Community Therapy Sex Difference

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)


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


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


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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