Cognitive Behavioural Therapy and Gambling

1. Sean Sullivan PhD
ABACUS Counselling Training & Supervision
Cognitive Behavioural Therapy (CBT)
and Gambling

2. • You are a 16 year old youth still at school who has just met ‘the girl of
your dreams’ and when you ask if she would like to go to a movie with
you she laughs and says, after looking at you with seeming amusement
finally says ‘No, I don’t think so.’
• You are crushed and try to laugh it off as a silly idea, and make an excuse
to leave. A friend later says that he saw her with a classmate and they
seemed to be very affectionate. You happen to pass them and she turns
to your classmate to whisper something and then both laugh.
• You go home and drink your parents’ alcohol until you are sick and vow
never to go out with a girl out unless she asks first.
• What were your thoughts and feelings at each point?
Exercise1: Youth Scenario

3. CBT basics
• Different people think differently about the same event, which influences
our feelings, and our responses
• We can be selective in our recollections and our beliefs of what are ‘facts’
• These can be cognitive distortions of reality, and be held without
awareness
• These cognitive distortions can cause negative, stressful and discouraging
emotions through ‘automatic thoughts’, and cause problematic
behaviours
• How we think about experiences are capable of change, and so change
these emotions, behaviours

4. Principles of Cognitive Therapy
CBT is problem focused and goal oriented
• List problems
• Set specific goals
• Identify & work out obstacles to goals
• Develop/teach problem solving strategies

5. The CBT Theoretical Basis

6. Essentially CBT…
Combines:
• the cognitive restructuring approach of Cognitive Therapy
with
• the behavioural modification techniques of Behavioural Therapy

7. The CBT Perspective
• CBT proposes the there are biological, psychological and social reasons
why people both feel and behave (i.e. biopsychosocial approach albeit
in which biology may limit ability to change)
• However, although people may have mental health and addiction
problems influenced by biological risks, these problems primarily arise
from learning (modelling, operant and classical conditioning)

8. CBT is Based Upon the Belief That…
• Dysfunctional emotions, physical reactions, and behaviours are not
directly triggered by events themselves, but by our evaluation of the
event
• When appraising an event, we are often selective about what we
consider to be “the facts” – often they are cognitive distortions or
subjective realities
• These false realities can trigger “automatic thoughts”, often illogical,
contributing to negative emotions or avoidance of troubling situations

9. CBT Model
Thoughts
Feelings
Behaviour
Physical body response
EVENT

10. CBT Thought Components
• Automatic thoughts – negative, brief, ‘unthinking’, irrational,
dysfunctional, usually resulting in self-defeating emotions and behaviours
e.g. “It’s a sign she’s going to leave me!”
• Conditional thoughts (these underlay the automatic thoughts) – learned
over time and believed to be totally true, helping them make sense of
why things occur e.g. “If I do everything that people want then I won’t be
rejected”
• Core beliefs or schemas (underlay conditional thoughts) – deep and
fundamental beliefs about themselves e.g. “I am undesirable”

11. Core belief
Conditional ‘if-then’ beliefs
Automatic thought
Event
Response
emotion & behaviour
Early life
experiences eg.
abuse, lack of
nurture
Compensatory
strategies e.g.
gambling
The CBT Problematic Thought Process

12. Exercise 2: Julie
• Julie, 17, has a core belief that he will never succeed in life because she is less
intelligent than others
• She drinks and gambles to avoid these constant thoughts (on weekends, much
more than her mother knows)
• What a) conditional belief (e.g. ‘If I am… then I will survive’) might he have?
• What automatic thoughts might arise when:
1. She is asked by her teacher to tell the class tomorrow about her uncle who
has just won a medal in rowing
2. John, a classmate, says she must be the thinking intelligent type because
she doesn’t say anything during class and would like to know her better
3. She works after school and notes a supervisor has possibly made a mistake
that will result in a lot of costs for the business. The supervisor has gone
home when the manager asks Julie ‘How’s it all going Julie?’

