious in the short term, but it is unclear whether treatment effects are maintained over time. Cognitive Motivational Behavior Therapy (CMBT) We propose that strategically integrating motivational style elements into cognitive and behavioral interventions can reduce attrition and improve treatment outcomes for gambling disorder. The goal of MI is to reduce ambivalence in gamblers and boost their intrinsic motivation to change. As people are more likely to follow their own beliefs than external advice ( Naar & Safren, 2017 , p. 7), this process often involves eliciting “change talk,” where individuals express their own awareness of the harmful effects of gambling and their desire to change. Brief MI may provide the initial impetus for entering treatment; however, motivation is not a linear process and is prone to fluctuations ( Prochaska, DiClemente & Norcross, 1992 ). For many clients, brief motivational interventions alone may not cultivate a lasting commitment to change, resulting in non-compliance or attrition (e.g., Carlbring et al., 2010 , 2012 ; Pfund, Whelan et al., 2020 ). This challenge may be particularly pronounced in individuals with severe gambling disorder. Therapists must therefore closely monitor and address motivational shifts, not only to encourage initial attendance but also to sustain clients’ engagement and prevent premature termination. Retention is critical, given evidence that maintaining clients in face-to-face therapy is associated with better outcomes for gambling disorder ( Pfund, Peter et al., 2020 ). Beyond enhancing clients’ motivation to undergo treatment, it is crucial to equip them with tools to challenge maladaptive thoughts and behaviors. CBT provides essential cognitive and action-oriented skills that can empower clients to manage their gambling urges effectively. To sustain motivation, it is most beneficial to teach these skills within a supportive and respectful therapeutic relationship. Given that MI is described as a “person-centered counseling style for addressing the common problem of ambivalence about change” ( Miller & Rollnick, 2013 , p. 21), we propose that engagement and retention in CBT improve when cognitive and behavioral skills building is integrated with a motivational interviewing style throughout the treatment process. Purpose of the Present Study In this study we evaluated the efficacy of Cognitive Motivational Behavior Therapy (CMBT; Wulfert, Blanchard & Martell, 2003 ) which systematically integrates elements of Motivational Enhancement Therapy (MET; Miller, Zweben, DiClemente & Rychtarik, 1994 ) with a gambling-specific cognitive behavioral intervention ( Ladouceur, 1999 ) while maintaining an MI-consistent style throughout treatment. An exploratory study by Wulfert, Blanchard, Freidenberg, and Martell (2006) showed promising results, with all participants in CMBT completing treatment and a 12-month follow-up assessment compared to only 67% of patients who received treatment as usual (TAU). CMBT led to significant improvements in gambling frequency, intensity, and expenditures that were maintained during follow-up. However, conclusions were tentative due to non-random assignment, lack of follow-up data for the TAU condition, and the small sample size. To examine the clinical efficacy of CMBT under controlled circumstances, in this study we conducted a randomized clinical trial with treatment-seeking patients diagnosed with gambling disorder. Participants were randomized to 12 sessions of CMBT or referral to at least 12 sessions of weekly Gamblers Anonymous (GA) meetings, although participants could opt to attend more. The impact of these conditions on retention and gambling behavior was monitored during treatment and a six-month follow-up period. Additionally, in a secondary analysis we explored whether baseline readiness to change moderated treatment effects on any outcomes. As readiness to change is theorized to be an important mechanism underlying motivationally enhanced therapy, we expected participants with low readiness to change to derive greater benefits from participating in CMBT than GA. Method Participants Participants were recruited from patients seeking help for gambling problems at an outpatient treatment center (hereafter referred to as Center) in the Northeastern United States. Research staff conducted a semi-structured clinical interview to determine eligibility. Individuals meeting criteria for gambling disorder as defined by the Diagnostic and Statistical Manual for Mental Disorders (4 th ed.; DSM-IV-TR ; American Psychiatric Association, 2000 ) were invited to participate in the study if they were of legal gambling age (18 years or older), had at least a 6 th grade education and did not meet exclusion criteria (psychotic symptoms, organic brain disease, alcohol or drug dependence, suicidality). Individuals who were not interested or eligible became part of the Center’s regular clinical caseload. Of 87 eligible patients, 46 agreed to participate in the study, comprising 32 men (69.6%) and 14 women (30.4%). They were randomly assigned to either Cognitive Motivational Behavior Therapy or Gamblers Anonymous with the constraint that gender was equally distributed across conditions. Participants’ mean age was 43.7 years ( SD = 11.7); their racial/ethnic composition was predominantly Caucasian (84.4%), followed by African American (10.2%), Hispanic (2.2%), and Asian (2.2%). While 8.7% had not completed high school, most participants had at least a high school diploma (30.4%) or some college (45.7%), and 15.2% held a college degree. Most participants were married or cohabitating (56.5%) while the remainder were never married (23.9%) or separated/divorced/widowed (19.5%) Interventions Clients were informed that according to Center policy, clients receiving individual or group therapy would also attend GA meetings. Eligible participants were informed that in this study, they would either be randomly assigned to 12 weeks of individual psychotherapy or referred to GA; and if they desired, after 12 weeks, those in GA would be eligible to receive