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Exposure Therapy for Gambling Disorder: Systematic Review and Meta-analysis

Exposure Therapy for Gambling Disorder: Systematic Review and Meta-analysis Purpose of Review Cognitive behaviour therapy is the gold standard for the treatment of gambling disorder. Obstacles remain regarding its efficacy, namely relapses and difficulty in implementing cognitive restructuring for some clients. Given these observations, behavioural interventions for gambling disorder, such as exposure therapy, which aims to decrease gambling craving, may be effective as a complementary or alternative intervention to cognitive behaviour therapy. This systematic review and meta-analysis aims to explore how exposure therapy for gambling disorder has been studied and to evaluate its efficacy. To answer these questions, 3406 studies, retrieved using PsycNet, Medline and Google Scholar, were screened. Recent Findings After two screenings, 13 papers were selected for the systematic review and five were statistically com- bined for the meta-analysis. Quantitative results support exposure therapy’s efficacy to decrease gambling craving at post- intervention (g = − 0.955) and at last follow-up (6 or 12 months; − 1.010). Results also show a large decrease in gambling severity as documented by screening instruments (− 1.087) as well as time spent gambling (− 2.136) at post-intervention. Furthermore, a large decrease in gambling measured via screening instruments (− 1.162) and erroneous beliefs (− 1.308) was found at last follow-up. Summary This is the firs t meta-analysis on behavioural exposure therapy for gambling disorder. Results support that exposure therapy reduces gambling cravings and severity, as well as time spent gambling and erroneous beliefs. These results are dis- cussed in comparison to other therapeutic approaches and are interpreted according to the high risk of bias in included studies. Keywords Gambling disorder therapy · Cognitive-behaviour therapy · Exposure therapy Introduction gambling found some benefits of CBT in the short term; only a few studies demonstrated long-term benefits [4 ]. Gambling disorder (GD) is recognised as a persistent and Many problem gambling etiological models consider recurrent problematic gambling behaviour leading to clini- erroneous beliefs as a significant contributing factor in cally significant impairment or distress [1 ]. To this day, developing GD [5–8]. Given this contribution, it is natural cognitive behaviour therapy (CBT) is the most empirically that many CBT interventions include and may primarily validated treatment for GD [2 , 3]. CBT integrates behav- rely on cognitive restructuring. Cognitive restructuring ioural interventions with aspects of cognitive therapy. It is comprises both the identification of erroneous thoughts used alone or in combination with motivational interven- and the restructuring of those thoughts. The most used tions. A recent systematic review of treatments for problem technique to identify erroneous beliefs is exposure to a gambling scenario [9 ]. Cognitive therapy by itself could have no better benefits in the short or long term relative to This article is part of the Topical Collection on Gambling an active control condition (exposure therapy) [4] Recent addiction management literature [10, 11] also * Pierre-Yves Bergeron demonstrates that exposure to a gambling scenario may also pierre-yves.bergeron.2@ulaval.ca be used as a stand-alone therapy. The rationale for exposure Ecole de Psychologie, Université Laval, Quebec City, therapy is that by definition, addiction is a learned behaviour Canada resulting from the coupling of substance use and pleasure, Département de Psychoéducation Et de Psychologie, and can therefore be un-learned. In order to support the Université du Québec en Outaouais, Gatineau, Canada Vol.:(0123456789) 1 3 180 Current Addiction Reports (2022) 9:179–194 unlearning process, cue-exposure therapy presents individu- were the most commonly documented efficacy variables als with relevant drug cues to extinguish the conditioned in GD therapy studies. Lastly, erroneous beliefs are often response [12–14]. This conceptualisation is based on learn- documented in GD intervention studies [9 ], as they are ing theory, according to which drugs represent an uncon- believed to be central to GD aetiology and maintenance ditioned stimulus, and the effects are the unconditioned [5–7]. Documenting exposure therapy’s efficacy in lowering responses. By associative learning, neutral stimuli such as erroneous beliefs will provide a way to contrast its efficacy visual, olfactory, tactile and auditory cues can elicit a condi- to other therapeutic approaches. tioned craving response, as these cues are frequently paired with drug use [13, 15, 16]. Objectives Exposure in the Gambling Literature The main objective of this systematic review and meta- Exposure has taken different forms in gambling treatment, analysis was to document the use of exposure therapy as a such as imaginal desensitisation and exposure with response behavioural treatment of GD and to evaluate its efficacy. To prevention [17–20]. These variations of exposure therapy do so, the current study sought to determine to what extent share the same core conceptualisation as cue-exposure exposure therapy reduces: (1) gambling craving; (2) severity therapy for addiction and can take the form of imaginal, of problem gambling; (3) gambling behaviour; (4) erroneous in vivo or virtual reality exposure [21, 22]. Battersby et al. beliefs; and (5) increases perceived self-efficacy. [21] use exposure therapy to specifically target gambling craving. Gambling craving can manifest as physical sensations such as heart palpitations or muscle tension, Method emotional states like stress and increased arousal, or as thoughts pertaining to different aspects of gambling (i.e. dreams of winning or negative flashbacks; [23]). To Protocol extinguish craving induced by gambling cues, Battersby et  al. [21] use graded exposure where initial cues elicit This systematic review and meta-analysis was conducted less craving, thus making them easier to cope with and according to the recommendations outlined in the Cochrane progressively become more challenging. Authors suggest Handboock for Systematic Reviews of Interventions [27]. that this type of graded exposure makes it easier for patients Findings were reported according to the Preferred Reporting to concentrate on cravings elicited by the cue and experience Items for Systematic Reviews and Meta-Analyses (PRISMA) a reduction of craving over time. It is expected that cravings statement [28]. will diminish over the course of therapy through a process called habituation. Search Strategy To date, only one study has sought to summarise exposure therapy’s efficacy for the treatment of GD. In their 2008 In order to be included in the meta-analysis, potential narrative review, Dowling, Jackson and Thomas [18] studies must have (1) an exposure therapy condition; (2) concluded that exposure therapy appears to be a promising one or more of the following measurements: severity of technique for the treatment of GD, yet requires further GD, gambling behaviours (money spent, time spent, etc.), empirical evidence to confirm its efficacy. This review did craving intensity and perceived self-efficacy; (3) data for not predetermine which outcome measures would be used to pathological or at-risk gamblers according to a screening quantify exposure therapy’s efficacy in treating GD. Given instrument or clinical interview; (4) been written in French the key role of craving in exposure therapy’s rationale [21], or English; and (5) been published since 1980, year of the an investigation of exposure therapy should first establish introduction of pathological gambling in the DSM-III. its efficacy in lowering the craving to gamble. Dowling Studies that documented the efficacy of CBT programs with et al.’s [18] review included studies that contained data on exposure therapy as one of the treatment components were perceived self-efficacy in controlling gambling behaviour excluded. [24] making it another important outcome to investigate. A three-step systematic review of the literature was Perceived self-efficacy is defined as an individual’s belief conducted to identify relevant studies. First, the electronic in their ability to resist an opportunity to gamble in a databases PsychNET (via APA), MEDLINE (via PubMed) given situation [25, 26]. A systematic review by Chrétien and Google Scholar were screened up to July 1st, 2019. et al. [9 ] found that reported gambling behaviour (i.e. the For PsychNET and Google Scholar, the