gambling mindfulness present

1. 2 Case Introduction
“Lauren” (apseudonym) independentlycontactedthe researcherafterlearningof the research
program.At the time of interview,Laurenwas61 yearsof age withfouradultchildrenandfour
grandchildren.She reportedthatshe had previouslylivedinanabusive relationshipfor30 years
withherhusbandwithwhomshe wasnow separated.Afterseparation,Laurencontinuedhaving
intermittentcontactwithherestrangedhusbandwhowasa source of stressfor her.Althoughshe
continued tooccupythe familyhome,heronlysource of income wasa pension.Laurenreported
that she had a mortgage and no otherdebts.
Lauren’s39-year-olddaughterwasherprimarysupport.However,she reportedthatherthree
adultsons,whoresidedwithher,were experiencingpersonal andemotional difficulties.Her
relationshipwithmostmembersof herfamilywascharacterizedbytensionanddisputes.Althoughshe
refrainedfromsubstance use,she reportedthatone of hersonshad a
substance-use problem.Despite suchdifficulties,Laurenreportedthatshe feltsafe athome.
3 PresentingComplaints
Laurenreporteddifficultiesrelatingtoelectronicgamingmachines(EGMs) andno difficulty
withanyother formof gambling.Inthe 5 weekspriortothe intervention, Laurenlostanaverage
of AUD$144 perweekonEGM gambling.She attendedlocal gamingvenuesanaverage of 0.8
timesperweek,where she remainedforanaverage of 1.4 hr per week.Laurenreportedthather
gamblingpriortothe 5-weekbaselineperiodwas well inexcessof the timesreportedandthat
she still consideredherself aproblemgambler.
The initial assessmentinterview revealedthatLaurenwaspreoccupiedwithgambling,had
made repeatedattemptstodiscontinue,hadreturnedanotherdaytorecoup previousmonetary
losses,andhadusedgamblingasa meansof escapingfromproblemsanddysphoricaffect.
Accordingto the DiagnosticandStatistical Manual of Mental Disorders(4thed.,textrev.;
DSM-IV-TR;AmericanPsychiatricAssociation,2000),pathological gamblingischaracterized
“by recurrentandpersistentmaladaptive gamblingbehavior”(p.663). To meetthe criteriafor

2. pathological gambling,apersonmustmeet5 outof the 10 criteriato be so diagnosed.Assuch,
Laurendidnot satisfyfull DSM-IV-TRcriteriaforpathological gambling.The term“problem
gambler”isoftenappliedtopersonswhoexhibitsome of these criteria(Volberg,2002).
The interviewalsorevealedevidence of generalizedanxietyandpastdepressiveepisodes.
Preintervention assessmentusingthe BeckAnxietyInventory(BAI) andBeckDepression
Inventory–II(BDI-II)indicated“severe anxiety”and“moderate depression,”respectively.She
reportedcurrentmoodas lowbecause of a recentdispute withanadultson.Her treatmentgoal
was to abstainfromall gamblingactivities.
4 History
Laurenbegangamblingat the age of 46 yearson EGMs. She reportedthatshe gambledtorecoup
previousgamblinglossesandthatgamblingfrequencyintensifiedfollowingthe deathof herfrequent
Laurenbegangamblingat the age of 46 yearson EGMs. She reportedthatshe gambledtorecoup
previousgamblinglossesandthatgamblingfrequencyintensifiedfollowingthe deathof her
motherseveral monthslater.Since thistime,Laurenreportedongoing issueswithgeneralized
anxietyanddepression,andhadexperiencedaheartattack. She hadongoingdisputeswithher
adultsonswho continuedtoreside inherhome.Laurenreportedthatshe hadlimitedsocial support
and engagedinfewleisure activities. She alsohadlimiteddisposable income.Laurenconsidered
that such factorscontributedtoherdesire togamble.She identifiedthathergamblinghad
become a problematage 56. Followingthis,LaurenengagedinCBTfor problemgamblingfor
several years andparticipatedinamindfulness/yogacourse forproblemgambling.
