Community Ment Health J (2009) 45:468475

DOI 10.1007/s10597-009-9244-1

ORIGINAL PAPER

Community Treatment for Problem Gambling:

Sex Differences in Outcome and Process
Tony Toneatto 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. Participants attended approximately seven sessions of cognitivebehavioral 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 progression 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 gamblingrelated treatment interventions (e.g., identification of highrisk 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;

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: tony_toneatto@camh.net
T. Toneatto
Department of Psychiatry, University of Toronto, Toronto,
ON, Canada

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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 resolution 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 outcomes and might be expected to influence the nature of the
treatment intervention since the specific content of treatment 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 pharmacological (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 Education and Training on Addiction 2000; Petry 2005;

Community Ment Health J (2009) 45:468475

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 outcomes 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 cognitive-behavioral treatment. In addition, differences in the
treatment process, including both specific and non-specific
variables, were examined. The study employed a onegroup, 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 appointment. Potential participants were asked if they were interested 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.

469

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, substance use and abuse, and treatment history. The frequencies 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), testretest reliability (r = .78) and criterionrelated validity (r = .83 with DSM-IV pathological gambling symptoms). The Brief Symptom Inventory-18 (BSI18; Derogatis 2000) measured current symptoms of anxiety, 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 populations has been reported as well (Derogatis 2000). Gambling 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 consistency 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 substance 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 Psychiatric 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 6month follow-up assessment.

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470

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 participants 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 therapists 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 evaluation of the clients progress in addressing the gambling
behavior, identification of variables that may have interfered with clinical progress, and the development of
interventions to further facilitate behavior change. Identification 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 participant 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

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Community Ment Health J (2009) 45:468475

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 association 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, chancebased types of problem gambling (e.g., slots, bingo, lotteries) 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

Community Ment Health J (2009) 45:468475

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 gambling 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.

471

Follow-Up Assessment
Gambling Behavior
At the 6-month follow-up, men were more likely to report
complete abstinence from gambling since treatment termination (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%) compared to 6.3% of the women, v2 (1) = 3.56, P \ .06.

Concurrent Disorders
Gambling Severity
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.

Table 1 Description of
gambling onset, severity and
expenditures, by sex

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 followup, 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 interpreted cautiously. This analysis indicated continued difficulty with problem gambling, in particular the continued

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

Gambling expenditures-baseline (C$)
Gambling expenditures-post treatment (C$)

9.66 (8.96)

4.53 (4.87)

5,639 (5,489)

6,588 (9,023)

860 (1,234)

1,470 (11,410)

-5,372 (5,785)

-5,662 (10,716)

Change in gambling expenditures-follow-up (C$)

%DSM-IV criteria for pathological gambling-baseline

77.3

87.5

%DSM-IV criteria for pathological gambling-follow-upe

20.6

58.3

t (16.98) = -2.62, P \ .05;

t (57) = 2.36, P = .05;
c
t(57) = -2.15, P \ .05;
d
t (45.3) = 2.78, P \ .01;
e 2
v (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)

Change in number of DSM symptoms endorsedf

M(SD) pathological gambling symptoms-baseline

4.18 (3.33)
6.43 (2.38)

1.33 (2.93)
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)

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Community Ment Health J (2009) 45:468475

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)

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

20.6
23.5

58.3
58.3

Cards-baseline

43.2

68.8

Cards-followupa

52.4

90.9

Repeated unsuccessful efforts to controlc

Restless/irritable when cutting downd

Racetrack-baselineb

63.6

100

Gambling to escape problemse

29.4

75.0

Racetrack-follow-up

81.0

90.9

Chasing lossesf

23.5

58.3

Sports-baselinec

70.5

100

Lying to others about gamblingg

23.5

58.3

Sports-follow-upd

66.7

100

Committing illegal acts

17.6

8.3

Lotteries-baseline

38.6

37.5

Jeopardizing relationshipsh

29.4

58.3

Lotteries-follow-up

42.9

27.3

41.7

86.4

68.8

Rely on others to relieve desperate

financial situationi

14.7

Bingo-baseline

81.0

72.7

50.0

12.5

Bingo-follow-up
Slot machines-baseline

Slot machines-follow-upf
a

61.9

9.1

v (1) = 4.75, P \ .05; v (1) = 7.93, P \ .01; v (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

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/
Table 3 Mental health, substance abuse and gambling treatment
history, by sex
Variable

Men
Women
(n = 44) (n = 16)

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

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 treatment were similar for men and women.
Treatment Process and Program Satisfaction

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

Currently being treated by a
psychiatrista

34.9

60.0

6.8

26.7

Gambling treatment
Ever attended gamblers anonymous

29.5

50

Ever attended other treatment for

gambling problem

22.7

25

Mental health treatment

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 percent of the sample attended greater than ten sessions. Few
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)

Ever prescribed medication for anxiety

18.2

35.7

Did not like my therapist

0 (0)

8.3 (1)