following search amount of time and money spent gambling) and severity equation was used: {exposure OR virtual reality OR of problem gambling measured with screening instruments imaginal desensitization OR imaginal relaxation OR “in 1 3 Current Addiction Reports (2022) 9:179–194 181 vivo”} AND {gambl*} in any field and index terms. For time and money spent gambling, the frequency of gam- Medline, the following search strategy was used: {exposure bling, GD screening scores and erroneous beliefs and per- therapy OR Virtual Reality Exposure Therapy OR ceived self-efficacy measured with validated self-report Desensitization, Psychologic} AND {gambl*} where the questionnaires. first part of the criteria was in MESH terms. These strategies were developed with the help of a specialised social sciences Unit of Analysis librarian. The reference lists of selected articles were also retrieved from the databases to identify other potential Analyses compared data for a number of outcome vari- eligible studies. Lastly, authors of selected studies were ables from baseline to post-intervention and last follow-up contacted by e-mail to inquire about unpublished data. No using Hedges’ g as the measure of effect [29, 30]. Hedges’ paper was added to the screening by the use of the last two g provides a standardized mean difference with a correc- strategies. tion for small sample size and is interpreted as a z score, where the output represents the number of pooled stand- Study Selection ard differences between two timepoints [29, 31]. In the present study, a negative Hedges’ g indicates a decrease First, study eligibility was determined by reading article in the given variable at post-intervention or last follow- titles and abstracts. For the first step of article screening, up. Hedges’ g is interpreted similarly to Cohen’s d, where interrater agreement between the first author and a graduate 0.2, 0.5 and 0.8 represent small, medium and large effects, research assistant was based on a random sample of 10% of respectively [29, 32]. Effect sizes were calculated using the studies. The first author carried out the rest of the screen- Biostat software Comprehensive Meta-analysis (Biostat ing. Studies that passed the initial screening were then read Inc., Engelwood, NJ) using timepoint means, standard in their entirety. For this second selection, interrater agree- deviations and pre-post-correlation estimates for each ment was based on the full-sample and carried out by the variable. Pre-post-correlation estimates were calculated first author and an undergraduate research assistant. Disa- using data from other gambling clinical studies [33, 34]. greements were settled by consensus. Forest plots were also calculated according to these analy- ses, including Hedges’s g, variance and global effect size Data Extraction for each variable according to a random measure effect with a 95% confidence interval. As suggested by the Cochrane Collaboration [27], a data extraction form was developed to gather all relevant study information. The data extraction form included information Results on authors, methodology (experimental design, condition assignment), participant characteristics, outcome measures Descriptive Data Analysis and results. A double data entry was carried out by the first author and a trained undergraduate research assistant. Disa- greements were settled by consensus. Sample Assessment of Risk of Bias in Included Studies As shown in Fig.  1, 3406 publications were initially screened, and from those, 3393 were excluded. Most of In accordance with the Cochrane Risk of Bias assess- these articles were excluded because they did not include ment tool [27], each of the following study’s risk of bias exposure therapy. Interrater agreement reached 95.1% for was rated “High”, “Low” or “Unclear”: random sequence the screening and 99% for the full sample. Thirteen arti- generation (selection bias); allocation concealment (selec- cles were retained for the final sample. Even though four tion bias); blinding of participants, personnel and outcome were single-case studies and one had only two partici- assessors (detection bias); incomplete outcome data (attri- pants, these studies are included in the study descriptive tion bias); selective outcome reporting (reporting bias); and as they provide input on how exposure therapy has been other potential threats to validity (see [28] for a complete used on gambling treatment. The meta-analysis therefore description). includes six studies. Outcome Measures Of the 13 selected studies, Riley, Smith and Oakes (2011) [23] had Gambling craving was the primary outcome variable in two eligible groups for the current meta-analysis. Therefore, these this study. Secondary outcome variables included the •• groups are presented separately as [43] and [44 ] (see Table 1). 1 3 182 Current Addiction Reports (2022) 9:179–194 Fig. 1 PRISMA study selection flowchart Records identified from*: PsycNet = 686 Medline = 1421 Google Scholar 1052 ClinicalTrials.org = 0 Retrieved from review and meta-analyses = 247 Records screened Records excluded (n =3406) (n = 2882) Reports sought for retrieval Reports not retrieved (n = 557) (n =33) Reports excluded: Reports assessed for eligibility No exposure therapy (n = 271) (n =524) No data regarding pathological or at-risk gamblers (n = 98) Did not address sought after outcome variable (n = 28) Exposure therapy carried exclusively in context of larger CBT therapy (n = 26) Theoretical study design, reviews or meta-analyses (n = 72) Duplicates (n = 9) Insufficient intervention description (n = 4) Data from other study (n = 3) Studies included in review (n =13) From 13 selected studies, 948 participants were allocated [37–39], three imaginal exposure [34, 35, 40] and seven used •• •• to an exposure condition. Excluding single-case studies a mix of both techniques [36, 41–43, 44 , 45, 46 , 47]. Six [36, 39, 42, 47], the mean number of participants was 104.9 of the seven studies using both imaginal and in vivo expo- (SD = 104.1, median = 49). Participants from 12 studies sure included a gradual increase in difficulty by first using •• •• [34–39, 41–43, 44 , 45, 46 ] reported gambling mostly imaginal exposure and then in vivo exposure [36, 42, 43, •• •• or exclusively on electronic gambling machines, while the 44 , 45, 46 , 47]. Participants met with a therapist 7.4 majority of participants in the remaining study [40] bet on times on average (median = 9.5) and took part in an aver- horse races. age of 23.1 exposure sessions (either with the therapist or Eight of the included studies provided baseline descrip- as betweensession homework; SD = 19.9, median = 14). •• tive data on time spent gambling [34,  36–39, 43, 44 , Table 2 provides characteristics of the exposure session for 47] and four on money spent on gambling[34,  37–39]. each study. Participants in these studies spent an average of 6.9  h per week (SD = 2.2, min = 3.8, max = 12.8) gambling and Theory and Learning Processes Behind Exposure Therapy had spent an average of $441.40 USD per week on gam- bling (SD = 455.30, median = 150). Table 1 provides data Five studies considered habituation to be the mechanism •• on participant characteristics, study localisation as well of action of the intervention [36, 42, 43, 44 , 45, 47]. One as included studies referencing number for the current study aimed to lower gambling behaviour and craving, a article. definition considered similar to habituation for the current review [37]. Two studies involved altering the behaviour Intervention  completion mechanism such that participants would no longer feel compelled to gamble in a gambling environment Nine studies were carried out in outpatient settings [34, [40, 41]. One study [38] aimed to increase participants’ per- •• •• 35, 37–39, 42, 43, 44 , 45, 46 ], three in inpatient set- ceived self-efficacy through craving resistance. The remain- tings [36, 40, 41] and one study did not specify the con- ing studies did not describe their intervention’s mechanism •• text of treatment [47]. Three studies used in vivo exposure of action [34, 35, 39, 46 ] 1 3 Included Screening Identification Current Addiction Reports (2022) 9:179–194 183 Table 1 Participants’ sociodemographic characteristics Study Reference N (final) Gender (Men %) Age Country Problematic game Hours spent Gambled money number gambling (per (USD per week) month) Blaszczynski 2005 [25] 79 (47) 77 37.1 (10.9) MI60% EGM 12.8 (9.2) 1352 (median = 150) 32% horse betting 8% combination of both Blaszczynski 2003 [36] 9 (2) 55 32.5 (7.7) 55% Australia 90% EGM MI MI 15% Croatia 15% many games 30% other Dham 2015 [37] 1 (1) 100 56 MI MI 30 MI Echeburúa 1996 [38] 