5 Assessment
Approval forthisresearch(EthicsnumberCF08/1123-2008000551) wasgrantedby the Monash
UniversityStandingCommittee onEthicsinResearchInvolvingHumans.Laurencompleteda
range of self-reportmeasuresthatassessdiagnosticstatus(structuredclinicalinterview forpathological
gambling[SCIP] andclinical interview),evaluate treatmentoutcomes(gamblingfrequency,

3. gamblingduration,gamblingexpenditure,anxiety,and depression),measure mindfulnessasa
processof change variable,andinvestigatetreatmentcompliance andacceptability(mindfulness
practice and clientsatisfaction).Diagnosticmeasureswere employedatassessmentinterview
and self-reportmeasureswere completedatpreintervention,postintervention,4-week
DiagnosticStatusMeasure
SCIP.The SCIP (Walker,Anjoul,Milton,&Shannon,2006) assessesgambling-relatedsymptoms
accordingto diagnostic(DSM-IV-TR) criteria.The consensusof expertopinionisthatDSM
criteriashouldbe usedtodefine treatmentpopulations(Walker,Toneatto,etal.,2006).
The GamblingSelf-EfficacyQuestionnaire(GSEQ).Itisa 16-itemmeasure thatwas administered
duringtherapy.ThisinstrumenthighlightedLauren’sunique automaticresponsestohigh-risk
situationsthatcouldleadherto furthergambling.The GSEQ(May,Whelan,Steenbergh,&
Meyers,2003) has highinternal consistency(Cronbach’sα =.96) and goodtest–retestreliability
(r = .86). The relationshipbetweenGSEQscoresand othermeasuresprovide goodevidence of
convergentvalidity.
TreatmentOutcome Measures
Gamblingbehavior.Gamblingfrequency,duration,andexpenditurewere assessedusingdaily
diaryentriescompletedbythe participant.OnlyEGMgamblingwasrecorded,giventhatLauren
reportednoparticipationinanyotherformof gambling.
BAI.The 21-itemBAI(Beck& Steer,1990) was designedtoevaluatebehavioral,emotional,
and physiological symptomsof anxietyandisa reliable,valid,andwidelyusedmeasure of anxiety
duringthe past week.Eachsymptomisratedon a 4-pointscale,rangingfrom0 (notat all) to
3 (severely).The instrumenthasexcellentinternal consistency(α =.92); hightest–retestreliability
(r = .75); a clearfour-factorstructure correspondingtoneurophysiology,subjective,autonomic,
and paniccomponentsof anxiety;andgooddiscriminantvalidity(Beck&Steer,1990,
1991; Leyfer,Ruberg,&Woodruff-Borden,2006).

4. BDI-II.The BDI-II(Beck,Steer,&Brown,1996) isa 21-iteminventoryforthe assessmentof
the severityof state depression.Eachitemisratedona 4-pointscale rangingfrom0 to 3, and the
BDI-IItotal score isderivedbysummingthe itemscores.The psychometricpropertiesof the BDIII
have beenwell establishedwithevidence of soundinternalconsistency(α =.92), test–retest
reliability(r=.93), and content,construct,factorial,anddiscriminantvalidity(Becketal.,1996).
6 Case Conceptualization
Laurendescribedhergamblingbehaviorasa copingstrategythathad a negative impactonher
functioning.Withrepeatedassociationsbetweengamblingandongoingstressors,Laurenappeared
poisedtodevelopamore seriousgamblingproblem.Duringtherapy, Laurencompleted
the GSEQ, whichrevealedthatshe didnotfeel confidentthatshe couldcontrol hergamblingif
there were fightsathome.Therefore,hergamblingmaybe conceptualizedasa maladaptive coping
strategythat wasadoptedsoonafterthe deathof hermother,whichhasbeenperpetuatedby
an inabilitytoeffectivelydeal withongoingstress,relatingprimarilytofinancial difficultyand
familial disputes.Gamingvenuesappeartohave providedarefuge fromthese difficultiesby
facilitatingsuppressionof associatedworriesandnegative affectsolongas herfundsremained.