individual therapy and those in therapy could attend GA meetings for aftercare. Referral to Gamblers Anonymous (GA). Participants assigned to GA met with a long-time GA fellow who volunteered at the Center. He provided participants with information about GA and encouraged them to attend meetings. We engaged this volunteer as a patient advocate to monitor the GA referrals’ well-being as they had no contact with Center or research staff during the 12-week treatment course of the study. The advocate made monthly calls, offering referral to individual counseling if participants wished to discontinue the study. None of the GA referrals required or desired a referral. Cognitive Motivational Behavior Therapy (CMBT). The experimental treatment, CMBT, is an integrated 12-session therapy developed from theoretical foundations and a blending of MET and CBT techniques ( Wulfert, Blanchard & Martell, 2003 ). CMBT was pilot tested in an exploratory study at the Center against treatment as usual ( Wulfert et al., 2006 ) and consists of three basic, interrelated components: Motivational Enhancement: During the first three sessions, the emphasis is on motivational enhancement using strategies adapted from the Motivational Enhancement Therapy Manual used in Project MATCH ( Miller, Zweben, DiClemente & Rychtarik, 1994 ). Given that most gamblers are ambivalent about changing their gambling habits or quitting when they first enter treatment, these sessions aim to use motivational enhancement techniques. They include strategies such as providing personalized feedback about gambling behavior and consequences based on the results of the initial assessment, developing discrepancy between where the client currently is versus where he or she wants to be, eliciting self-motivational statements and change talk, communicating that the client is free to choose treatment goals while at the same time asking him or her to anticipate the possible consequences of specific choices and providing a rationale for abstinence. The overarching purpose of these strategies is to guide participants from a lower to a higher level of readiness and stabilizing their resolve to change (see Prochaska, DiClemente, & Norcross, 1992 ). Consistent with MI, participants are asked to develop their own treatment goals during this phase. While the therapist encourages them to consider abstinence as the safest choice, some clients opt for a harm-reduction approach. In such cases, the therapist assists the client to develop behavioral goals and gambling limits. Over the course of treatment, clients tend to exceed these self-imposed limits. This opens the door for the therapist to guide the client toward a trial period of abstinence, which is considered the most prudent treatment outcome for serious gambling disorder. With time and repeated lapses, a number of clients accept abstinence as a way of life. Cognitive and Behavioral Therapy Techniques: While maintaining the collaborative and guiding style of motivational interviewing, cognitive and behavioral techniques are implemented over eight sessions. Participants learn to identify external and internal triggers and cognitive biases that increase the likelihood of gambling. Modeled after Sylvain et al. (1997) , strong emphasis is placed on a correct understanding of the concepts of chance and the odds of winning to undermine the client’s belief that gambling is an exciting way to make money. Clients develop a thorough understanding that they can’t predict the outcome of games of chance and grasp – based on their own experience – that in the long run the rate of return is negative. Then they are taught effective cognitive and behavioral coping skills and problem-solving techniques to combat urges and resist gambling. Deep-seated core beliefs that play a critical role in maintaining dysfunctional behavior ( Padesky, 1994 ) are also addressed, such as equating money with being loved, admired or viewed as successful. The final session focuses on relapse prevention strategies, providing clients with solution-focused tools to prevent a possible lapse from turning into a full-blown relapse. CMBT Therapists CMBT was administered by two masters-level clinicians with ample experience in treating addictive disorders. The therapists received comprehensive training in a full-day workshop and extensive individual training in MI and CBT strategies specific to gambling disorder, and they completed two supervised training cases. An experienced consultant reviewed the session tapes from each therapist’s training cases and provided feedback on treatment adherence. Throughout the study, therapists participated in weekly supervision meetings with a licensed clinical psychologist. Supervision included the review of case notes and audio-taped therapy sessions to ensure a high standard of care and adherence to the treatment protocol. Assessment Measures Gambling severity. In addition to collecting participants’ demographic information, trained assessors conducted two structured interviews to assess the presence of gambling disorder. The NORC DSM-IV Screen for gambling problems (NODS; Hodgins, 2002 ) was used to diagnose gambling disorder. Gambling severity was established with the South Oaks Gambling Screen (SOGS; Lesieur & Blume, 1987 ), which has been shown to be valid according to DSM criteria when used dimensionally ( Goodie et al., 2013 ). A score of 5 or more on the SOGS is indicative of likely pathological gambling ( Lesieur & Blume, 1987 ). As several subclinical cut-offs have been used in past research ( Cox, Enns, Michaud, 2004 ; Lesieur & Blume, 1987 ; Goodie et al., 2015), we opted to use the cut-offs of 3 and 4 for subclinical problem gambling proposed by Cox and colleagues (2004) as the participants were from a similar community sample. Past-three-month versions of the instruments were used that had demonstrated good test-retest reliability and validity ( Wulfert et al., 2005 ). Gambling behavior. Days gambled and dollar amount spent in the three months prior to each assessment point was recorded using the timeline-follow-back method for