16 (16) 44 35 (11) MI EGM 24.3 (25.6) 99.6 Echeburúa 2000 [39] 23 (23) 87 36 (13.7) 100% Spain EGM 52.2 127 Echeburúa 2002 [40] 1 (1) 0 47 MI EGM 26.1 187 McConaghy 1988 [41] 10 (10) 95 35 MI 70% horse racing MI MI 10% EGM 20% combination of both McConaghy 1991 [42] 80 (43) 94.7 42 MI MI MI MI Oakes 2008 [43] 1 (1) 0 31 MI EGM MI MI •• Riley 2011 [44 ] 496 (496) 51.4 43.7 (12.6) MI 89.9% EGM 14.5 (9.6) MI (metropolitan) •• Riley 2011 (rural) [44 ] 55 (55) 54.5 45.3 (11.7) MI 90.1% EGM 19.7 (6.3) MI Smith 2010 [45] 127 (83–80 ) 54 43.1 (12.7) MI 86.6% EGM MI MI Smith 2015 [35] 49 (43) 50 45.5 (12) MI EGM 16 (25.6) MI •• Tolchard 2006 [46 ] 1 (1) 0 50 MI EGM MI MI Data are mean (standard deviation) unless stated otherwise. Hours spent gambling are normalised to month format when necessary. MI missing information, EGM electronic gambling machine. Follow-up number of participants differs according to each variable. due to the lack of blinding of study personnel, random Outcome Variables sequence generation and allocation concealment. The most common outcome variables were time spent •• •• gambling at post-intervention [34, 36, 39, 43, 44 , 46 ]; Meta‑analyses gambling craving using the Gambling Urge Scale [48; 45, •• 46 ], visual analogue scale [34, 35] or categorical scale Four variables were analysed at post-treatment and at the longest available follow-up. Five studies [35, 37, 39, 47] [40]; erroneous beliefs using the Gambling-Related Cog- •• nitions Scale [49; 36, 45, 46 ] and the Gambling Beliefs had too few participants (≤ 2) and therefore could not be statistically combined for Hedges’ g. One study [38] com- Questionnaire [50; 35]; and subjective indicators [37–39, 47]. Studies also used three GD screening instruments: bined outcome variables in the Inadaptation Scale [54], making it impossible to include them in analyses. Two three used the Victorian Gambling Screen [VGS; 51; 36, •• 45, 46 ], three used the South Oaks Gambling Screen more studies [40, 41] also contained selected outcome vari- •• ables measured categorically and were thereby unable to be [SOGS; 52; 42, 43, 44 , 47] and one used the Canadian Problem Gambling Index [53; 36]. Table  3 provides a pooled with the continuous data from the other studies. For •• studies included in the meta-analyses [34, 37, 43, 44 , 45], detailed account of the gambling related outcomes for the •• selected studies. last follow-up is either 6 [46 ] or 12 months [34, 37, 45]. No analysis could be carried out on perceived self-efficacy, as only one study had enough participants for this outcome. Risk of Bias in Selected Studies Figure 2 shows the forest plot for each analysis accord- ing to a random effects model with 95% confidence interval. Risk of bias of the included studies is presented in Table 4. Included variables pertained to gambling craving, GD screen- The studies included in this review had a high risk of bias ing instruments, time spent gambling and erroneous beliefs. 1 3 184 Current Addiction Reports (2022) 9:179–194 1 3 Table 2 Treatment description Study Therapeutic mechanism Intervention aim Number of meetings Number of exposure Type of exposure Intervention description Blaszczynski 2005 MI MI 1 15 Imagination - Muscle relaxation - Imaginal exposure with emphasis on gambling craving until extinction (10–20 min) - Home imaginal exposure with audiocassette, three times a day, five days a week Blaszczynski 2003 MI Reduction in subjective 10 10 Imagination - Imaginal exposure using arousal and heart rate an audiocassette specific responses to main problematic game (EGM or horse betting) Dham 2015 Habituation MI MI MI Imagination and in vivo Graded exposure - Imaginal exposure with response prevention - In vivo exposure with response prevention - Exposure homework Echeburúa 1996 Make exposure cues lose Gambling abstinence 6 (6.5 h) MI In vivo Graded exposure with: their power to induce urge - Stimulus control: and gambling behaviour maintaining control of money and avoiding situations or routes of risk - Response prevention: forces to experience gambling craving and learn to resist this desire Echeburúa 2000 Learn how to resist this Gambling abstinence MI MI In vivo Graded exposure with: desire in a gradual, more - Stimulus control: self-controlled way maintaining control of money and avoiding situations or routes of risk - Response prevention: forces to experience gambling craving and learn to resist this desire Echeburúa 2002 MI Gambling abstinence 9 (+ 3 evaluation sessions) 54 (6 exposure per In vivo Graded in vivo exposure week for 9 weeks) involving a relative as co-therapist McConaghy 1988 Behaviour completion - Lower level of arousal 14 14 Imagination Imaginal desensitisation: mechanism - Reduction in gambling - Muscle relaxation - Imaginal exposure with response prevention Current Addiction Reports (2022) 9:179–194 185 1 3 Table 2 (continued) Study Therapeutic mechanism Intervention aim Number of meetings Number of exposure Type of exposure Intervention description McConaghy 1991 MI MI 14 14 Imagination or In vivo Two different treatment: - Imaginal desensitisation   ○ Muscle relaxation   ○ Imaginal exposure with response prevention - In vivo brief ○ In vivo exposure with response prevention lasting 20 min McConaghy 1991 (suite) MI MI 5 5 In vivo In vivo exposure with response prevention for one hour at a time Oakes 2008 Habituation MI 6 60 à 84 Imagination and in vivo Graded exposure until habituation. From imaginal exposure to in vivo exposure Riley 2011 (metropolitan) Habituation MI 11.29 (SD = 12.60) MI Imagination and in vivo Graded exposure until habituation. From imaginal exposure to in vivo exposure Riley 2011 (rural) Habituation MI 11.29 (SD = 12.60) MI Imagination and in vivo Graded exposure until habituation. From imaginal exposure to in vivo exposure Smith 2010 Habituation - Master urge to gamble MI MI Imagination and in vivo - Graded exposure using - Feel comfortable being audiocassettes alone in a gambling - From imaginal exposure venue with money in to in vivo exposure in the close proximity of gambling venues familiar gaming machines to each participant - Not requiring any - Exposure homework for 5 modifying factors to help to 7 weeks cope with their urge to gamble Smith 2015 MI MI 12 MI Imagination and in vivo - Graded exposure with stimulus control - Stimulus control is faded out as weeks progress - From imaginal exposure to in vivo exposure 186 Current Addiction Reports (2022) 9:179–194 1 3 Table 2 (continued) Study Therapeutic mechanism Intervention aim Number of meetings Number of exposure Type of exposure Intervention description Tolchard 2006 Habituation Eliminate the gambling 1 1 Imagination and in vivo - Graded exposure within a urge using habituation single session - From imaginal exposure to in vivo exposure outside gambling venue and inside gambling venue - Progression to the next step when craving has dropped to 50% initial craving MI missing information. Table 3 Outcome variables related to gambling in each selected study Blaszczynski Blaszczynski Dham Echeburúa Echeburúa Echeburúa McConaghy McConaghy Oakes Riley Smith Smith Tolchard Total 2005 2003 2015 1996 2000 2002 1988 1991 2008 2011 2010 2015 2006 Time spent gambling X X X X X 5 Craving X X X X X 5 Eroneous beliefs X X X X 4 Subjective indicator X X X X 4 Victorian Gambling Screen X X X 3 Therapeutic success X X X 3 South Oaks Gambling Screen X X X 3 Frequency of gambling X X 2 Money spent X X 2 Self-control X X 2 Preoccupations towards gambling X 1 Problem Gambling Severity Index X 1 Current Addiction Reports (2022) 9:179–194 187 Table 4 Bias assessment using Cochrane risk assessment tool Study Random sequence Allocation Blinding Attrition bias Selective outcome Other potential generation concealment reporting threats to validity a b Blaszczynski 2005 - - - - ? ? Blaszczynski 2003 + + - - - ? Dham 2015 - - - + - ? Echeburúa 1996 + ? - + ? ? Echeburúa 2000 + + + + ? ? Echeburúa 2002 - - - + + ? McConaghy 1988 + ? - + ? - McConaghy 1991 + ? + - - - Oakes 2008 - - - + ? ? Riley 2011 - - - + ? ? Smith 2010 - - ? + ? ? Smith 2015 + + + + + ? Tolchard 2006 - - - + - ? High risk of bias Uncertain risk of bias Low risk of bias •• Given that the two groups [44 ] documenting SOGS Craving score did not have follow-up measures, VGS score in the •• two remaining studies [45, 46 ] represents GD screen- Three studies were included in the analyses of exposure •• therapy’s impact on craving post-treatment [34, 45, 46 ]. ing instrument scores for the last measure. Pooled VGS scores decreased from 38.14 (sd = 10.87) to 15.83 Pooled results show a decrease in mean Gambling Urge pooled Scale [32] and visual analogue scale scores from 12.31 (sd = 16.33) at last measure, equivalent to a Hedge’s g pooled of − 1.69 (CI = [− 2.750, − 0.63]), p = 0.002, which indicates (sd = 6.49) to 8.17 (sd = 6.12). This decrease is pooled pooled equivalent to a Hedge’s g of − 0.955 (CI = [− 1.78, − 0.13]), a large effect [29, 32]. p = 0.024, corresponding to a large effect [29, 32]. Two studies were included in the analyses of expo- Time Spent Gambling sure therapy’s impact on craving at last measure [45, •• 46 ]. Pooled mean scores on the Gambling Urge Scale Four studies (totalling five groups; 1R, 4R, 10R, 11R, [48] decreased from 13.71 (sd = 7.32) t o 2.89 pooled 13R) were included in the analysis of exposure therapy’s (sd = 10.21) at last measure. This decrease is equivalent pooled impact on time spent gambling at post intervention. The to a Hedge’s g of − 1.010 (CI = [− 1.51, − 0.51]), p < 0,001, average hours spent gambling per month decreased from corresponding to a large effect [29, 31, 32]. 