Once her limitedfundswere exhausted,Laurenwouldagainbecome confrontedbyherpersonal
difficultiesandthe consequencesof hergambling-relatedactions,resultinginadeterminationto
refrainfromgamblinginthe future.Yet,herresolve wascontinuallyunderminedbythe ongoing
nature of herpersonal difficulties,resultinginareturnto gambling.Thiscyclical patternhad
beenevidenttoLaurensince 2004 andwas growinginintensity.
Despite frequentattemptstodiscontinue gamblingsince 2004, the positive experience of
abstinence wasrapidlyoverwhelmedbyongoingstressorsthatrelatedprimarilytofinancial worries,
concernsabouther physical health,anddisputeswithinherimmediatefamily.Lauren
reportedthatgamblingofferedaplace of “peace,quiet,andcomfort”andwouldnotleave the
venue until all hermoneyhadbeenspent.Ondeparting,she experienceddejectiononrealizing

5. that all hermoneyhad beenlost.Althoughshe hadpreviouslyreceivedtraditional CBTforher
gamblingproblem, she wasprone tolapsesthatinvolvedthoughtssuchas“I have notbeenfora
while,”“Ideserve togo,”and“I missgambling.”Despite voluntarilyexcludingherself from
local gamingvenues,she reportedseveralsuccessful attemptsateludingdetection.However,
Laurenhas maintainedthe resolve toovercome hergamblingproblemandhasadoptedahealthier
lifestyle followingherrecentheartattack.Thiscombinationof factorssuggestedthataformal
mindfulnessinterventionwasalikelyappropriate andeffective treatmentforLauren. 7 Course of
TreatmentandAssessmentof Progress
The treatmentprotocol wasadaptedfor problemgamblersfromthe manualizedMBCTintervention
developedbySegal etal.(2002). AlthoughMBCT isnormallypracticedina groupformat,
deliveryof mindfulness-basedtreatmentsinindividualizedformatsisalsoconsideredappropriate
(Lau & Yu, 2009). Many mindfulnessinterventionssuchasACT and DBT routinelyteach
mindfulnessskillstoindividuals(Baer,2003). The therapistwasan accreditedMBCT facilitator
withan ongoingmindfulnesspractice.Laurenwasprovidedwithagamblingdiary5 weeksprior
to the interventiontoestablishabaseline of dailygamblingfrequency,expenditure,andduration,
and assessprogressoverthe interventionandfollow-upphases.A dailymindfulnessdiarywas
alsoprovidedtorecordmindfulnessfrequencyanddurationoverthe interventionandfollow-up
phases. Consistentwiththe general structure of MBCT,Laurenparticipatedineightweekly
MBCT-PG sessions,eachof 2 hr duration.Four-weekand10-weekfollow-upsessionswere
conducteFromFigures1,2, and 3, it can be seenthatgamblingbehaviordeclinedwhen comparedwith
baseline.ByWeek3,Laurencompletelyabstainedfromgambling,whichwasmaintained
throughoutthe treatmentandfollow-upperiods.FromFigure 4,itcan be seenthatLauren
engagedina regular40-minmeditationpractice fromWeek1of the intervention.Frequencyof
thismeditationpractice declinedinWeek2,thenincreasedoverthe course of the interventionin
accordance withhomeworkrequirements.However,Laurendiscontinuedherdailymeditation
practice overthe follow-upperiod.Figure4alsodisplaysthe frequencyof use of the 3-min

6. breathingspace thatwas introducedinWeek3of the intervention.Laurenusedthistechnique
regularlyoverthe interventionperiod,anditwasthe onlymindfulnesspractice utilizedoverthe
follow-upperiod.toconsolidatelearninganddiscusspractical issuesrelatingtohermindfulnesspractice.