gambling (TLFB-G). The TLFB-G has strong psychometric properties ( Weinstock et al., 2004 ) and yields conservative and accurate effect size estimates of gambling behavior that are better than or equal to other self-report measures ( Paul et al., 2024 ). The amount of money participants had lost gambling in the past three months showed extreme variability due to a wide disparity in participants’ levels of income and differences in their preferred mode of gambling. In addition, this variable showed a severe positive skew that impacted model residuals. We therefore calculated the amount of money gambled as a percentage of baseline for the post- and follow-up assessments, which corrected these issues. Readiness to change. Participants’ readiness to change their gambling behavior was established with the University of Rhode Island Change Assessment Scale (URICA; DiClemente & Hughes, 1990 ), a 32-item scale that we adapted to gambling. The URICA is derived from the transtheoretical model of behavior change in addictions ( Prochaska, DiClemente & Norcross, 1992 ) and measures four stages of behavior change described as precontemplation (not yet recognizing that change is needed), contemplation (aware of the need for change but undecided), action (engaging in efforts to change), and maintenance (seeking to sustain improvements). We calculated the means for each of the four stage subscales and subtracted the mean of precontemplation from the sum of the means of the other three scales. Higher total scores indicated greater readiness to change. Collateral reports. With participants’ written agreement, we contacted significant others (spouses, partners, adult children, relatives, close friends) via telephone to confidentially inquire about whether the participant had engaged in gambling, on how many days, and how much money he or she lost. We asked significant others to estimate on a scale from 1 (not at all sure) to 5 (very sure) how certain they were about the information they provided. Procedure The university’s institutional review board and the treatment center’s (hereafter Center) ethics board approved the study. The Center’s standard treatment for gambling disorder is individual or group therapy plus referral to GA. With the Center’s permission, participants who agreed to enter the study were randomly assigned to either 12 weekly sessions of CMBT or attending at least once weekly GA meetings for 12 weeks. All participants were informed that after 12 weeks they could enter individual CMBT (those in GA) or attend GA meetings for follow-up (those in CMBT). Participants underwent four individual assessments (pre and post treatment, and 3 and 6 months post treatment follow-up) conducted by trained assessors who were kept blind to treatment condition, and they received $50 (pre and post), $60 (3-month), and $75 (6-month follow-up) as compensation for their time and effort. Data Analytic Approach We tested the assumption that gamblers randomized to CMBT would attend more sessions than those referred to GA and would gamble on fewer days and with less money. Descriptive statistics ( Wickham et al. 2015 ; dplyr and psych packages; Revelle 2017) and graphs ( ggplot2 and ggeffects packages; Lüdecke, 2018 ; Wickham, 2016 ) were generated in R v4.2.1 and SPSS 27. Statistical analyses were completed using zero-inflated poisson regression ( pscl package) and linear mixed effects modeling ( lme4 and emmeans packages; Bates et al., 2015 ; Lenth et al., 2018 ). Linear mixed models handle missing data via Restricted Maximum Likelihood estimation, which estimates plausible values for missing data informed by other observed data. Kendall’s Rank Correlation test in SPSS was used to examine collateral concordance. We used zero-inflated poisson regressions to assess if (1) individuals randomized to CMBT were more likely to complete the treatment phase compared to those referred to GA and (2) participants in CMBT remained in treatment for more sessions than those in GA. The inverse of the number of sessions in treatment was converted into a count, such that individuals who completed all 12 sessions of treatment would be coded as 0, whereas someone who completed only 4 weeks would be coded as 8. Three clients referred to GA attended more than 12 sessions and thus were coded as 0. Thus, the logit component of the model assessed differences between groups in treatment completion, while the Poisson count model examined differences in the number of sessions not attended. Next, we employed linear mixed effect modeling to analyze the effect of Treatment x Assessment Timepoint on treatment targets (i.e., number of GA meetings attended in the past 3 months, readiness to change) and gambling outcomes. Assessment timepoint was treated as a categorical variable to accommodate variability between assessments. We specified a random intercept and Satterthwaite-approximated degrees of freedom. Non-significant treatment by time interactions were removed from the model to simplify interpretation of the lower-order effects. We first evaluated the impact on the intended treatment targets. Then, we assessed treatment efficacy using three dependent variables, each measured as monthly average over the past three months prior to the assessment point: number of days gambled, percent of baseline money spent gambling, and gambling severity based on SOGS scores. We examined the number of individuals at each threshold of SOGS scores (“Absent” ≤ 2, “Pre-clinical” = 3 – 4, “Likely clinical” ≥ 5) at each follow-up timepoint. Generalized linear models of these results did not converge, thus we used a Fisher exact test at each timepoint. As a check of treatment adherence and mechanisms, we also examined if the groups differed based on the number of GA meetings attended and their readiness to change. As an additional check of gambling outcomes, we examined the concordance of significant others’ collateral reports and participants’ self-reports on gambling behavior using Kendall’s Rank Correlation test. To identify predictors of treatment response, we conducted a post-hoc analysis