18.51 (sd = 6.52) to 3.21 (sd = 4.33) h post-treat- pooled pooled ment. A large effect was observed for this outcome with a Hedge’s g of − 2.16 (CI = [− 3.05, − 1.27), p < 0.001 [29, GD Screening Instruments 32]. Two studies were included in the analysis of exposure •• •• Three studies totalling four groups [44 , 45, 46 ] were therapy’s impact on time spent gambling at last measure included in the analysis of exposure therapy’s impact on GD •• [39, 46 ]. Mean hours spent gambling per month fell from screening instruments at post-intervention. SOGS pooled 18.02 (sd = 8.05) to 2.90 (sd = 2.72). Hedge’s g pooled pooled average scores decreased from 9.57  (sd = 4.33) to 4.01 pooled was non-significant, − 2.45 (CI = [− 5.34, 0.44]), p = 0.096. •• (sd = 4.37) in two groups [44 ] and VGS pooled scores pooled decreased from 38.14 (sd = 10.87) to 29.13 (sd pooled pooled Erroneous Beliefs = 10.01) at post-intervention for the two other groups [45, •• 46 ]. Hedges’ g was − 1.09 (CI = − 1.54, − 0.64), p < Two studies were included in the analyses of exposure 0.001, corresponding to a large effect [29, 32]. therapy’s impact on erroneous beliefs at post intervention 1 3 188 Current Addiction Reports (2022) 9:179–194 Craving : last measure GD n Fig. 2 Meta-analyses’ Forest-plots 1 3 Current Addiction Reports (2022) 9:179–194 189 GD screening instruments: last measure Time spent gambling: last measure Fig. 2 (continued) 1 3 190 Current Addiction Reports (2022) 9:179–194 Erroneous beliefs: post intervenon Erroneous beliefs: Last measure Fig. 2 (continued) •• [45, 46 ]. Pooled mean Gambling Related Cognitions Discussion Scale [49] scores decreased from 68 (sd = 21.5) to 55.4 pooled (sd = 19.5) which was also non-significant, Hedge’s This systematic review and meta-analysis aimed to describe pooled g = − 0.65 (CI = [− 1.34, 0.04]), p = 0.064. how exposure therapy is implemented in the treatment of Two studies were included in the analyses of exposure GD, as well as its efficacy in reducing cravings, gambling therapy’s impact on erroneous beliefs at last measure [45, behaviour and screening test scores, as well as decreasing •• 46 ]. Pooled Gambling Related Cognitions Scale [48] erroneous beliefs and improving perceived self-efficacy. mean scores decreased from 68 (sd = 21.5) to 34.15 pooled (sd = 25.14). A large effect was observed for this meas- pooled Studies Description ure, Hedge’s g = − 1.31 (CI = [− 2.00, − 0.62]), p < 0.001 [29, 32]. To date, exposure therapy for GD has been most widely Table 5 summarises data relating to quantitative analyses studied in predominantly male participants, with more recent for each outcome. 1 3 Current Addiction Reports (2022) 9:179–194 191 Table 5 Summary of quantitative findings Variable Pre intervention Post intervention Last follow-up Hedges’ g CI (95%) p pooled mean pooled mean (pooled pooled mean (pooled sd) sd) (pooled sd) GD screening instruments (pre-post- 9.57 (4.33) 4.01 (4.37) N/A − 1.087 − 1.536, − 0.637 < 0.001 intervention) 38.14 (10.87) 29.13 (10.01) Victorian gambling screen (pre-last 38.14 (10.87) N/A 15.83 (16.33) − 1.162 − 1.976, − 0.347 0.002 follow-up) Time (pre-post intervention) 18.51 (6.52) 3.22 (4.32) N/A − 2.136 − 3.034, − 1.238 > 0.001 Time (pre-intervention – last 18.02 (8.05) 8.05 2.90 (2.72) − 2.452 − 5.340, 0.437 0.096 follow-up Craving (pre-post intervention) 12.31 (6.49) 8.17 (6.12) N/A − 0.955 − 1.782, − 0.129 0.024 Craving (pre-intervention—last 13.71 (7.32) N/A 2.88 (10.21) − 1.010 − 1.508, − 0.512 > 0.001 follow-up) Erroneous beliefs (pre-post 68 (21.5) 55.4 (19.5) N/A − 0.653 − 1.343, 0.038 0.064 intervention) Erroneous beliefs (pre-intervention – 68 (21.5) N/A 34.15 (25.14) − 1.308 − 1.999, − 0.617 < 0.001 last follow-up) Pooled means and SD are presented in two lines to differentiate SOGS score (first result) and VGS score (second result). Hedges’ g, CI, and p data combine results from SOGS and VGS on this line. studies striving to include more women in their samples. be the new learning brought about by exposure, which Exposure therapy for GD was studied in two countries, Aus- would in turn reduce the craving to gamble. Given that tralia and Spain, and participants mainly preferred electronic this conceptualisation has yet to be applied to GD, future gambling machines. Participants were mostly seen individu- studies in line with this understanding would further clarify ally and in outpatient settings. how exposure therapy works, while potentially providing Most studies presented a mix of imaginal and in vivo a treatment description that better reflects participants’ exposure with exposure intensity gradually progressing as subjective experience. participants became increasingly capable of successfully Last of all, the analysis of selected studies shows a high confronting each cue. Most exposure therapy studies were risk of bias as a result of insufficient blinding of study per - theoretically based on habituation, such that exposure to dif- sonnel, random sequence generation and allocation con- ferent gambling cues induces craving, yet as the craving is cealment. Moreover, only two to three studies conducted in not acted upon, it decreases and would ultimately be extin- Spain and Australia could be included in each meta-analysis. guished. This rationale is akin to systematic desensitisation This highlights the necessity for more methodologically as originally developed in the 1950s [55]. sound studies to evaluate exposure therapy for GD in order Only three studies had therapeutic mechanisms other to better ascertain its efficacy. than habituation. McConaghy et  al.’s studies [40, 41] conceptualise exposure therapy as a means of altering the Exposure Therapy’s Efficacy behaviour completion mechanism, leading patients to no longer feel compelled to gamble in a gambling environment. Exposure therapy had a large effect on craving reduction at McConaghy et al. (1988) [40] conclude that it is not possible post intervention and was even larger at 6- and 12-month to determine if the behaviour completion mechanism better follow-up. Confidence intervals were also closer to the cor - explains exposure therapy’s efficacy. Echeburúa el al. responding g measure, indicating that results are more homog- [38] conceptualise that exposure therapy raises perceived enous at follow-up. These results from the limited literature self-efficacy to not gamble when faced with gambling on exposure therapy support its efficacy in lowering gam- situations. This conceptualisation resembles that of more bling cravings. The effect of exposure therapy was larger at recent inhibitory learning views of exposure therapy for follow-up, which is similar to other studies of CBT [see 57]. anxiety [56]. According to this model, exposure does not Improved results at follow-up may be attributable to partici- produce the unlearning between a cue and a conditioned pants’ continued application of techniques learned in therapy; response but rather produces a new learning that inhibits however, this has yet to be empirically tested. It is important the conditioned response. Combining this conceptualisation to mention that one study did not include follow-up data on to Echeburúa et  al.’s (2000) [38], craving would be the gambling craving, which may explain the more homogenous conditioned response and increased self-efficacy would results and higher effect size data. Overall, it is surprising that 1 3 192 Current Addiction Reports (2022) 9:179–194 only five of the 13 studies tested exposure therapy’s effect on who evaluated GD therapies including CBT, motivational reducing craving, given this variable’s crucial importance to interviewing therapy, integrative therapy and other psycho- treatment rationale. therapeutic interventions, found 