TreatmentProtocol
The treatmentprotocol wasadaptedfor problemgamblersfromthe manualizedMBCTintervention
developedbySegal etal.(2002). Guidedaudio presentationsforeachof the meditations
were providedtoLaurenat the endof eachsession.
Sessions1to 4: Mindfulness.The firstfoursessionsof MBCT-PGfocusedonteachingmindfulness
techniquestoLauren.PsychoeducationinSession1introducedthe conceptsof automaticity,
wherebyhabitual activitiesare performedwithoutconsciousattention(Logan,2004) and
mindfulness,wherebypresent-momentthoughts,feelings,andsensationsare attendedtowithout
tryingto change anything(Kabat-Zinn,2005). Mindfulnesspractice thenbeganwiththe bodyscan
technique thatwasusedtohelpLaurengain greaterawarenessof physical sensationsinthe
body,usuallythe mostnoticeablemanifestationof thoughtprocessesandfeelingsthatoperate
outside awareness. Session2thenfocusedondealingwithbarrierstohermindfulnesspractice.
Generally,MBCTparticipantsencountermanyobstacleswhenadoptingaregularmindfulness
practice (Segal etal.,2002). However,Laurenreportedthatshe practicedthe prescribed40-min
mindfulnesshomeworkeachdayanddidnotreport anydifficulty.
However,inSession3,Laurenreportedadecline inthe frequencyof her40-minmindfulness
practice.She indicatedthather“mindkeptwandering”andthatshe had “difficultyconcentrating”
whenpracticingherhomework.These experiencesappearedtorelate toaresumptionof gambling
duringthe week,whichresultedinalossof AUD$1,600. Althoughdistressing,thisfinancial loss
afforded some insightintothe nature of herdistressthatshe came to perceive intermsof thoughts,
feelings,andbodysensations.Introductionof awide range of mindfulnesstechniquesinthis
session,includingsittingmeditation,3-minbreathingspace,yoga, andwalkingmeditation
offeredavarietyof meansbywhichLaurencouldpractice her mindfulnessskillsandinterrupt

7. automaticresponsesshe commonlyexperiencedpriortoor followingagamblingepisode.
Session4exploredthe presentmomentbyencouragingLaurentobe mindful of hercurrent
experience.Thiscreatedaspace forher to observe thoughts,feelings,andbodysensationsinvoked
by eventsandbecome free of habitual automaticreactionsbyrespondingmindfullyeachtime
theyoccurred.She reportedthatshe beganto “do thingswithintention”andto“take notice of what
she was doing.”The GSEQ (Whelan,Steenbergh,&Meyers,2007) wasadministeredduringthis
sessiontohighlighthigh-risksituationsthatwere relevantforher.Inparticular,Laurendidnot
feel confidentthatshe couldcontrol hergamblingif there were fightsathome.Thisinsightprovided
an opportunityforherto respondmindfullywhenthissituationoccurredinthe future.
Sessions5to 8: RespondingtoGambling-RelatedCognitions.Sessions5to 8 of MBCT-PG
providedinstructioninmindfullyrespondinganddealingwithgambling-relatedthoughtsorfeelings.
Duringthisphase of MBCT-PG,Lauren continuedtorefrainfromgamblingandreported
takingmore notice of her currentexperience.Session5focusedondevelopinganaccepting
relationshipwithhergambling-relatedtriggersandurgesbybringingmemoryof herrecentgambling
experience tomindwhenengagedinmindfulnessmeditation.Thispractice allowedLauren
to explore herexperience andstaywithitwithoutactuallydoinganything.Session6consolidated
thisskill byhelpinghertodevelopagentle interestandcuriositytowardthe contentof her
gambling-relatedthoughts.She reportedoccasionsduringthe weekwhere she “neededtoescape”
and experienced“uncomfortable feelingsandthoughts”whenwalkingdownthe street.However,
she was able towatch these experiencesunfoldinthe presentmomentwithoutdoinganything.