using the three-way interaction of readiness to change x treatment x timepoint to determine whether individuals’ baseline readiness to change moderated how they responded to CMBT compared to GA. Within the GA group, we also examined if number of GA meetings attended during the 12-week treatment period predicted gambling outcomes at the follow-up time points. Estimated marginal means (EMM, emmeans package) are reported for significant findings from this analysis to preserve the continuous nature of GA meetings at meaningful levels (0 = no GA meetings, 3 = median number of GA meetings, 12 = full number of GA meetings). Results Preliminary Analyses Based on analysis of variance and χ 2 tests, there were no baseline differences in demographic variables between the groups with the exception of age ( Supplemental Table 1 ). We examined if age was associated with the outcome variables across all timepoints and found no association. Gambling outcome variables did not significantly differ at baseline between conditions ( p >.05). The majority of the 46 participants completed the post-treatment assessment (CMBT n =22, 95.7%; GA n =20, 87.0%), but more GA than CMBT participants were lost to the 3-month (CMBT n =22, 95.7%; GA n =18, 78.3%) and 6-month follow-up assessments (CMBT n =21, 91.3%; GA n =15, 65.2%) (see CONSORT diagram, Figure 1 ). Figure 1. Open in a new tab CONSORT diagram. Note: An initial 87 individuals were screened for preliminary eligibility. Forty-one participants were excluded because they did not meet the inclusion criteria, refused to participants because of risk of being randomized to GA, or had other reasons for declining. Twenty-three were randomized to each group. Of those 23, 1 person dropped out in the CMBT group during treatment, whereas 3 individuals dropped out from the GA group. An additional five individuals dropped out during the follow-up period in GA, whereas only 1 individual dropped out who had been randomized to CMBT. Participant Drop-out During Treatment All but one male of the 23 participants randomized to CMBT completed all twelve treatment sessions, whereas only six of 16 men (63.5%) and none of the seven women assigned to GA (0%) attended twelve GA meetings. In the first component of the ZIP regression, predicting if a participant was a completer or not, gamblers in CMBT were significantly more likely to complete treatment than those in GA, regardless of gender (treatment: b = −4.52, z =3.51, p <.001; gender: ( b = −1.57, z = −1.34, p =.181). Gamblers randomized to GA had a 65% lower probability to attend all twelve sessions than participants in CMBT ( Figure 2 ). In the second component of the ZIP regression predicting number of sessions missed, neither condition ( b = −.09, z = −.27, p =.788) nor gender ( b = −.07, z = −.43, p =.664) predicted the number of sessions left in treatment after dropout. Figure 2. Open in a new tab Treatment completion likelihood by treatment group. Note . CMBT = Cognitive Motivational Behavior Therapy, GA = Gamblers Anonymous, Tx = Treatment. Individuals in the CMBT group had a 65% greater probability of completing treatment as compared to individuals assigned to Gamblers Anonymous. Treatment Effect Sample size, means, and standard deviations are presented in Table 1 . Results from the outcome analyses are included in Table 2 . Table 1. Sample size, mean, and standard deviation of each gambling outcome at follow up CMBT GA Gambling Outcome BL n =23 Post n =22 3-mo n =22 6-mo n =21 BL n =23 Post n =20 * 3-mo n =17 6-mo n =15 Days gambled in past 90 days 16.6 ± 9.5 4.70 ± 6.90 3.94 ± 6.76 4.29 ± 7.15 14.1 ± 8.6 6.17 ± 7.94 5.13 ± 7.78 6.17 ± 9.74 $ gambled in past 90 days $3,315 ± 5,057 $305 ± 465 $330 ± 659 $271 ± 491 $3,917 ± 5,816 $1,952 ± 4,463 $2,310 ± 5,000 $1,309 ± 2,296 Percent of baseline $ gambled in past 90 days -- 20.8% ± 32.9 19.2% ± 33.7 20.6% ± 40.0 -- 62.2% ± 92.0 69.1% ± 102 63.0% ± 94.9 GA meetings attended 0.70 ± 2.55 0.27 ± 0.88 0 ± 0 0.24 ± 1.09 0.39 ± 1.67 6.32 ± 7.50 3.76± 5.06 3.00 ± 4.94 Readiness to Change (URICA) 7.74 ± 3.05 10.3 ± 1.34 10.6 ± 1.44 10.7 ± 1.62 10.50 ± 1.14 10.20 ± 1.41 9.87 ± 1.36 9.74 ± 1.32 Problem Gambling (SOGS) 10.9 ± 2.3 4.82 ± 3.69 3.50 ± 3.85 3.10 ± 3.77 12.20 ± 2.53 6.58 ± 3.47 5.18 ± 4.61 4.93 ± 4.98 Open in a new tab Note . CMBT = Cognitive Motivational Behavior Therapy, GA = Gamblers Anonymous, SOGS = South Oaks Gambling Screen, URICA = University of Rhode Island Readiness to Change Assessment, BL = baseline timepoint, mo = month. * One participant provided only the TLFB-G for the post timepoint, thus n =20 for gambling behavior and GA meeting attendance and n =19 for other outcomes. The follow-up assessments were post-treatment, e.g., 3-months following the completion of treatment. Table 2. Outcome results from the linear mixed models. GA Meetings Readiness to Change (URICA) % Baseline $ Gambled Days Gambled Problem Gambling Severity (SOGS) Predictor F Est . S.E . p F Est . S.E . p F Est . S.E . p F Est S.E . p F Est S.E . p Treatment - CMBT (0) vs. GA (1) 0.09 −0.30 1.03 0.769 1.74 0.58 0.44 0.190 0.000 0.000 17.1 1.000 0.16 0.78 1.94 0.670 4.86 1.90 0.86 0.033 Time 0.23 0.872 2.14 0.099 22.77 <.001 31.55 <.001 70.88 <.001 Post - Baseline −0.42 0.85 0.613 0.33 0.32 0.306 − 79.2 18.4 <.001 − 9.85 1.25 <.001 − 6.12 0.78 <.001 3 month - Baseline −0.69 0.85 0.416 0.66 0.32 0.042 − 80.8 11.8 <.001 − 10.51 1.29 <.001 − 7.44 0.78 <.001 6 month - Baseline −0.48 0.86 0.573 0.73 0.33 0.027 − 79.8 12.0 <.001 − 9.75 1.32 <.001 − 7.85 0.79 <.001 Treatment x Time 9.27 <.001 4.74 0.004 3.72 0.014 -- -- -- -- Treatment x Post - Baseline 6.39 1.23 <.001 −0.61 0.47 0.194 41.3 17.1 0.017 Treatment x 3 month - Baseline 3.87 1.25 0.003 − 1.32 0.48 0.007 52.3 17.6 0.004 Treatment x 6 month - Baseline 2.73 1.29 0.037 − 1.73 0.50 <.001 46.1 18.2 0.012 Open in a new tab Note . CMBT = Cognitive Motivational Behavior Therapy, GA = Gamblers Anonymous, SOGS = South Oaks Gambling Screen, URICA = University of Rhode Island Readiness to Change Assessment, Est = unstandardized estimates, S.E. = Standard error of the estimate, p = p- value. The follow-up assessments were post-treatment, e.g., 3 months following the completion of treatment. If the Treatment x Time effect was not significant, it was removed from the model. Bold type face indicates significant results. Readiness to Change. The treatment x time effect on readiness to change was significant, F (3, 112.99) = 4.73, p =0.004. As shown in Figure 3a , participants in CMBT showed progressively increasing readiness to change from baseline to post, which remained high at the 6-month follow-up. The inverse was true for those in GA, indicating that CMBT led to a higher readiness to change than GA. Due to low power, the difference between CMBT and GA achieved statistical significance only at 6-month follow-up, t (114.1)=2.30, p =0.023. Figure 3. Open in a new tab Change in gambling treatment targets and outcomes based on treatment group. Note . CMBT = Cognitive Motivational Behavior Therapy, GA = Gamblers Anonymous, SOGS = South Oaks Gambling Screen. Individuals in the CMBT group had higher readiness to change (3A), attended fewer GA meetings (3B), gambled on fewer days (3C), and had a lower SOGS score during the latter follow-up periods (3D) as compared to individuals in GA. Gambling Outcomes Days Gambled. The interaction of time by treatment condition was not significant, F (3, 113.81) = 1.97, p =0.122 ( Table 2 ), and was removed from the model. The effect of time was significant, F (3, 116.92) = 31.55, p <.001. Days gambled decreased from baseline to all follow-up timepoints ( p <.001; Table 1 ). However, treatment condition showed no significant effect, F (1, 42.20) = 0.16, p =0.690. Two individuals in CMBT and four referred to GA were completely abstinent at the post-treatment assessment. These individuals remained abstinent, except one person referred to GA who had returned to gambling by the 3-month follow-up. Money Gambled. For money spent gambling as a percentage of dollars gambled at baseline, the interaction of time by treatment was significant, F (3, 114.22) = 3.72, p =0.01 ( Table 2 ). Participants in CMBT gambled 21% of the baseline dollar amount at post treatment, 19% at 3-month, and 21% at 6-month follow-up. In contrast, participants in the GA group gambled 62% of the baseline dollar amount at post, 69% at 3-month, and 63% at 6-month follow up ( Table 1 , Figure 3b ). Gamblers Anonymous Meetings Attended. The interaction effect of time by treatment predicted the number of GA meetings attended in the past three months, F (3, 114.90) = 9.27, p <0.001 ( Figure 3c ). As expected, individuals referred to GA attended significantly more GA meetings at post-treatment ( p <0.001, Table 1 ), 3-month ( p <0.001), and 6-month follow-up ( p =0.02) relative to baseline, whereas those in CMBT did not attend more meetings at any timepoint ( p ’s>0.42). Gambling Severity. The interaction of time by treatment for SOGS was not significant, F (3, 113.85) = 0.38, p =0.77, and was removed from the model. Both the main effect of treatment, F (1, 42.42) = 4.86, p =0.03, and timepoint, F (3, 116.56) = 70.88, p <0.001, were significant ( Table 2 ). Participants in CMBT had lower SOGS scores throughout the study ( Table 1 , Figure 3d ) than those in GA. SOGS scores across both treatment groups were significantly higher at baseline than at any of the other timepoints ( Table 1 ). At the beginning of the study, all 23 participants per condition met the threshold for possible pathological gambling (SOGS ≥ 5). Of 22 clients in CMBT available for post-assessment, only 45.5% ( n =10) scored ≥ 5, 22.7% ( n =5) met the threshold for subclinical problem gambling (SOGS = 3 or 4), and 31.8% ( n =7) were below threshold (SOGS ≤ 2). Of the 21 CMBT clients available for the 6-month follow-up assessment, 57.1% ( n =12) scored ≤ 2. Of the 23 clients referred to GA, 19 completed the SOGS, and of those, 60.0% ( n =12) scored in the range for possible pathological gambling, 20.0% ( n =4) met the threshold for subclinical problem gambling, and 15.0% (n=3) scored below threshold (SOGS ≤ 2). Of the 15 GA-referred clients available for the 6-month follow-up assessment, 46.7% ( n =7) scored ≤ 2. As a note, generalized linear models did not converge, likely due to the small sample size. However, Fisher’s exact test revealed that a significantly larger proportion of individuals in CMBT were below the problem gambling cut-off as compared to the GA group at the 6-month follow-up ( p =0.034); the post and 3-month follow-up were not statistically significant ( p ’s > 0.28). Concordance. Kendall’s rank correlation tests were conducted to assess concordance between participants’ and significant others’ reports of days gambled and money spent gambling for each follow-up assessment period. Participants’ and their significant others’ reports were statistically significantly correlated ( p <.009) for all timepoints. The coefficients for money spent gambling were τ = .549 at post, τ = .407 at the 3-month, and τ =.677 at the 6-month follow-up; those for days gambled were τ = .613 at post, τ =.501 at the 3-month, τ =.677 and τ = .707 at the 6-month follow-up, indicating acceptable levels of reliability for primary behavioral outcomes. Secondary Analyses Readiness to change. Readiness to change at baseline moderated the effect of time by treatment on dollar amount gambled, F (3, 107.64) = 3.95, p =0.01, SOGS score, F (3, 106.73) = 3.50, p =0.02, and GA meetings attended, F (3, 107.96) = 4.07, p =0.01. Individuals in CMBT who were low on readiness to change at baseline gambled 99%-117% less money and had 1.0–2.9 lower SOGS scores during the follow-up time points than those in GA ( Figures 4a and 4b , Supplemental Table 2 ). In addition, only individuals who had average to high readiness to change attended more GA meetings relative to baseline, whereas individuals who had low readiness to change did not attend any more meetings than they had at baseline ( Figure 4c ). That is, when individuals were unmotivated to change their gambling at treatment entry, they responded significantly better to CMBT compared to GA. In contrast, individuals