14 RCTs. It is difficult to From a statistical viewpoint, a large decrease of gambling determine why exposure therapy has yet to be tested with screening instruments score was attained at post-treatment. a RCT design, but it is encouraging to see that 30% of the Using SOGS’s cut-off scores, pooled means decreased included studies used an empirical design with a lower risk •• •• from “probable pathological gambler” to “potential patho- of bias [44 , 45, 46 ]. Another limitation of this study is logical gambler”. Using VGS cut-off scores, pooled mean that studies were included regardless of their risk of bias due results decreased at post-intervention while remaining in the to the small number of studies meeting the inclusion crite- “problem gambler” range. For final follow-up, pooled mean ria. It was therefore necessary to combine this small num- results indicate a score of “borderline gambling”. These large ber of studies while remaining critical of results in order to decreases remain lower than what was obtained from CBT ascertain the pertinence of investigating exposure therapy’s in comparison to control in Cowlishaw et al.’s (2012) meta- efficacy for GD in future studies. Furthermore, the current analysis [2 ]. Looking at other therapies investigated in the meta-analysis used pre-post analyses within-participants due same meta-analysis, exposure therapy’s efficacy to lower to the lack of studies involving a control group; the pre-post participants gambling screening scores indicate that it is the design is known to overestimate effect sizes in comparison next best intervention to reduce GD severity. This result is to those computed from controlled studies [30]. The rigorous preliminary as it was derived from only a few studies with a study selection, with two independent interrater agreements high risk of bias. Nevertheless, these preliminary results are and double selection of data from selected studies, is the encouraging and support the efficacy of exposure therapy to main strength of the study. It is hoped that findings from reduce the severity of gambling behaviour. the present study showing the benefits of exposure therapy Results show that exposure therapy produces a substan- for GD will promote further, more methodologically rigor- tial decrease in time spent gambling at post-intervention, ous studies in order to reliably establish exposure therapy’s yet these results became non-significant at 6 to 12 months efficacy for treating GD. post-intervention. Given that confidence intervals were par - ticularly large at last follow-up, the loss of significance may be attributable to the larger variance resulting from a small Conclusion number of combined studies comprising few participants. Further studies with larger sample sizes are likely required to This study is the first meta-analysis on behavioural expo- detect statistical significance. Still, Echeburúa et al. (2000) sure therapy for GD. Pooled results from a small num- [38] have argued that adding relapse prevention after expo- ber of studies demonstrate a positive effect of exposure sure therapy produces more therapeutic success than expo- therapy for GD. The present study’s results show that sure therapy alone after 12 months. The effect of supple- exposure therapy reduces gambling cravings and sever- menting exposure therapy with relapse prevention should ity, as well as time spent gambling and erroneous beliefs. therefore also be studied in order to establish its added value. Future studies should investigate the efficacy of stand- Meta-analysis of two studies shows that exposure therapy ardized exposure therapy using a treatment manual in resulted in a non-significant decrease in participants’ erro- RCTs to obtain more reliable outcome da ta. Evaluating neous beliefs at post-intervention, yet showed a large and by which process exposure therapy leads to clinical effi- significant effect at 6 and 12 months. These results appear in cacy would also help in understanding the link between line with past studies suggesting that higher levels of errone- each efficacy variable. Overall, this study supports expo- ous beliefs are associated to with higher levels of problem sure therapy as a promising approach to the treatment of gambling severity [34, 58, 59]. Further studies evaluating GD and may assist in broadening therapeutic options for the impact of exposure therapy, a behaviour intervention, individuals suffering from GD. on erroneous beliefs will be necessary to better understand the exact mechanism driving the effect. Data Availability Data may be obtained via request. Limits and Strengths Declarations This meta-analysis was limited by the studies included for Ethics Approval Waived by the comité d’éthique de la recherche en analyses as these were few, at high risk of bias, and per- psychologie et en sciences de l’éducation de l’Université Laval on formed in only two countries (Australian and Spain). The 20/04/2018. literature search did not identify any randomised controlled Consent to Participate Not applicable. trials (RCTs). In comparison, Cowlishaw et al. (2012) [2 ], 1 3 Current Addiction Reports (2022) 9:179–194 193 Consent for Publication Not applicable. 10. Mellentin AI, Skøt L, Nielsen B, Schippers GM, Nielsen AS, Stenager E, et al. Cue exposure therapy for the treatment of alcohol use disorders: a meta-analytic review. Clin Psychol Rev. Conflict of Interest Stéphane Bouchard is president of, and owns 2017;57:195–207. https:// doi. org/ 10. 1016/j. cpr. 2017. 07. 006. shares in, Cliniques et Développement In Virtuo, a company that dis- 11. Trahan MH, Maynard BR, Smith KS, Farina AS, Khoo YM. tributes virtual environments, and any conflict of interest is managed Virtual reality exposure therapy on alcohol and nicotine: a sys- under UQO’s conflict of interest policy. The other authors declare no tematic review. Res Soc Work Pract. 2019;29(8):876–91. https:// conflict of interest. doi. org/ 10. 1177/ 10497 31518 823073. 12. Conklin CA, Tiffany ST. Cue-exposure treatment: time for Open Access This article is licensed under a Creative Commons Attri- change. Addiction. 2002;97(9):1219–21. https:// doi. or g/ 10. bution 4.0 International License, which permits use, sharing, adapta- 1046/j. 1360- 0443. 2002. 00205.x. tion, distribution and reproduction in any medium or format, as long 13. Drummond DC, Cooper T, Glautier SP. 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The relationship between gambling 10. 1111/j. 1440- 1584. 2011. 01199.x. [Metropolian group] cognitions, psychological states, and gambling: a cross-cultural 44.•• Riley B, Smith D, Oakes J. Exposure therapy for problem study of Chinese and Caucasians in Australia. J Cross-Cult Psy- gambling in rural communities: a program model and early chol. 2008;39(2):147–61. outcomes. Aust J Rural Health. 2011;19(3):142–6. https:// doi. or g/ 10. 1111/j. 1440- 1584. 2011. 01199.x. [Rural group]. Publisher's Note Springer Nature remains neutral with regard to This community study comparing the same therapy in jurisdictional claims in published maps and institutional affiliations. 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Current Addiction Reports Springer Journals

Exposure Therapy for Gambling Disorder: Systematic Review and Meta-analysis

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Abstract

Purpose of Review Cognitive behaviour therapy is the gold standard for the treatment of gambling disorder. Obstacles remain regarding its efficacy, namely relapses and difficulty in implementing cognitive restructuring for some clients. Given these observations, behavioural interventions for gambling disorder, such as exposure therapy, which aims to decrease gambling craving, may be effective as a complementary or alternative intervention to cognitive behaviour therapy. This systematic review and meta-analysis aims to explore how exposure therapy for gambling disorder has been studied and to evaluate its efficacy. To answer these questions, 3406 studies, retrieved using PsycNet, Medline and Google Scholar, were screened. Recent Findings After two screenings, 13 papers were selected for the systematic review and five were statistically com- bined for the meta-analysis. Quantitative results support exposure therapy’s efficacy to decrease gambling craving at post- intervention (g = − 0.955) and at last follow-up (6 or 12 months; − 1.010). Results also show a large decrease in gambling severity as documented by screening instruments (− 1.087) as well as time spent gambling (− 2.136) at post-intervention. Furthermore, a large decrease in gambling measured via screening instruments (− 1.162) and erroneous beliefs (− 1.308) was found at