Thissessionprovidedinstructioninacceptance of distressingthoughtsandfeelingsby
usingthe breathas a meansof redirectingherattentioneachtime these eventswerenoticed. Lauren
continuedtoabstainfromgamblingandpracticedmindfulnessexercisesregularly.
She notedthat she usedherbreathas a pointof reference towhichshe returnedeverytime she
noticeda gambling-relatedcognition.Session7includedseveral cognitive-behavioral techniques
commonlyusedintraditional CBT.Laurenlistedpleasure andmasteryactivitiesthat

8. couldbe usedinsteadof gambling,notedactivitiesthatcouldtriggera gamblingepisode,and
identifiedherownindividual relapsesignature.Of relevance tothe potential forrelapsewasher
thinkingaboutgamblingtoavoidpersonal problems.The final sessionthenlinkedthe learning
gainedwiththe future.The programwassummarized,relapseactionplanswere discussedand
reviewed,andLaurenwasadvisedtodevote approximately40mineach dayto a mindfulness
practice.Postinterventionmeasuresweredistributedandreturnedtothe researcherbypost.
Assessmentsof the BDI-II(Figure 5),BAI(Figure 6),andthe FFMQ (Figure 7) were taken
at preintervention,postintervention,4-weekfollow-up,and10-weekfollow-upphases.The
y-axisscale oneachfigure representsthe lowestscore tothe highestscore foreachmeasure.
Standarderror of measurementbars(SEM) was includedinthese graphssothatchange couldbe
assessedusinginference byeye (Cumming&Finch,2005). The SEM providedthe basisfor
determininga95% confidence intervalwithinwhichLauren’strue score waslocated.Significant
change is indicatedbyaclear andevidentgapbetweenthe SEMbars at eachphase.Moderate
change is indicatedbyaclear increase ordecrease inthe outcome variable butnogapbetween
the SEM bars at each phase.Nochange isindicatedbyminimal change inthe outcome variable
and no gapbetweenthe SEMbarsat eachphase. Figure 5 revealsthatBAIscoresfor Laurenindicated
“severe anxiety”atpreintervention
assessment.Thesescoressignificantlyreducedto“mildanxiety”atpostinterventionassessment.
BAIscores remainedatthislevel at4-weekand10-weekfollow-up.Figure 6displaysLauren’s
BDI-IIscores,whichindicated“moderatedepression”atpreinterventionassessment.BDI-II
scoressignificantlyreducedto“minimaldepression”atpostinterventionassessment.There was
a moderate decrease indepressionscoresfromthislevel at4-weekfollow-up,whichwasmaintained
at 10-weekfollow-upassessment.Overall,the assessmentmeasuresrevealedthatMBCTPG
was effective insignificantlyreducingsymptomsof anxietyanddepression.
Figure 7 displayseachof Lauren’smindfulnessfacetscores.There wasnochange inthe SEM
for the Describingfacetacrossthe assessmentperiod.There wasmoderate improvementinthe

9. SEM forthe Observingsubscaleof the FFMQat postinterventionassessment.However,there
was a moderate decrease inObservingat4-weekfollow-upandnochange at 10-weekfollow-up.
Althoughthe Actingwith Awarenessfacetdisplayednochange overthe interventionandat
4-weekfollow-up,there wasamoderate reductioninthisfacetat10-weekfollow-up,whichwas
significantwhencomparedwiththe preinterventionscore.A moderate improvementwas
observedin the Nonreactivitymindfulnessfacetatpostinterventionassessment,whichwas
maintainedacrossthe follow-upperiod.Similarly,there wasamoderate increase inthe Nonjudging
facetscoresat 4-weekfollow-up.The reductioninthisscore at10-weekfollow-upwas
nonsignificant.
Clientsatisfactiondatawascompiledusingthe CSQatthe conclusionof the therapy.Table 1
reflectsLauren’sresponsestothisquestionnaire.FromTable 1,itcan be seenthatLaurenwas
mostsatisfiedoverallwithMBCT-PGasa treatmentforhergamblingproblem.She wassatisfied
interms of the interventionmeetingherneedsandrecommendingthe service toothers,and
mostsatisfiedinall otherdomains.