Currently taking medication for anxiety

9.1

7.7

Missed a session and no follow-up

8.8 (3)

8.3 (1)

Ever been prescribed medication for

depressionb

32.6

60.0

Attending other treatment program

5.9 (2)

0 (0)

0 (0)

8.3 (1)

Currently taking medication for

depression

18.6

v2 (1) = 4.22, P \ .05;

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Difficulty attending appointments

v2 (1) = 3.50, P \ .06

26.7

Still in treatmenta
a

29.4 (10)

25 (3)

This question was asked following session 10; several participants

continued to attend treatment

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473

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 highrisk situations and triggers for their gambling, the development 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

Table 6 Evaluation of therapeutic environment, therapist and treatment, by sex

Variable

Men
Women
(n = 34) (n = 12)

Therapeutic environment, rating of agreement/strong agreement

Welcoming treatment atmosphere

91.2

Positive initial contact with agency

90.9

83.3

Comfortable in re-contacting agencya

97.1

80.0

Culture respected

96.6

88.9

100

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

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

Treatment factors, ratings of helpful/very helpful

v (1) = 3.54, P \ .06; v (1) = 5.89, P \ .05;

P \ .05; d v2 (1) = 4.56, P \ .05

63.6
2

v (1) = 5.21,

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 gambling and problem gambling, it is important to investigate
whether such differences are also obtained in treatment
outcomes. Very little is currently known about sex differences in gambling treatment outcomes. Brief cognitivebehavioral treatments commonly offered in most outpatient
settings may be unintentionally geared towards male-specific 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 termination 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 problem gambling within this growing demographic (Mark and
Lesieur 1992). The primary goal of this study was to
examine sex differences in outcomes following cognitivebehavioral 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, mens preferences for
strategic/skill-based gambling and the tendency to gamble heavily under conditions of negative affect and interpersonal 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 elevated 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

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to women. Men also reported a higher abstinence rate at the

6-month follow-up. Women continued to rate their gambling 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 cognitivebehavioral therapy (i.e., identifying high-risk situations,
discussing gambling-related cognitive distortions, develop
coping response) to be less helpful in reducing their gambling behavior in comparison to men. While these therapeutic 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 anxiety. 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 intervention (Hodgins and Holub 2007; Hodgins et al. 2005;
Petry 2005). Moreover, the DSM symptom patterns at
follow-up not only indicated a stronger functional relationship 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
Frischs (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 commonly 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 outcomes (Getty et al. 2000). More specifically, by identifying
the functional relationship between gambling behavior and

123

Community Ment Health J (2009) 45:468475

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 cognitivebehavioral treatment and pharmacological management
might also be indicated based on the presence of dysfunctional 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., relationship 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 findings of this study and thus serve as a caution against premature 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 comparisons were conducted for several of the statistical analyses, 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 interventions 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.

References
American Psychiatric Association. (1994). Committee on nomenclature and statistics. Diagnostic and statistical manual of mental

Community Ment Health J (2009) 45:468475

disorders (4th ed.). Washington, DC: American Psychiatric
Association.
Blanco, C., Hasin, D. S., Petry, N., Stinson, F. S., & Grant, B. F.
(2006). Sex differences in subclinical and DSM-IV pathological
gambling: Results from the national epidemiological survey on
alcohol and related conditions. Psychological Medicine, 36,
943953.
Blanco, C., Petkova, E., Ibanez, A., & Saiz-Ruiz, J. (2002). A pilot
placebo-controlled study of fluvoxamine for pathological gambling. Annals of Clinical Psychiatry, 14, 915.
Crisp, B. R., Thomas, S. A., Jackson, A. C., Smith, S., Borrell, J., Ho,
W.-Y., et al. (2004). Not the same: A comparison of female and
male clients seeking treatment from problem gambling counseling services. Journal of Gambling Studies, 20, 283299.
Crisp, B. R., Thomas, S. A., Jackson, A. C., Thomason, N., Smith, S.,
Borrell, J., et al. (2000). Sex differences in the treatment needs
and outcomes of problem gamblers. Research on Social Work
Practice, 10, 229242.
Daughters, S. B., Lejuez, C. W., Lesieur, H., Strong, D. R., &
Zvolensky, M. (2003). Towards a better understanding of
gambling treatment failure: Implications of translational
research. Clinical Psychology Review, 23, 573586.
Deegear, J., & Lawson, D. M. (2003). The utility of empirically
supported treatments. Professional Psychology: Research and
Practice, 34, 271277.
Derogatis, L. R. (2000). Brief symptom inventory-18 (BSI-18):
Administration, scoring, and procedures manual. Minneapolis,
MN: National Computer Systems.
Dowling, N., Smith, D., & Thomas, T. (2006). Treatment of female
pathological gambling: The efficacy of a cognitive-behavioral
approach. Journal of Gambling Studies, 22, 355372.
Ferris, J., & Wynne, H. (2001). The Canadian problem gambling
index: Users manual. Toronto, ON: Canadian Centre on
Substance Abuse.
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A
comparative study of psychotherapy (3rd ed.). Baltimore, MS:
Johns Hopkins University Press.
Getty, H. A., Watson, J., & Frisch, G. R. (2000). A comparison of
depression and styles of coping in male and female GA members
and controls. Journal of Gambling Studies, 16, 377391.
Grant, J. E., & Kim, S. W. (2002). Gender differences in pathological
gamblers seeking medication treatment. Comprehensive Psychiatry, 43, 5662.
Hodgins, D. C., Currie, S. R., & el-Guebaly, N. (2001). Motivational
enhancement and self-help treatments for problem gambling.
Journal of Consulting and Clinical Psychology, 69, 5057.
Hodgins, D. C., & Holub, A. (2007). Treatment of problem gambling.
In G. Smith, D. Hodgins, & R. Williams (Eds.), Research and
measurement issues in gambling studies (pp. 372399). Boston:
Elsevier.
Hodgins, D. C., Peden, N., & Cassidy, E. (2005). The association
between comorbidity and outcome in pathological gambling: A
prospective follow-up of recent quitters. Journal of Gambling
Studies, 21, 255271.
Hraba, J., & Lee, G. (1996). Gender, gambling and problem
gambling. Journal of Gambling Studies, 21, 83101.
Ibanez, A., Blanco, C., Moreryra, P., & Saiz-Ruiz, J. (2003). Gender
differences in pathological gambling. Journal of Clinical
Psychiatry, 64, 295301.