last follow-up. Summary This is the firs t meta-analysis on behavioural exposure therapy for gambling disorder. Results support that exposure therapy reduces gambling cravings and severity, as well as time spent gambling and erroneous beliefs. These results are dis- cussed in comparison to other therapeutic approaches and are interpreted according to the high risk of bias in included studies. Keywords Gambling disorder therapy · Cognitive-behaviour therapy · Exposure therapy Introduction gambling found some benefits of CBT in the short term; only a few studies demonstrated long-term benefits [4 ]. Gambling disorder (GD) is recognised as a persistent and Many problem gambling etiological models consider recurrent problematic gambling behaviour leading to clini- erroneous beliefs as a significant contributing factor in cally significant impairment or distress [1 ]. To this day, developing GD [5–8]. Given this contribution, it is natural cognitive behaviour therapy (CBT) is the most empirically that many CBT interventions include and may primarily validated treatment for GD [2 , 3]. CBT integrates behav- rely on cognitive restructuring. Cognitive restructuring ioural interventions with aspects of cognitive therapy. It is comprises both the identification of erroneous thoughts used alone or in combination with motivational interven- and the restructuring of those thoughts. The most used tions. A recent systematic review of treatments for problem technique to identify erroneous beliefs is exposure to a gambling scenario [9 ]. Cognitive therapy by itself could have no better benefits in the short or long term relative to This article is part of the Topical Collection on Gambling an active control condition (exposure therapy) [4] Recent addiction management literature [10, 11] also * Pierre-Yves Bergeron demonstrates that exposure to a gambling scenario may also pierre-yves.bergeron.2@ulaval.ca be used as a stand-alone therapy. The rationale for exposure Ecole de Psychologie, Université Laval, Quebec City, therapy is that by definition, addiction is a learned behaviour Canada resulting from the coupling of substance use and pleasure, Département de Psychoéducation Et de Psychologie, and can therefore be un-learned. In order to support the Université du Québec en Outaouais, Gatineau, Canada Vol.:(0123456789) 1 3 180 Current Addiction Reports (2022) 9:179–194 unlearning process, cue-exposure therapy presents individu- were the most commonly documented efficacy variables als with relevant drug cues to extinguish the conditioned in GD therapy studies. Lastly, erroneous beliefs are often response [12–14]. This conceptualisation is based on learn- documented in GD intervention studies [9 ], as they are ing theory, according to which drugs represent an uncon- believed to be central to GD aetiology and maintenance ditioned stimulus, and the effects are the unconditioned [5–7]. Documenting exposure therapy’s efficacy in lowering responses. By associative learning, neutral stimuli such as erroneous beliefs will provide a way to contrast its efficacy visual, olfactory, tactile and auditory cues can elicit a condi- to other therapeutic approaches. tioned craving response, as these cues are frequently paired with drug use [13, 15, 16]. Objectives Exposure in the Gambling Literature The main objective of this systematic review and meta- Exposure has taken different forms in gambling treatment, analysis was to document the use of exposure therapy as a such as imaginal desensitisation and exposure with response behavioural treatment of GD and to evaluate its efficacy. To prevention [17–20]. These variations of exposure therapy do so, the current study sought to determine to what extent share the same core conceptualisation as cue-exposure exposure therapy reduces: (1) gambling craving; (2) severity therapy for addiction and can take the form of imaginal, of problem gambling; (3) gambling behaviour; (4) erroneous in vivo or virtual reality exposure [21, 22]. Battersby et al. beliefs; and (5) increases perceived self-efficacy. [21] use exposure therapy to specifically target gambling craving. Gambling craving can manifest as physical sensations such as heart palpitations or muscle tension, Method emotional states like stress and increased arousal, or as thoughts pertaining to different aspects of gambling (i.e. dreams of winning or negative flashbacks; [23]). To Protocol extinguish craving induced by gambling cues, Battersby et  al. [21] use graded exposure where initial cues elicit This systematic review and meta-analysis was conducted less craving, thus making them easier to cope with and according to the recommendations outlined in the Cochrane progressively become more challenging. Authors suggest Handboock for Systematic Reviews of Interventions [27]. that this type of graded exposure makes it easier for patients Findings were reported according to the Preferred Reporting to concentrate on cravings elicited by the cue and experience Items for Systematic Reviews and Meta-Analyses (PRISMA) a reduction of craving over time. It is expected that cravings statement [28]. will diminish over the course of therapy through a process called habituation. Search Strategy To date, only one study has sought to summarise exposure therapy’s efficacy for the treatment of GD. In their 2008 In order to be included in the meta-analysis, potential narrative review, Dowling, Jackson and Thomas [18] studies must have (1) an exposure therapy condition; (2) concluded that exposure therapy appears to be a promising one or more of the following measurements: severity of technique for the treatment of GD, yet requires further GD, gambling behaviours (money spent, time spent, etc.), empirical evidence to confirm its efficacy. This review did craving intensity and perceived self-efficacy; (3) data for not predetermine which outcome measures would be used to pathological or at-risk gamblers according to a screening quantify exposure therapy’s efficacy in treating GD. Given instrument or clinical interview; (4) been written in French the key role of craving in exposure therapy’s rationale [21], or English; and (5) been published since 1980, year of the an investigation of exposure therapy should first establish introduction of pathological gambling in the DSM-III. its efficacy in lowering the craving to gamble. Dowling Studies that documented the efficacy of CBT programs with et al.’s [18] review included studies that contained data on exposure therapy as one of the treatment components were perceived self-efficacy in controlling gambling behaviour excluded. [24] making it another important outcome to investigate. A three-step systematic review of the literature was Perceived self-efficacy is defined as an individual’s belief conducted to identify relevant studies. First, the electronic in their ability to resist an opportunity to gamble in a databases PsychNET (via APA), MEDLINE (via PubMed) given situation [25, 26]. A systematic review by Chrétien and Google Scholar were screened up to July 1st, 2019. et al. [9 ] found that reported gambling behaviour (i.e. the For PsychNET and Google Scholar, the following search amount of time and money spent gambling) and severity equation was used: {exposure OR virtual reality OR of problem gambling measured with screening instruments imaginal desensitization OR imaginal relaxation OR “in 1 3 Current Addiction Reports (2022) 9:179–194 181 vivo”} AND {gambl*} in any field and index terms. For time and money spent gambling, the frequency of gam- Medline, the following search strategy was used: {exposure bling, GD screening scores and erroneous beliefs and per- therapy OR Virtual Reality Exposure Therapy OR ceived self-efficacy measured with validated self-report Desensitization, Psychologic} AND {gambl*} where the questionnaires. first part of the criteria was in MESH terms. These strategies were developed with the help of a specialised social sciences Unit of Analysis librarian. The reference lists of selected articles were also retrieved from the databases to identify other potential Analyses compared data for a number of outcome vari- eligible studies. Lastly, authors of selected studies were ables from baseline to post-intervention and last follow-up contacted by e-mail to inquire about unpublished data. No using Hedges’ g as the measure of effect [29, 30]. Hedges’ paper was added to the screening by the use of the last two g provides a standardized mean difference with a correc- strategies. tion for small sample size and is interpreted as a z score, where the output represents the number of pooled stand- Study Selection ard differences between two timepoints [29, 31]. In the present