13. Aims & Assumptions of CBT

14. Assumptions of CBT
• Abnormal behaviour is cause by abnormal thinking processes
• People respond to the world through their mental construct of it
• If peoples’ mental representations are inaccurate or their reasoning
processes are inadequate then their emotions and behaviour may
become disordered

15. Cognitive Behaviour Therapy
• “You learn to test the meaning and usefulness of various thoughts
and…
• This changes the thinking patterns that keep you locked into
dysfunctional moods, behaviours or relationship interactions...
• CBT enables you to learn how to make changes in your life when your
thoughts alert you to potential problems”
Greenberger, D. & Padesky, C.A. (1995)

16. Brief Recap

17. CBT Therapy: Focus’ on the Present
We can’t change the past
but we can change
the way we think about it.

18. Goals of CBT
• To recognise patterns of thinking and behaving that have developed as
a maladaptive way to address past problems
• To reduce both the frequency and the severity of symptoms that cause
emotional distress
• To develop better (adaptive) responses when triggers arise that often
lead to the problematic thoughts, emotions and behaviours
• Improvement or increase in the range of coping skills
• Prevent relapses once new adaptive responses are being learned and
adopted

19. The role of the therapist in a CBT intervention

20. CBT therapy
Often viewed as ‘coaching’ – therapist challenges dysfunctional thinking and
guides towards alternative thinking.
So the therapist:
– Identifies the client’s problem
– Reaches agreed goals of the therapy in concrete terms
i.e. not ‘feel better’ but e.g. reduce drinking to two days a week and
maximum 6 standard drinks at one time

21. Six CBT ingredients
Following identification of the client’s problems
1. Assess the relationship between their thoughts, the emotional problems,
the behaviour problems, an the environment (functional analysis)
2. Assist in raising awareness and developing skills to recognise and cope
with dysfunctional thoughts/cognitions and the problematic physiological
responses
3. Develop client’s skills in recognising triggers, decisions that appear to be
irrelevant to the trigger, and their ability to deal with urges and impulses
e.g. to respond with addictive behaviours, or respond to depressive
triggers
4. Identification of high risk situations that have occurred in the past and
could reoccur
5. Encouragement to participate and complete (and return) homework that
practises skills between sessions
6. Practice of these skills during sessions

22. An example of CBT use (1)

23. Socratic questioning
• This technique is an important strategy that is used for guidance
towards insight and new learning and can be used in all cognitive
approaches
• The process can be a number of Socratic questions that are inter-
connected and linked and can lead the client from their existing
problematic thoughts towards a more logical, objective conclusion
about their experiences

24. Examples of Socratic questioning for raising awareness, and to become more
objective.
Socratic clarifying questions:
• What would be an example of that?
• If I understand correctly you’re saying…Is that correct?
Guiding around assumptions
• What are you assuming in that concern?
• What could we assume instead?
Reason/evidence question
• How would you justify to someone that that was always correct?
• What would change your mind?
Socratic questioning

25. Jenny, 15, has come to the notice of police when she was picked up with
others outside of a nightclub, all of them older and heavily intoxicated.
When she is dropped home after a safety check, her mother says she
doesn’t know what to do and it’s all out of her control being a solo mother
with other children. You speak with Jenny following two further incidents
because she’s becoming a ‘regular’ and CYFS may become involved. Jenny,
when sober, is quiet and tells you she feels ugly and stupid, and when she
drinks, she stops worrying about it and is also accepted by her mates. This
surprises you as she looks nice, seems intelligent, and until recently was
doing well at school.
In pairs, using Socratic questioning, try to help Jenny objectively see herself
and raise awareness of alternatives to her coping strategy
Exercise 3: Jenny

26. An example of CBT use (2)

27. Overview of CBT therapy
3 main categories of coping strategies:
• Problem solving
• Social skills and support
• Cognitive restructuring

28. Problem
3. Unrealistic
problem
Usually due to depressive
distortions
Use Cognitive
Restructuring strategies
Realistic actual problem
or loss
Solvable?
1. Yes 2. Not easily
Structured
problem
solving
Support &
coping
strategies
CBT: 3 Main Problem Categories

29. Six steps of SPS
1. Define the problem
2. Brainstorm solutions
3. Weigh up pros and cons of each potential solution
4. Decide on the best potential solution
5. Carry out the steps required for this solution
6. Review the attempt

30. Exercise 4: Structured Problem Solving
Mary often feels depressed. She has been drinking heavily and CYFS liaises
with you to assist her because her son, Denny, 11 is at risk, and younger
daughter is in CYFS care.
Mary says WINZ also now requires her to obtain part-time work. She says
she is a trained nurse, but thinks no service will be interested in her time
restraints, her possible need to retrain, and transport difficulties (she only
has her ex-husband’s Harley which she got in lieu of maintenance). When
she thinks of these problems she throws her hands up and gets more
depressed.
Can you help Mary using SPS?