8 ComplicatingFactors
Laurenwas requiredtocomplete adailydiaryentry torecord frequencyanddurationof her
mindfulnesspractice usingthe formsdevisedbySegal etal.(2002). Lauren reliablyreported
frequencyof hermindfulnesspractice,butpractice durationentrieswere inconsistentandinsufficient
despite the therapist’sattemptstoencourage more preciserecording.Thisinformation
was,therefore,supplementedbyinterview information.Takentogether,thisdatarevealedLauren’s
unwillingnesstosustainaregular40-minmeditationpractice overthe follow-upperiod as
recommendedbySegal
9 Accessand Barriersto Care
Laurenwas providedwithinformationatinterview pertainingtootherformsof counselingand
problem-gamblingservicesthatcouldbe usedif anydistresswasexperiencedduringthe course
of the program. 10 Follow-Up

10. Laurencompletedatreatmentprotocol thatinvolvedasessionwiththe therapist4weeksand
againat 10 weeksfollowingthe conclusionof the intervention.Self-reportmeasureswere
administeredonbothoccasions,course contentwasreviewed,andprogresswasdiscussed.
Laurenremainedgamblingabstinentandheranxietyanddepressionscoresremainedatsubclinical
levelsoverthe follow-upperiod.However,the prescribed40-min,dailymindfulness-meditation
practice was notmaintained.Instead,Laurenpreferredtoemploythe 3-minbreathingspace
regularlyasa way of diffusingpresent-momentgambling-relatedcognitions.Lackof significant
improvementinDescribing,Observing,andActingwithAwarenessfacetsoverthe follow-up
periodmayreflectthislapse.
11 TreatmentImplicationsof the Case
The aim of thisstudy wasto investigate the utilityof MBCT-PGfor a problemgambler.As
hypothesized,MBCT-PGsignificantlyreducedgamblingfrequency,duration,andexpenditure,
and significantlyimprovedLauren’spsychological functioning.However,the hypothesis
that MBCT-PG wouldimprove fivefacetsof mindfulnesswaspartiallysupported,as
onlyObserving,Nonjudging,andNonreactivitymindfulnessfacetsdisplayedevidence of
moderate improvement.Inaddition,althoughLaurenfailedtomaintainthe prescribedmindfulness-
meditationpractice,she consideredMBCT-PGanacceptable approachfor hergambling
problem.
Thiscase studyhas a numberof implicationsforutilizing third-waveCBTforproblemgambling.
Most notably,Laurencompletelyabstainedfromgamblingatthe conclusionof the intervention
and thisimprovementwasmaintainedoverthe 10-weekfollow-upperiod.Previous
interventionssuchastraditional CBThadnot beencompletelysuccessfulforLaurenasshe had
experiencedmultiplegamblinglapses.Althoughshe continuedtoexperience urgestogamble
duringMBCT-PG, she successfullyrefrainedfromgamblingbymindfullyrespondingeachtime
such urgesoccurred.Thisresponse isinsharpcontrast to heruse of gamblingasa meansof

11. escapingpresent-momentpersonal difficulties,whichshe habituallyengagedinpriortothe
developmentof hermindfulnessskills.AsMBCT-PGtargetshabitual cognitionsthatlie largely
outside consciousawareness,itispossible thatthe interventionismore effective thantraditional
CBT for thisclientbecause itmore consistentlyimpactedthe underlyingfeelingsandurges
responsible forhergamblingactivity.Althoughasingle case studycannotdemonstrate efficacy
of the intervention,thisresultnonethelessdemonstratesthatathird-wave CBTapproachsuch as
MBCT-PG has potential inimprovingproblem-gamblingoutcomesoverthatof traditional CBT forsome
problemgamblers.Randomizedcontrolledstudieswithlargersamplesare requiredto
establishthe efficacyof MBCT inthe treatmentof problemgambling.
