The role of mindfulness in problem gambling and implications for treatment

Mindfulness-based interventions have been identified as a ‘third wave’ in the cognitive behavioural tradition which may improve problem gambling outcomes. However, there is a paucity of research that has investigated the mechanisms by which mindfulness may impart therapeutic benefit. The broader mindfulness literature suggests that mindfulness functions by promoting awareness and acceptance of present moment cognitive and emotional states associated with the experience of psychological distress. These states include rumination, thought suppression, and emotional dysregulation. While an inverse relationship has been found between dispositional mindfulness and problem gambling severity, no study has yet investigated whether such states mediate the relationship between dispositional mindfulness and psychological distress, and whether psychological distress is associated with indices of problem gambling behaviour, such as problem gambling severity, gambling expenditure, gambling frequency, gambling duration, gambling pre-occupation, and gambling urges. Furthermore, no study has yet investigated the efficacy of a manualised mindfulness-based intervention in improving problem gambling outcomes. Investigation into the role of mindfulness in problem gambling behaviour and implications for treatment are the primary aims of this thesis. Measures of rumination, thought suppression, emotional dysregulation, and psychological distress were utilised with clinical samples and the relationship between dispositional mindfulness and problem gambling behaviour was explored. Following this, the efficacy of mindfulness-based cognitive therapy for problem gambling was investigated.   Description of the Overall Program of Research Methodology of studies investigating mechanisms of mindfulness Study 1. Gamblers Help Southern regularly survey current clients of this service to gain an extended understanding of their experience of the service. An additional survey questionnaire was distributed as part of this survey to consenting clients. It included demographic questions and questions relating to problem gambling behaviour using the Gambling Urges Scale (GUS) and single items relating to problem gambling severity, expenditure, frequency and duration. Psychological distress was measured using the Kessler-6 (K6). Measures of the mechanisms of mindfulness included the Rumination subscale of the Rumination-Reflection Questionnaire (RRQ), the Repair subscale of the Trait Meta-Mood Scale (TMMS), and White Bear Suppression Inventory (WBSI). Dispositional mindfulness was assessed using the Mindfulness Awareness Assessment Scale (MAAS). The participants were 78 (49 male and 29 female) self-identified problem gamblers who were new clients of a metropolitan Melbourne problem gambling service. Males ranged from 21 to 76 years of age (Mdn=43, M=44.6, SD=12.9) and females ranged from 37 to 76 years of age (Mdn=58, M=57, SD=10.8). Study 2. A packet of problem gambling screening tools was developed by Gamblers Help City and the Problem Gambling Research and Treatment Centre to assess gambling behaviour and psychological functioning of new clients attending this service. The packet included demographic questions. Gambling behaviour was assessed using the Problem Gambling Severity index (PGSI) of Canadian Problem Gambling Severity Index (CPGI), and single items relating to gambling pre-occupation, gambling expenditure, gambling frequency and gambling duration. Psychological distress was measured using the K6. Measures of the mechanisms of mindfulness included three subscales from the Distress-Tolerance Scale (DTS). Finally, dispositional mindfulness was assessed using the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). Participants were 205 (148 male, 55 female, 1 unreported) self-identified problem gamblers who were new clients of a metropolitan Melbourne problem gambling service. Males ranged from 21 to 67 years of age (Mdn = 37, M = 38.4, SD = 11.3) and females ranged from 25 to 74 years of age (Mdn = 47, M = 46.2, SD = 10.5). Methodology of study investigating mindfulness-based intervention for problem gambling A series of advertisements were placed in local newspapers seeking problem gamblers for a randomised controlled trial (RCT) of mindfulness-based cognitive therapy for problem gambling (MBCT-PG). However, recruitment attempts were insufficient for a formal RCT study. Consequently, several case studies were conducted to provide supporting evidence for the efficacy of MBCT-PG. Diagnostic information was based on the Structured Clinical Interview for Pathological Gambling (SCIP), a demographic questionnaire, and questions relating to problem gambling expenditure, gambling frequency, and gambling duration. A baseline of gambling behaviour was established prior to the intervention and participants completed pre-intervention, post-intervention, and follow up questionnaires. Psychological distress was measured using the Beck Anxiety Inventory and Beck Depression Inventory-II. The Five Facet Mindfulness Questionnaire (FFMQ) was used to assess process of change, treatment compliance was assessed using a diary to record mindfulness frequency and duration, and treatment acceptability was assessed using the Client Satisfaction Questionnaire. Results and Interpretation Study 1 and Study 2 were combined into one paper entitled ‘Mechanisms of action in the inverse relationship between dispositional mindfulness and problem gambling behaviour’. The treatment seeking sample of problem gamblers in Study 1 and Study 2 displayed significantly lower dispositional mindfulness scores than a normative sample of adult community members and university students. Study 1 found that psychological distress was significantly related to indices of problem gambling behaviour as measured by problem gambling urges, problem gambling severity, gambling expenditure, and gambling frequency. Study 1 had an insufficient sample size for a hierarchical regression analysis. However, statistically significant relationships were found between dispositional mindfulness, psychological distress, and the indices of problem gambling behaviour. These results suggest that psychological distress mediates the inverse relationship between dispositional mindfulness and the indices of problem gambling behaviour. Study 1 also demonstrated that there were statistically significant relationships between dispositional mindfulness, mechanisms of mindfulness (thought suppression, rumination, and emotional dysregulation), and psychological distress. This suggests that these mechanisms of mindfulness may act as mediators in the inverse relationship between dispositional mindfulness and psychological distress. A mediational analysis performed in Study 2 confirmed that ‘attention being absorbed by negative emotions’ is an important mediator in the inverse relationship between dispositional mindfulness and psychological distress. Moreover, Study 2 confirmed that psychological distress mediates the inverse relationship dispositional mindfulness and indices of problem gambling behaviour. The case study was entitled ‘Mindfulness-based cognitive therapy for problem gambling’. This article was accepted for publication in ‘Clinical Case Studies’. The participant abstained from gambling and anxiety and depression scores significantly reduced to sub-clinical levels over the assessment period. Exploration of mindfulness facets revealed MBCT-PG may be useful in promoting acceptance of distressing thoughts and emotions. However, the participant did not maintain an intensive mindfulness meditation practice over the follow-up phase of the intervention. Taken together, the results of this program of research indicate that mindfulness could play an important role in improving problem gambling intervention outcomes.