study, a negative Hedges’ g indicates a decrease First, study eligibility was determined by reading article in the given variable at post-intervention or last follow- titles and abstracts. For the first step of article screening, up. Hedges’ g is interpreted similarly to Cohen’s d, where interrater agreement between the first author and a graduate 0.2, 0.5 and 0.8 represent small, medium and large effects, research assistant was based on a random sample of 10% of respectively [29, 32]. Effect sizes were calculated using the studies. The first author carried out the rest of the screen- Biostat software Comprehensive Meta-analysis (Biostat ing. Studies that passed the initial screening were then read Inc., Engelwood, NJ) using timepoint means, standard in their entirety. For this second selection, interrater agree- deviations and pre-post-correlation estimates for each ment was based on the full-sample and carried out by the variable. Pre-post-correlation estimates were calculated first author and an undergraduate research assistant. Disa- using data from other gambling clinical studies [33, 34]. greements were settled by consensus. Forest plots were also calculated according to these analy- ses, including Hedges’s g, variance and global effect size Data Extraction for each variable according to a random measure effect with a 95% confidence interval. As suggested by the Cochrane Collaboration [27], a data extraction form was developed to gather all relevant study information. The data extraction form included information Results on authors, methodology (experimental design, condition assignment), participant characteristics, outcome measures Descriptive Data Analysis and results. A double data entry was carried out by the first author and a trained undergraduate research assistant. Disa- greements were settled by consensus. Sample Assessment of Risk of Bias in Included Studies As shown in Fig.  1, 3406 publications were initially screened, and from those, 3393 were excluded. Most of In accordance with the Cochrane Risk of Bias assess- these articles were excluded because they did not include ment tool [27], each of the following study’s risk of bias exposure therapy. Interrater agreement reached 95.1% for was rated “High”, “Low” or “Unclear”: random sequence the screening and 99% for the full sample. Thirteen arti- generation (selection bias); allocation concealment (selec- cles were retained for the final sample. Even though four tion bias); blinding of participants, personnel and outcome were single-case studies and one had only two partici- assessors (detection bias); incomplete outcome data (attri- pants, these studies are included in the study descriptive tion bias); selective outcome reporting (reporting bias); and as they provide input on how exposure therapy has been other potential threats to validity (see [28] for a complete used on gambling treatment. The meta-analysis therefore description). includes six studies. Outcome Measures Of the 13 selected studies, Riley, Smith and Oakes (2011) [23] had Gambling craving was the primary outcome variable in two eligible groups for the current meta-analysis. Therefore, these this study. Secondary outcome variables included the •• groups are presented separately as [43] and [44 ] (see Table 1). 1 3 182 Current Addiction Reports (2022) 9:179–194 Fig. 1 PRISMA study selection flowchart Records identified from*: PsycNet = 686 Medline = 1421 Google Scholar 1052 ClinicalTrials.org = 0 Retrieved from review and meta-analyses = 247 Records screened Records excluded (n =3406) (n = 2882) Reports sought for retrieval Reports not retrieved (n = 557) (n =33) Reports excluded: Reports assessed for eligibility No exposure therapy (n = 271) (n =524) No data regarding pathological or at-risk gamblers (n = 98) Did not address sought after outcome variable (n = 28) Exposure therapy carried exclusively in context of larger CBT therapy (n = 26) Theoretical study design, reviews or meta-analyses (n = 72) Duplicates (n = 9) Insufficient intervention description (n = 4) Data from other study (n = 3) Studies included in review (n =13) From 13 selected studies, 948 participants were allocated [37–39], three imaginal exposure [34, 35, 40] and seven used •• •• to an exposure condition. Excluding single-case studies a mix of both techniques [36, 41–43, 44 , 45, 46 , 47]. Six [36, 39, 42, 47], the mean number of participants was 104.9 of the seven studies using both imaginal and in vivo expo- (SD = 104.1, median = 49). Participants from 12 studies sure included a gradual increase in difficulty by first using •• •• [34–39, 41–43, 44 , 45, 46 ] reported gambling mostly imaginal exposure and then in vivo exposure [36, 42, 43, •• •• or exclusively on electronic gambling machines, while the 44 , 45, 46 , 47]. Participants met with a therapist 7.4 majority of participants in the remaining study [40] bet on times on average (median = 9.5) and took part in an aver- horse races. age of 23.1 exposure sessions (either with the therapist or Eight of the included studies provided baseline descrip- as betweensession homework; SD = 19.9, median = 14). •• tive data on time spent gambling [34,  36–39, 43, 44 , Table 2 provides characteristics of the exposure session for 47] and four on money spent on gambling[34,  37–39]. each study. Participants in these studies spent an average of 6.9  h per week (SD = 2.2, min = 3.8, max = 12.8) gambling and Theory and Learning Processes Behind Exposure Therapy had spent an average of $441.40 USD per week on gam- bling (SD = 455.30, median = 150). Table 1 provides data Five studies considered habituation to be the mechanism •• on participant characteristics, study localisation as well of action of the intervention [36, 42, 43, 44 , 45, 47]. One as included studies referencing number for the current study aimed to lower gambling behaviour and craving, a article. definition considered similar to habituation for the current review [37]. Two studies involved altering the behaviour Intervention  completion mechanism such that participants would no longer feel compelled to gamble in a gambling environment Nine studies were carried out in outpatient settings [34, [40, 41]. One study [38] aimed to increase participants’ per- •• •• 35, 37–39, 42, 43, 44 , 45, 46 ], three in inpatient set- ceived self-efficacy through craving resistance. The remain- tings [36, 40, 41] and one study did not specify the con- ing studies did not describe their intervention’s mechanism •• text of treatment [47]. Three studies used in vivo exposure of action [34, 35, 39, 46 ] 1 3 Included Screening Identification Current Addiction Reports (2022) 9:179–194 183 Table 1 Participants’ sociodemographic characteristics Study Reference N (final) Gender (Men %) Age Country Problematic game Hours spent Gambled money number gambling (per (USD per week) month) Blaszczynski 2005 [25] 79 (47) 77 37.1 (10.9) MI60% EGM 12.8 (9.2) 1352 (median = 150) 32% horse betting 8% combination of both Blaszczynski 2003 [36] 9 (2) 55 32.5 (7.7) 55% Australia 90% EGM MI MI 15% Croatia 15% many games 30% other Dham 2015 [37] 1 (1) 100 56 MI MI 30 MI Echeburúa 1996 [38] 16 (16) 44 35 (11) MI EGM 24.3 (25.6) 99.6 Echeburúa 2000 [39] 23 (23) 87 36 (13.7) 100% Spain EGM 52.2 127 Echeburúa 2002 [40] 1 (1) 0 47 MI EGM 26.1 187 McConaghy 1988 [41] 10 (10) 95 35 MI 70% horse racing MI MI 10% EGM 20% combination of both McConaghy 1991 [42] 80 (43) 94.7 42 MI MI MI MI Oakes 2008 [43] 1 (1) 0 31 MI EGM MI MI •• Riley 2011 [44 ] 496 (496) 51.4 43.7 (12.6) MI 89.9% EGM 14.5 (9.6) MI (metropolitan) •• Riley 2011 (rural) [44 ] 55 (55) 54.5 45.3 (11.7) MI 90.1% EGM 19.7 (6.3) MI Smith 2010 [45] 127 (83–80 ) 54 43.1 (12.7) MI 86.6% EGM MI MI Smith 2015 [35] 49 (43) 50 45.5 (12) MI EGM 16 (25.6) MI •• Tolchard 2006 [46 ] 1 (1) 0 50 MI EGM MI MI Data are mean (standard deviation) unless stated otherwise. Hours spent gambling are normalised to month format when necessary. MI missing information, EGM electronic gambling machine. Follow-up number of participants differs according to each variable. due to the lack of blinding of study personnel, random Outcome Variables sequence generation and allocation concealment. The most common outcome variables were time spent •• •• gambling at post-intervention [34, 36, 39, 43, 44 , 46 ]; Meta‑analyses gambling craving using the Gambling Urge Scale [48; 45, •• 46 ], visual analogue scale [34, 35] or categorical scale Four variables were analysed at post-treatment and at the longest available follow-up. Five studies [35, 37, 39, 47] [40]; erroneous beliefs using the Gambling-Related Cog- •• nitions Scale [49; 36, 45, 46 ] and the Gambling Beliefs had too few participants (≤ 2) and