As hypothesized,Laurenrecordedasignificantreductioninanxietyanddepressionscoresto
subclinical levelsoverthe assessmentperiod.Becausecomorbiddisorderssuchasanxietyand
depressionare importantandinfluentialpathwaysbothintoandoutof pathological gambling
(National ResearchCouncil,1999),there isconsensusthatevaluationsof interventionsforproblem
gamblingmeasure these conditionsastreatmentoutcomes(Walker,Toneatto,etal.,2006).
FindingsfromthisstudysuggestthatMBCT-PG mayaddresssome aspectsof comorbidity.
Randomizedcontrolledstudiesevaluatingthesecomorbidconditionsare requiredtoconfirmthe
efficacyof MBCT-PG inimprovinganxietyanddepression.
Preliminarydataasto the mechanismsbywhichMBCT-PGexertsitseffectongambling
behaviorandpsychological functioningoutcomessuggestedpartial supportfor the hypothesis
that MBCT-PG wouldimprove fivefacetsof mindfulness.Baeretal.(2006) statedthat complex
constructssuch as mindfulnessshouldbe analyzedata facetlevel toclarifythe relationship
betweenthe facetsandothervariablesof interest. The Observingfacetisrelatedto
opennesstoexperience andattendingtointernal andexternal stimuli,the Describefacetreflects
the abilitytorecognize andlabel emotional states,andthe ActingWithAwarenessfacetmeasures
attentiontocurrentactivityandavoidingautomaticpilot(Baeretal.,2006). Although
scoresfor Observingdisplayedmoderateimprovementoverthe interventionphase when

12. Laurenwas practicingher40-min mindfulnessmeditations,adecline wasobservedoverthe
follow-upphase whenthese more intensive practiceswere notemployed.The Describe facet
displayednochange acrossthe assessmentperiod,suggestingthatLauren’smindfulnesspracticehad
little influence onherabilitytorecognize andlabel hercurrentemotional status. Similarly,
there wasno change in the ActingWithAwarenessfacetoverthe interventionandat
4-weekfollow-up.Thisfacetthendeclinedsignificantlybythe 10-weekfollow-upwhencompared
withthe preinterventionassessment.These resultssuggestthat these facetsrespondtoa
prolongedmindfulness-meditationpractice anddegrade if aneffective practice isnotincorporated
withineverydaylife.
Segal etal. (2002) recommendaregular,dailymindfulnessmeditationof 40min,witha regular,
daily,brief practice preferabletoa longerinfrequentpractice.Laurendidnotcomplywith
thisrecommendationandengagedinthe 40-minmeditationpractice inconsistentlyoverthe
intervention phase andabstainedfromthispractice overthe follow-upphase.Instead,Lauren
preferredtouse the 3-minbreathingspace onlywhenshe became confrontedbyagamblingrelated
urge or desire.Althoughthe use of the 3-minbreathingspace appearstoaccountfor
Lauren’sabstinence fromgamblingoverthe follow-upperiod,aprolongeddailymindfulnessmeditation
practice is critical forsustainedtherapeuticbenefit(Baer,2003; Melbourne Academic
MindfulnessInterestGroup,2006; Segal etal.,2002). Carmodyand Baer(2008) found
that home practice of the formal meditationexerciseswassignificantlycorrelatedwiththe degree
of change infacetsof mindfulness.Baeretal.(2008) alsofoundthat meditationexperience was
significantlyandpositivelycorrelatedwithall of the mindfulnessfacetswiththe exceptionof
actingwithawareness.Furthermore,changesinmindfulnessscale scoresmediatethe relationship
betweenmeditationpractice andwell-being(Carmody,Baer,Lykins,&Olendzki,2009).
Lack of improvementinLauren’sabilitytoattendtostimuli,labelemotional states,andavoid
the tendencytooperate onautomaticpilottherefore suggestsstrongpossibilityof future relapse
if an intensive mindfulness-meditationpractice isnotregularlymaintained.