31. Some tools used in CBT

32. Goals List
(interventions are
linked to client’s
goals)
What could get in
the way- barriers
What I can do to
remove barriers
Who could help
and support me
Identifying Goals

33. Think of something you may want to achieve, but haven’t yet, and feel a
bit ambivalent about it:
Using an “identifying goals” sheet, work with your partner/s to list the
barriers, ways to overcome barriers and supports, in relation to the
change they would like to make. Then reverse roles.
Exercise 5: Identifying Goals

34. Following identification of the client’s problems
1. Assess the relationship between their thoughts, the
emotional problems, the behaviour problems, an the
environment (functional analysis)
Remember: Six CBT ingredients

35. Triggers
What sets me
up to gamble
My thoughts and feelings
before
Gambling
What did I do?
Positive things
that happened
Negative
things that
then happened
(after)What I was
thinking
What I was
feeling
Going home
from work on
payday
All work & no
play -can’t
stand this!
Bored
Angry
Unhappy
Pulled into pub
to play pokies
No longer
bored
Chance of
winning big
Came home
late, no money,
argued
Argument with
husband
He doesn’t
appreciate me
Annoyed
Sad
Stormed out &
drove down to
pub
Escaped from
feeling sad and
annoyed
Felt guilty and
talking less
with husband
Feeling lonely
and few
friends
I can gamble a
little and stop
before losing
too much
Excited,
happy
Drove to
casino
Not lonely
when there,
treated well
with respect
Lost more than
expected. No
money to go
out with
friends
Functional Analysis
What leads up to the gambling and the functional relationship of gambling to the consequences

36. • Think of a recent example of a client’s gambling slip
• Was there something that they thought ‘caused’ them to go and gamble
(e.g. bad day)
• What might they have thought to themselves as they decided to gamble
• What could they have been feeling
• Where did they go to gamble?
• What positives did they probably experience?
• What negatives did they experience?
• Would it have helped if they developed a strategy to question/check
their thoughts before following them?
Exercise 6: Functional Analysis

37. Situation Strategy Ideas
Supports,
Support people
When alone and feeling
low or bored
When its ‘free time’ and
no-one expects me to be
somewhere
When bills come in and I
don’t have enough
money
Try to plan to have a
friend present or meet
for coffee
Arrange an appointment
so that I’m expected to
be somewhere
Talk to a budgeter
A friend or GA buddy
Good friend around who
knows I’ve given up
gambling
My counsellor
High Risk Situations: My Strategies

38. Event Mood
at the
time
1-10
Automatic
thought
(hot thought –
most intenseve
emotion)
Evidence that
supports
Evidence
doesn’t
support
Other
possibility/
balanced
thoughts
Mood
rating
now 1-10
Cognitive Restructuring

39. • Cognitive restructuring - requires more than positive thinking
• Clients may need to take concrete action to solve the problem, learn new skills,
or develop a broader network of support
• Start with the form, then do it in your mind as good reflective thinking
whenever you’re feeling stressed
Cognitive Restructuring

40. • Some automatic thoughts are triggers for relapse – therapy can
reduce risk
• CBT techniques for relapse prevention include tools for:
• Identifying early warning signs
• Identifying strategies to counteract
• De-construct lapses – learning experience
• Identifying high risk situations
Relapse Prevention

41. The
situation
Prior thoughts,
feelings and
expectations
What I did
e.g. drink,
gambled
What else I
could have
done
Expected
outcome if I
used
alternatives
Friday,
after work
– mates
invite me
to pub
where
there are
pokies
Had a hard week
Bored and feeling
like a break
Didn’t want to sound
like under wife’s
thumb
I’ll only go for one
drink and not
gamble
Probably 8-
10 glasses
beer and
then played
pokies for
two hours
losing a lot
Gone out with
wife instead
Said I had a
family
function
Got realistic
about my
gambling
Wouldn’t feel
bad
Had a good
time
Mates would
have believed
me
No regret
about
gambling
Relapses:
Debriefing and Identifying Alternatives

42. Cognitive Distortions

44. • All or nothing thinking (black & white thinking) “Losers come 2nd”
• Over-generalisation “I never get things right - typical!” (signals: ‘never’ &
‘always’)
• Mental filter only seeing what is wrong, ignoring positives “95%! Where
did I go wrong?”
• Disqualifying the positive “Yes, I did succeed, but it was a fluke” (positives
‘don’t count because…)
• Mind reading “He didn’t get back to me, so I must have failed”
• Fortune telling – treating future as if already fact – “I’ll never meet the
right person!”
Cognitive Distortions

