Bruce S. Liese, PhD, ABPP, Beck Institute Faculty
Professor of Family Medicine, Community Health, and Psychiatry
University of Kansas Medical Center

Nick arrives early for his therapy appointment. Sitting in the waiting room, he feels restless. At 63 years-old, Nick has always been restless, but today his restlessness is much more intense.

Contributing to Nick’s tension is knowing that he will soon tell his therapist that he has lapsed; he has gone to the casino and gambled again after more than six months of abstinence. He feels ashamed and disappointed in himself. He feels despair as he thinks about the consequences of past gambling episodes, afraid that this is just the beginning of another protracted relapse. He thinks about broken promises and the behaviors that jeopardize everything that matters to him.

Promptly at 1:00 pm, Nick’s therapist opens the waiting room door and welcomes Nick back for his weekly CBT session. After nearly six months of regular weekly visits, Nick’s therapist, Dr. Sara Jones, can see it in his face: Nick is struggling.

Nick has been seeing Dr. Jones, a cognitive behavioral therapist, for help with multiple psychological problems. Most of these emerged when Nick’s wife, Jenny, discovered that Nick had secretly gambled away their entire retirement savings. Jenny’s discovery occurred on a Friday and by the end of an emotionally devastating weekend, Jenny had packed Nick’s bags, pointed at the front door of their home, and said, “Don’t bother coming back until this problem is fixed.”

A female therapist meets with a male client struggling with gambling disorder.

Fortunately, Dr. Jones is knowledgeable about gambling disorder – a mental health problem that has expanded globally as gambling has become increasingly legal and accessible. Gambling disorder symptoms may include a preoccupation with gambling, increased spending on gambling, emotion dysregulation when trying to reduce or quit, lapses and relapses, gambling when distressed, returning to gamble after losses, lying about gambling, jeopardizing relationships by gambling, and seeking additional sources of money to resolve financial losses.

Presently, it’s possible to gamble at casinos, sports events, and from just about anywhere via the Internet. While some prefer more traditional “table games” (e.g., poker, roulette) and slot machines, others binge on lottery tickets. Sports betting has become popular due to the accessibility of betting outlets like FanDuel and DraftKings. Most recently, companies like Kalshi make it possible to gamble on just about anything, including the results of political elections.

Dr. Jones is a skilled therapist who understands the importance of providing structure in each session. Nick’s gambling disorder has caused chaos in his life, and he feels relief as Dr. Jones remains focused on his most salient concerns (e.g., intense periods of sadness and loneliness, urges to gamble, etc.). Throughout their sessions, Dr. Jones systematically identifies skills needed for addressing these concerns instead of getting distracted by topic changes or minor details.

Dr. Jones provides a warm, authentic, nonjudgmental, collaborative relationship, fully understanding the shame and stigma so often associated with gambling disorder.

Dr. Jones realizes that an accurate, ongoing, iterative case conceptualization is vital to the care of patients with gambling disorder, especially since patients with gambling disorder often have co-existing mental health problems (e.g., depression, anxiety, bipolar illness), financial problems, relationship problems, and more.

Psychoeducation is important, as it enables people with gambling disorder to understand how their thoughts and beliefs are intimately linked to gambling behaviors. The following are examples of Nick’s thoughts and beliefs, identified by Dr. Jones:

  • “The more I gamble, the greater my chances of winning.”
  • “I don’t feel depressed and lonely when I’m at the casino.”
  • “I have to keep gambling to recoup my losses.”
  • “This is my lucky day.”

By providing psychoeducation, Dr. Jones helps Nick understand how such thoughts can lead to a lapse or relapse. Perhaps more importantly, Dr. Jones teaches Nick that change is possible.

Standardized techniques are vital to implementing cognitive and behavioral changes. Many of these techniques are the same as those used in treating depression and anxiety. For example, daily thought records help people become aware of the triggers, thoughts, beliefs, etc. that lead to gambling. The advantages-disadvantages analysis, or decisional balance, helps Nick systematically reflect on his reasons for abstaining from gambling.

Dr. Jones begins each CBT session by asking Nick: “What would you like to work on today?” She follows with a mood check (“How are you feeling today?”) and by bridging from the last session (e.g., “How long has it been since you last gambled?”). As they talk, Dr. Jones recognizes that Nick feels profound sadness and shame. It’s obvious that Nick’s recent lapse was related to his restlessness and despair. In the current session, Dr. Jones decides to teach Nick about the importance of self-forgiveness and self-compassion. In the following session she emphasizes the importance of behavioral activation strategies for addressing Nick’s restlessness.

Nick reports that he leaves each session feeling more hopeful and less ashamed; however, he and Dr. Jones agree that, together, they have much more work to do.

Recommended Reading: 

Liese, B. S., & Beck, A. T. (2022). Cognitive-behavioral therapy for addictive disorders. New York: Guilford Press.

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