who were highly motivated to change at treatment entry responded well to either CMBT or GA. Figure 4. Open in a new tab Baseline readiness to change as moderator of treatment outcome. Note . CMBT = Cognitive Motivational Behavior Therapy, GA = Gamblers Anonymous, SOGS = South Oaks Gambling Screen, Ave = Average. Low, Average, and High refers to -1 SD, Mean, and + 1 SD readiness to change at baseline. Individuals randomized to CMBT who had low readiness to change at baseline gambled less money ( Figure 4A ) and had lower SOGS scores ( Figure 4B ) at follow-up compared to individuals with similarly low readiness to change in GA. Individuals randomized to GA with high readiness to change at baseline were more likely to attend GA meetings than individuals with low readiness to change at baseline ( Figure 4C ). GA meeting attendance. Participants assigned to GA attended 6.32 ± 7.5 meetings on average (median = 3, minimum = 0, maximum = 22) during the 12-week treatment period. Gender did not significantly predict number of GA meetings attended ( W =62.5, p =0.09), although there was a tendency for women to attend fewer meetings than men. For participants in GA, attendance at meetings during treatment predicted fewer dollars spent gambling, F (3, 45.92) = 2.97, p =0.04, fewer days spent gambling, F (3, 45.00) = 5.48, p =0.003, and a lower SOGS score, F (3, 46.71) = 3.83, p =0.02, compared to baseline. Individuals who attended no GA meetings during the treatment phase gambled approximately the same amount of money as they did at baseline ( Supplemental Table 3 ) and the same number of days at all timepoints, whereas those who attended 12 sessions gambled less money and fewer days relative to baseline. Although all individuals had reduced SOGS scores relative to baseline (all p ’s < 0.02), SOGS scores were highest for those who attended fewer GA meetings ( Supplemental Table 3 ) and lowest among those who attended more GA meetings. Discussion Treatment Outcomes This study showed that a motivationally enhanced cognitive behavioral intervention (CMBT) effectively supports the retention in treatment of individuals with gambling disorder. Specifically, 22 of 23 participants (95.6%) completed the full twelve-week course of CMBT and the scheduled follow-up assessments, with only one additional participant being lost to the 6-month follow-up assessment. In contrast, among the 23 gamblers referred to GA, three (13%) discontinued their participation during the 12-week active treatment phase and did not attend any GA meetings. Of the 20 remaining participants who presented for the post assessment, seven (30.4%) had attended no GA meetings, resulting in a total of 43.5% of individuals assigned to GA receiving no dose of GA whatsoever. Additionally, seven participants (30.4%) attended fewer than the recommended 12 sessions of GA meetings, while only six (26.1%) attended 12 or more meetings. The high rate of non-compliance with GA attendance was not unexpected, as similar findings have been documented in previous studies (e.g., Petry et al., 2006 ; Stewart & Brown, 1988 ). In contrast, the unusually high retention rate observed in CMBT represents an uncommon and significant outcome, one rarely reported in studies where clients with gambling problems were treated using MI or CBT. We propose that the 12 face-to-face treatment sessions, delivered by experienced and well-trained therapists, were crucial in cultivating the motivation necessary for CMBT participants to complete the treatment. Furthermore, we suggest that implementing CBT techniques within a motivational interviewing framework was key to improving client retention. Consistent with the emphasis by Ladouceur and colleagues on addressing clients’ misperceptions about their ability to predict and control chance events (e.g., Sylvain et al., 1997 ), CMBT therapists took deliberate care to convey, in an empathic manner, the fundamental principle that all forms of gambling inevitably lead to a negative rate of return. In the long run, the “house always wins,” meaning that the more one gambles, the more one is likely to lose. For many CMBT participants, gaining an understanding of the nature of chance, connecting it to their personal experiences, and recognizing the reasons behind their significant financial losses often led to a transformative “Eureka!” moment. This realization seemed to boost clients’ motivation to refrain from gambling. Although lapses did occur, therapists leveraged these setbacks as opportunities to reinforce the idea that chance events are inherently unpredictable and that continued gambling ultimately results in losses far more often than in wins. The results also provided evidence that retention in CMBT was associated with a reduction in gambling behavior. This is consistent with a recent meta-analysis by Pfund et al. (2020) indicating that greater attendance at face-to-face treatment sessions is related to better outcomes. The higher retention rate in CMBT versus GA referral was reflected in lower gambling expenditures over the course of the study. CMBT participants reduced money spent gambling from baseline to post-treatment by 80% and maintained this level of fiscal restraint during follow-up. In contrast, GA participants reduced money spent gambling from pre to post by 38% of baseline and maintained approximately the same reduction during follow-up. By the 6-month follow-up assessment, both CMBT and GA participants also gambled on significantly fewer days compared to baseline, with GMBT participants reducing gambling frequency from 17 to 4.3 days and those referred to GA from 14 to 6.7 days per month. This 2.4-day difference was not statistically significant and may reflect a lack of power due to the small sample size. For similar reasons, we may also not have found a statistically significant difference in gambling severity measured by SOGS scores. Participants in CMBT reduced SOGS scores from 11 to 3, and those in GA from 12 to 5 from baseline to 6-month follow-up. Thus, both groups reported significantly fewer gambling disorder symptoms at the end of