45. Sue (18), a sole child, is very thin and her mother is distraught as she seems to
have little resistance to any opportunistic virus. Sue however considers herself
overweight and ‘bloated’. Her mother said it seemed to change when Sue started
High School and girls in her class teased her about being fat (she was a little
overweight then, her mother said). Her mother says that her failing marriage isn’t
helping and Sue has always been close to her father; but they’re trying to keep it
together so as not to cause their daughter more stress. Sue doesn’t appear to
have friends at school, although she says she has many on Facebook. Sue enjoys
reading about teen fashion and her magazines display models who are thin,
happy and popular. Lately she is playing a game on her phone and this will go on
for hours, with little sleep or leaving her room. The costs of the game have
increased as she wants to buy skins for her avatar, but her parent pay for this as
it’s keeping her interested in something and harmless, isn’t it?
What appear to be the factors affecting Sue; are they accurate? If not, why is Sue
buying in to them?
Exercise 7: Sue

46. • By setting up an experiment to test the truth of the belief can raise
awareness – validity testing of an automatic thought or schema
• I can’t resist gambling (schema: I’m weak)
• Experiment: Outcome that will disprove this belief – If I can avoid going
to my favourite venues for a week then I have proved I can resist
gambling
• Strategy: rehearse resisting, identify alternative strategies, get support
(but don’t deliberately expose myself to risk situations to test)
Cognitive Distortions: Validity Testing

47. CBT with Addictions

48. First
• Identify level of
motivation and
monitor throughout
• Detoxification if
required if coexisting
AOD
• Harm reduction usual
CBT approach
• Identify coexisting
problems –integrated
approach (research
shows if alcohol use
addressed then
increases by 16.7
times recovery from
mood/anxiety
disorder if don’t
address the alcohol
problem)
Approach
• Functional analysis
with focus on
triggers, & what
maintains use
• Identify through
above the role of
environment, skills
(and deficits)
• Identify high risk
situations
Practice
• Learn new skills &
when to apply
• Self-monitors
success or required
changes
• Anticipate risk
• Manage situations
until becomes a habit
or normal behaviour
• Learn or apply
relapse prevention
CBT with Addictions

49. CBT for Depression

50. • If depression isn’t severe, then counselling can include self-help
resources such as using manuals or online programmes with CBT
approach
• Less severe depression, more suitable for CBT may have
• Shorter period of depression
• Depression starts when older
• Few previous periods of depression
• If more severe depression, consider involving other health professionals
(GP, psychiatrist) as well
Depression

51. • Involving whanau important
• Often relationship may be strained with the depressed
person
• Good for whanau to be aware of signs that a relapse
or more severe depression is occurring
Depression: Involving Whanau

52. Engage
• Engage with
client
• Explain CBT
approach
• Motivate to work
together with
counsellor to
address issues
together
• Provide
information at
appropriate
cognitive level
and identify
personality
disorders
Assess
• Assess &
explain
symptoms are to
do with
depression
• Explain
symptoms will
reduce as CBT
process rolls out
• Consider
medication
needs
The work
• Keep diary of
daily activities
and how these
affect her mood
• Address
distorted
thoughts
• Identify triggers
• Develop coping
skills and
relapse
prevention
strategies
CBT & Depression Overview

53. • Complete an assessment of depression and other possible factors
• Give feedback
• Develop of a treatment plan with client input
• Plan may include daily activities (structured, problem-focussed)
• Routine, with pleasurable opportunities developed
• Identify and challenge negative thoughts
• Typically includes education about depression (that it is not laziness, and
thoughts may be negative about themselves)
CBT & Depression Overview

54. • May include ‘behavioural activation’ – doing things in a structured way
to refocus on normality
• May be alongside medication especially if the depression is moderate to
severe
• May use self help manuals with CBT focus
• May include homework such as keeping a daily diary of activities
CBT & Depression Overview

55. • Assess and give feedback of how tiredness or poor concentration are
symptoms of depression
• That the depression will affect how their world and life may look (negative)
• Explain how symptoms may reduce as the depression lifts (from the CBT
therapy) to give hope
• Agree on focussing upon development of daily activities will help reduce
depression (e.g. daily diary of activities and how they may improve mood
Depression: CBT Process

56. • As client notices the routine daily activities resulted in improved mood
their confidence around the future will improve
• Also important that the client notices what has occurred when their
mood gets worse as this may assist in identifying automatic negative and
irrational thoughts that persist
• Considering alternative conclusions when these happen can be good
learning of other coping behaviours
Depression: CBT Process

57. Summary