475
Kim, S. W., & Grant, J. E. (2001). An open naltrexone treatment
study in pathological gambling disorder. International Clinical
Psychopharmacology, 16, 285289.
Ladd, G., & Petry, N. (2003). A comparison of pathological gamblers
with and without substance abuse treatment histories. Experimental and Clinical Psychopharmacology, 11, 202209.
Lesieur, H. R., & Blume, S. B. (1991). When lady luck loses: The
female pathological gambler. In N. van den Bergh (Ed.),
Feminist perspectives on addictions (pp. 181197). New York:
Springer.
Mark, M. E., & Lesieur, H. R. (1992). A feminist critique of problem
gambling research. British Journal of Addiction, 87, 3350.
National Centre for Education and Training on Addiction. (2000).
Current best practice interventions for gambling problems: A
theoretical and empirical review. Melbourne, VIC: Victorian
Government Department of Human Service.
Pallanti, S., Rossi, N. B., Sood, E., & Hollander, E. (2002).
Nefazodone treatment of pathological gambling: A prospective
open-label controlled trial. Journal of Clinical Psychiatry, 63,
559564.
Petry, N. M. (2005). Pathological gambling. Washington, DC:
American Psychological Association.
Potenza, M. N., Steinberg, M. A., McLaughlin, S. D., Wu, R.,
Rounsaville, B. J., & OMalley, S. S. (2001). Gender-related
differences in the characteristics of problem gamblers using a
gambling help line. American Journal of Psychiatry, 158, 1500
1505.
Robson, E., Edwards, J., Smith, G., & Colman, I. (2002). Gambling
decisions: An early intervention program for problem gamblers.
Journal of Gambling Studies, 18, 235255.
Toneatto, T. (2005). A perspective on problem gambling treatment:
Issues and challenges. Journal of Gambling Studies, 21, 7580.
Toneatto, T. (unpublished data). The psychometric properties of the
inventory of gambling situations.
Toneatto, T., & Ladouceur, R. (2003). The treatment of pathological
gambling: A critical review of the literature. Psychology of
Addictive Behaviors, 28, 4292.
Toneatto, T., & Millar, G. (2004). Assessing and treating problem
gambling: Empirical status and promising trends. Canadian
Journal of Psychiatry, 49, 173181.
Toneatto, T., & Nguyen, L. (2007). Individual characteristics and
problem gambling behaviors. In G. Smith, D. Hodgins, & R.
Williams (Eds.), Research and measurement issues in gambling
studies (pp. 279305). Boston: Elsevier.
Trevorrow, K., & Moore, S. (1998). The association between
loneliness, social isolation and womens electronic gaming
machine gambling. Journal of Gambling Studies, 14, 263284.
Turner, N., & Littman-Sharpe, N. (unpublished). The inventory of
gambling situations.
Volberg, R. A. (1994). The prevalence and demographics of
pathological gamblers: Implications for public health. American
Journal of Public Health, 84, 237241.
Volberg, R. A. (2003). Has there been a feminization of gambling
and problem gambling in the United States? Journal of
Gambling Issues, 8, 135.
Walker, M., Toneatto, T., Potenza, M. N., Petry, N., Ladouceur, R.,
Hodgins, D. C., et al. (2006). A framework for reporting
outcomes in problem gambling treatment research: The Banff,
Alberta Consensus. Addiction, 101, 504511.

123

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