13. Lauren’sscoresfor the NonreactivityandNonjudgingfacetsrevealedmoderate improvement
despite anapparentlackof prolongedmindfulnesspractice overthe follow-upperiod.
Baer etal. (2006) consideredthesefacetstobe negativelyrelatedtothoughtsuppressionand
Althoughlittleresearchonmediational mechanismshasbeenconducted,thoughtsuppression
has beenfoundtopartiallymediatethe relationshipbetweenmindfulnessandother
addictive disorderssuchasalcohol use (Bowen,Witkiewitz,Dillworth,&Marlatt,2007). Taken
together,these findingssuggestthatMBCT-PGassistedLaurentoaccept hergambling-related
urgesand desires,whichwouldordinarilyhave overwhelmedanyrational understandingof her
gamblingbehaviorandresultedinagamblingepisode.Thisobservationalsoprovidessupport
for the proposal thatMBCT may alteravoidantstylesof cognitiveprocessingandemotiondysregulation
implicatedinproblemgambling(Di Dio&Ong, 1997; Williams,Teasdale,Segal,&
Soulsby,2000).
However,givenLauren’slackof sustainedmindfulnesspractice andhertendencytolapse
withinabstinence,the 10-weekfollow-upperiodemployedinthisstudymaybe insufficientto
assessthe long-termsuccessrate of thisintervention.Otherpsychological treatmentsforproblem
gamblingreporta 70% successrate at 1 yearand 50% at 2 years(Pallesenetal.,2005). As
such,future studiesshouldinclude alongerfollow-upperiodinterspacedwithregularfollow-up
sessionstoestablishamore definitive successrate forthe intervention.
Despite thisdifficulty,LaurenconsideredMBCT-PGan acceptable approachforhergambling
problem.Giventhatgamblersresistseekingtreatmentandattempttohandle problemsby
themselves(Tavares,Martins,Zilberman,&el-Guebaly,2002),suchan endorsementmaybe
valuable inenticingproblemgamblerstoseektreatmentearlier.However,the requirementfora
sustainedmeditationpractice mayreduce the appeal of the interventionformanyproblemgamblers.
Toneattoetal. (2007) reportedthata mindfulnessinterventionforproblemgamblingmay
onlybe effectivewhere otherinterventionshave failed.Thisisconsistentwithfindingsreported

14. inmindfulnessstudiesof otherpopulations.Forexample,MBSRiscommonlyusedforpain
managementafterothermedical avenueshave beenexhausted(Grossman,Niemann,Schmidt,
& Walach, 2004; Kabat-Zinn,2005).Similarly,MBCTfor preventionof relapse fromdepression
ismore likelytobe effectiveforanindividualif he orshe had experiencedthree ormore
priordepressive episodes(Coelho,Canter,&Ernst,2007). Assuch, MBCT-PG mayonlybe
useful whenaproblemgamblerhasexhaustedothertreatmentoptionsandretainsthe motivation
to practice mindfulnessskillsonaneverydaybasis.Thisissueisanimportantareafor future
research.
AlthoughreasonsforLauren’sgamblingabstinence remainsspeculative,MBCT-PGwas
effectiveineliminatingLauren’sgamblingbehaviorinthe contextof the familialandfinancial
difficultiesshe continuedtoexperience.Thiscase studyreflectsone wayinwhichpeople such
as Laurencan learnto cope withsuchdifficultiesmore adaptively.
12. RecommendationstoCliniciansandStudents
MBCT-PG requiressignificantlymore researchtoestablishthe approachasan alternative intervention
to traditional CBTor as an adjunctapproach followingtreatment.Basedonthisstudy,
there isevidence thatproblemgamblersmaybenefitfromMBCT-PG, particularlyforthose with
comorbiddisordersorwhere othertreatmentshave failed.However,benefitsmayonlybe maintained
if commitmenttoa dailymindfulness-meditationpractice issustained