the study. Readiness to change A noteworthy finding was that participants’ motivation to change their gambling behavior at the outset of treatment influenced outcomes for those assigned to GA, but not for those in CMBT. Regardless of their initial level of motivation, individuals in CMBT significantly decreased gambling expenditures and frequency during treatment and follow-up periods. In contrast, only those GA participants with initial moderate to high motivation to change attended more GA meetings and reduced their gambling behavior whereas those with low readiness to change did not increase GA attendance and continued gambling at baseline levels. These findings suggest that the motivational intervention integral to CMBT effectively promoted behavior change. The results also indicate that successful outcomes in GA are more likely for individuals who are already motivated to change, thereby engaging more actively in GA group meetings. Gender considerations regarding GA referral As reported above, all women assigned to CMBT completed the 12 treatment sessions, whereas none of the women assigned to GA completed 12 GA sessions. The relatively small sample size did not allow us to formally analyze gender differences, but a visual inspection of the data suggested that women in CMBT had better outcomes than those referred to GA. As GA groups are predominately comprised of males ( Johnson, Nora, Bustos, 1992 ), men may be more likely to engage with and benefit from GA (Kim, Hodgins, Bellringer & Abbott, 2016), whereas women may have different needs and experience gender-related concerns in GA ( Avery & Davis, 2008 ; Crisp et al., 2004 ; Mark & Lesieur, 1992 ; Merkouris et al., 2016 ). Notably, after we shared our concerns with the Center, the agency introduced a women-specific GA group to better meet the needs of this population. Presumed consequences of non-compliance with treatment Any study where a significant non-compliance rate is observed, such as the 35% dropout rate from GA and a high non-attendance rate at GA meetings, even among those who remained in the study, raises the question of what happens to those who drop out. For gamblers, the following scenarios are possible: they recover on their own or they continue gambling as before or worse. Spontaneous recovery is a possibility – a longitudinal study of non-treatment-seeking gamblers found that a portion of them had markedly improved on their own ( Slutske, 2006 ). However, for treatment-seeking individuals with gambling disorder, a more likely scenario is that those who drop out lacked sufficient motivation and continue gambling as before. For example, Grant and colleagues (2004) retrospectively evaluated gamblers’ reasons for attrition from treatment and found that nearly 50% left because they missed the thrill of gambling. Other studies found that many problem gamblers leave treatment and don’t return for follow-up assessments, not because they have their gambling under control but because they continue to be ambivalent, their life circumstances changed (e.g., separation or divorce), or they feel ashamed or guilty for having resumed gambling ( Dunn, Delfabbro, & Harvey, 2012 ; Nilsson et al., 2023 ). This assumption aligns with observations from this study. As reported, there was a significant variation among the 15 GA participants we retained through the 6-month follow up. Readiness to change at baseline was associated with greater attendance at GA meetings, which in turn was associated with lower gambling frequency and expenditures and fewer symptoms endorsed on the SOGS during treatment and follow-up. GA participants with low initial readiness to change never attended any GA meetings and at the follow-up assessments showed no significant improvement from baseline in gambling expenditures and frequency. Limitations There were several strengths to the current study, including the use of reliable and valid outcome measures, the assessment of potential treatment mechanism, the validation of self-reports by obtaining the confidential reports of significant others and finding good concordance between both data sources, and a very high treatment retention and completion rate of participants in CMBT. However, there were also several limitations. One limitation was that the mechanisms of change between the two interventions were not comparable. Although the treatment-seeking gamblers were randomly assigned to CMBT and GA, we compared a manualized treatment (CMBT) with a non-standardized fellowship support group (GA). To more accurately assess the effectiveness of CMBT in promoting retention and positive treatment outcomes, future research should compare it with a manualized treatment that shares similar therapeutic processes, such as a purely cognitive behavioral intervention like CBT. This would show whether initiating treatment with strengthening clients’ motivation to change and then maintaining an MI style while helping clients develop the cognitive and behavioral skills necessary to change behavior leads to fewer dropouts and better treatment outcomes than CBT alone. Caution is necessary when generalizing the present findings to other populations. First, the sample size in this study was relatively small, limiting the statistical power for more nuanced analyses such as exploring potential subgroup differences. Therefore, replication of these finding with a larger sample of individuals with gambling disorder is essential to validate the results and improve generalizability. Second, our study included individuals with co-occurring alcohol and substance issues, as defined by DSM-IV-TR criteria, specifically individuals with alcohol or substance abuse, rather than dependence. Under a DSM-5 framework, which views substance-related conditions along a continuum of severity, this would equate to including participants with “mild” alcohol use disorder (AUD) or substance use disorder (SUD), as opposed to those with “moderate” or “severe” forms of these disorders. Although existing literature suggests some overlap between gambling disorder and AUD/SUD, there is limited evidence to guide whether concurrent or sequential treatment of these co-occurring conditions, especially in their more severe forms, results in superior outcomes. Therefore, further research is critically needed to address this gap and clarify the best approach to managing these comorbid disorders. An additional limitation is that the data were aggregated into three-month periods, thus making it difficult to assess the distribution of the GA meetings. Participants could attend more than one meeting per week and are often encouraged by group facilitators to do so. Nevertheless, using the number of sessions allowed us to examine the “dose” of GA received, offering a more nuanced perspective. Indeed, three individuals referred to GA attended 20 or more sessions, which makes the significant differences observed between the two groups particularly striking. It might also be questioned why we only enlisted a single individual as patient advocate to contact individuals referred to GA monthly and inquire about their well-being. Even though this person played no role in the clients’ treatment or attendance at GA meetings, we cannot rule out that some idiosyncratic characteristic of this patient advocate influenced clients’ persistence with or dropout from GA. Additionally, while the evaluation of the CMBT therapists’ adherence to treatment relied on the expertise of a consultant who reviewed the training cases, and the judgment of the supervising psychologist, there is a potential for subjective bias. Despite the comprehensive training and supervision of CMBT therapists, future studies should include more systematic and objective measures of treatment fidelity. This could involve the use of validated checklists or independent evaluators who are trained to assess specific components of treatment delivery. Incorporating formal treatment integrity checks will contribute to a more robust understanding of the comparative effectiveness of CMBT, particularly if comparing it to other well-established interventions such as face-to-face CBT. A final limitation was the use of the SOGS as a measure of problematic gambling. It is known that the SOGS has a high false-positive rate for problem gambling (Goodie et al., 2015). In the current study, we used the SOGS primarily as a continuous measure of problem gambling severity, thus bypassing some of these issues. But we also reported the subgrouping to provide further context and nuance to the continuous measures. Additionally, we did not rely on the SOGS to determine eligibility for the study, which was established with a semi-structured clinical interview and the NODS. If future studies employ the SOGS for continuity with previous research, it should be combined with other gambling assessments and clinical interviews, such as the Structured Clinical Interview for the DSM ( First et al., 2015 ). Conclusions and Future Directions The present study suggests that CMBT is an effective intervention for men and women with gambling disorder, including for individuals who initially exhibit low motivation to change. In contrast, while GA also effectively reduced gambling problems, this happened only for individuals who arrived with a sufficient degree of readiness to change and were committed to attend GA meetings. Based on observational evidence from our study, we also suggest that women may have better outcomes in a therapist-guided treatment like CMBT compared to a male-oriented self-help group like GA. But this conclusion is tentative and requires future research to determine whether an all-female GA group provides greater benefits for women. One particular advantage of CMBT may be its integration of a motivational interviewing style that the therapist maintains while teaching clients the necessary cognitive and behavioral skills to provide them with effective tools to combat their gambling addiction. Previous studies have typically focused exclusively on either MI or CBT skills building separately, or they have provided only a brief MI session before transitioning to a CBT intervention. In this study, we placed considerable emphasis not only on enhancing clients’ initial readiness to change their gambling behavior but also on maintaining a motivational, client-centered style within the therapeutic relationship while teaching clients the cognitive and behavioral skills necessary to resist gambling. This appears to have had a very beneficial effect on clients’ retention and willingness to complete treatment. However, we cannot be entirely certain of this because we did not conduct a dismantling strategy. Future research should therefore compare CMBT against CBT which is the current treatment of choice for gambling disorder and does not include the motivational components offered in CMBT. Such a design would more conclusively demonstrate what motivational enhancement adds to cognitive restructuring and behavioral skills building. Supplementary Material Supplemental tables NIHMS2055301-supplement-Supplemental_tables.pdf (207.9KB, pdf) Public Health Significance. Gambling disorder is associated with significant costs to society, including serious financial losses, bankruptcy, job loss, and many others; however, individuals with gambling disorder are notoriously difficult to engage and retain in psychological treatment. Results of this study show that Cognitive Motivational Behavior Therapy (CMBT) effectively engages individuals with gambling disorder in treatment, prevents premature dropout to a significantly larger degree, and reduces money lost gambling more than referral to Gamblers Anonymous (GA). Acknowledgments Research reported in this publication was supported by the National Institute of Mental Health under award number R21MH64568. Footnotes We have no known conflict of interest to disclose. References American Gaming Association (2023. October 9). American attitudes toward gaming 2023. Retrieved July 11, 2024, from https://www.americangaming.org/resources/american-attitudes-2023/ [ Google Scholar ] American Psychiatric Association. 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