therefore could not be statistically combined for Hedges’ g. One study [38] com- Questionnaire [50; 35]; and subjective indicators [37–39, 47]. Studies also used three GD screening instruments: bined outcome variables in the Inadaptation Scale [54], making it impossible to include them in analyses. Two three used the Victorian Gambling Screen [VGS; 51; 36, •• 45, 46 ], three used the South Oaks Gambling Screen more studies [40, 41] also contained selected outcome vari- •• ables measured categorically and were thereby unable to be [SOGS; 52; 42, 43, 44 , 47] and one used the Canadian Problem Gambling Index [53; 36]. Table  3 provides a pooled with the continuous data from the other studies. For •• studies included in the meta-analyses [34, 37, 43, 44 , 45], detailed account of the gambling related outcomes for the •• selected studies. last follow-up is either 6 [46 ] or 12 months [34, 37, 45]. No analysis could be carried out on perceived self-efficacy, as only one study had enough participants for this outcome. Risk of Bias in Selected Studies Figure 2 shows the forest plot for each analysis accord- ing to a random effects model with 95% confidence interval. Risk of bias of the included studies is presented in Table 4. Included variables pertained to gambling craving, GD screen- The studies included in this review had a high risk of bias ing instruments, time spent gambling and erroneous beliefs. 1 3 184 Current Addiction Reports (2022) 9:179–194 1 3 Table 2 Treatment description Study Therapeutic mechanism Intervention aim Number of meetings Number of exposure Type of exposure Intervention description Blaszczynski 2005 MI MI 1 15 Imagination - Muscle relaxation - Imaginal exposure with emphasis on gambling craving until extinction (10–20 min) - Home imaginal exposure with audiocassette, three times a day, five days a week Blaszczynski 2003 MI Reduction in subjective 10 10 Imagination - Imaginal exposure using arousal and heart rate an audiocassette specific responses to main problematic game (EGM or horse betting) Dham 2015 Habituation MI MI MI Imagination and in vivo Graded exposure - Imaginal exposure with response prevention - In vivo exposure with response prevention - Exposure homework Echeburúa 1996 Make exposure cues lose Gambling abstinence 6 (6.5 h) MI In vivo Graded exposure with: their power to induce urge - Stimulus control: and gambling behaviour maintaining control of money and avoiding situations or routes of risk - Response prevention: forces to experience gambling craving and learn to resist this desire Echeburúa 2000 Learn how to resist this Gambling abstinence MI MI In vivo Graded exposure with: desire in a gradual, more - Stimulus control: self-controlled way maintaining control of money and avoiding situations or routes of risk - Response prevention: forces to experience gambling craving and learn to resist this desire Echeburúa 2002 MI Gambling abstinence 9 (+ 3 evaluation sessions) 54 (6 exposure per In vivo Graded in vivo exposure week for 9 weeks) involving a relative as co-therapist McConaghy 1988 Behaviour completion - Lower level of arousal 14 14 Imagination Imaginal desensitisation: mechanism - Reduction in gambling - Muscle relaxation - Imaginal exposure with response prevention Current Addiction Reports (2022) 9:179–194 185 1 3 Table 2 (continued) Study Therapeutic mechanism Intervention aim Number of meetings Number of exposure Type of exposure Intervention description McConaghy 1991 MI MI 14 14 Imagination or In vivo Two different treatment: - Imaginal desensitisation   ○ Muscle relaxation   ○ Imaginal exposure with response prevention - In vivo brief ○ In vivo exposure with response prevention lasting 20 min McConaghy 1991 (suite) MI MI 5 5 In vivo In vivo exposure with response prevention for one hour at a time Oakes 2008 Habituation MI 6 60 à 84 Imagination and in vivo Graded exposure until habituation. From imaginal exposure to in vivo exposure Riley 2011 (metropolitan) Habituation MI 11.29 (SD = 12.60) MI Imagination and in vivo Graded exposure until habituation. From imaginal exposure to in vivo exposure Riley 2011 (rural) Habituation MI 11.29 (SD = 12.60) MI Imagination and in vivo Graded exposure until habituation. From imaginal exposure to in vivo exposure Smith 2010 Habituation - Master urge to gamble MI MI Imagination and in vivo - Graded exposure using - Feel comfortable being audiocassettes alone in a gambling - From imaginal exposure venue with money in to in vivo exposure in the close proximity of gambling venues familiar gaming machines to each participant - Not requiring any - Exposure homework for 5 modifying factors to help to 7 weeks cope with their urge to gamble Smith 2015 MI MI 12 MI Imagination and in vivo - Graded exposure with stimulus control - Stimulus control is faded out as weeks progress - From imaginal exposure to in vivo exposure 186 Current Addiction Reports (2022) 9:179–194 1 3 Table 2 (continued) Study Therapeutic mechanism Intervention aim Number of meetings Number of exposure Type of exposure Intervention description Tolchard 2006 Habituation Eliminate the gambling 1 1 Imagination and in vivo - Graded exposure within a urge using habituation single session - From imaginal exposure to in vivo exposure outside gambling venue and inside gambling venue - Progression to the next step when craving has dropped to 50% initial craving MI missing information. Table 3 Outcome variables related to gambling in each selected study Blaszczynski Blaszczynski Dham Echeburúa Echeburúa Echeburúa McConaghy McConaghy Oakes Riley Smith Smith Tolchard Total 2005 2003 2015 1996 2000 2002 1988 1991 2008 2011 2010 2015 2006 Time spent gambling X X X X X 5 Craving X X X X X 5 Eroneous beliefs X X X X 4 Subjective indicator X X X X 4 Victorian Gambling Screen X X X 3 Therapeutic success X X X 3 South Oaks Gambling Screen X X X 3 Frequency of gambling X X 2 Money spent X X 2 Self-control X X 2 Preoccupations towards gambling X 1 Problem Gambling Severity Index X 1 Current Addiction Reports (2022) 9:179–194 187 Table 4 Bias assessment using Cochrane risk assessment tool Study Random sequence Allocation Blinding Attrition bias Selective outcome Other potential generation concealment reporting threats to validity a b Blaszczynski 2005 - - - - ? ? Blaszczynski 2003 + + - - - ? Dham 2015 - - - + - ? Echeburúa 1996 + ? - + ? ? Echeburúa 2000 + + + + ? ? Echeburúa 2002 - - - + + ? McConaghy 1988 + ? - + ? - McConaghy 1991 + ? + - - - Oakes 2008 - - - + ? ? Riley 2011 - - - + ? ? Smith 2010 - - ? + ? ? Smith 2015 + + + + + ? Tolchard 2006 - - - + - ? High risk of bias Uncertain risk of bias Low risk of bias •• Given that the two groups [44 ] documenting SOGS Craving score did not have follow-up measures, VGS score in the •• two remaining studies [45, 46 ] represents GD screen- Three studies were included in the analyses of exposure •• therapy’s impact on craving post-treatment [34, 45, 46 ]. ing instrument scores for the last measure. Pooled VGS scores decreased from 38.14 (sd = 10.87) to 15.83 Pooled results show a decrease in mean Gambling Urge pooled Scale [32] and visual analogue scale scores from 12.31 (sd = 16.33) at last measure, equivalent to a Hedge’s g pooled of − 1.69 (CI = [− 2.750, − 0.63]), p = 0.002, which indicates (sd = 6.49) to 8.17 (sd = 6.12). This decrease is pooled pooled equivalent to a Hedge’s g of − 0.955 (CI = [− 1.78, − 0.13]), a large effect [29, 32]. p = 0.024, corresponding to a large effect [29, 32]. Two studies were included in the analyses of expo- Time Spent Gambling sure therapy’s impact on craving at last measure [45, •• 46 ]. Pooled mean scores on the Gambling Urge Scale Four studies (totalling five groups; 1R, 4R, 10R, 11R, [48] decreased from 13.71 (sd = 7.32) t o 2.89 pooled 13R) were included in the analysis of exposure therapy’s (sd = 10.21) at last measure. This decrease is equivalent pooled impact on time spent gambling at post intervention. The to a Hedge’s g of − 1.010 (CI = [− 1.51, − 0.51]), p < 0,001, average hours spent gambling per month decreased from corresponding to a large effect [29, 31, 32]. 18.51 (sd = 6.52) to 3.21 (sd = 4.33) h post-treat- pooled pooled ment. A large effect was observed for this outcome with a Hedge’s g of − 2.16 (CI = [− 3.05, − 1.27), p < 0.001 [29, GD Screening Instruments 32]. Two studies were included in the analysis of exposure •• •• Three studies totalling four groups [44 , 45, 46 ] were therapy’s impact on time spent gambling at last measure included in the analysis of exposure therapy’s impact on GD •• [39, 46 ]. Mean hours spent gambling per month fell from screening instruments at post-intervention. SOGS pooled 18.02 (sd = 8.05) to 2.90 (sd = 2.72). Hedge’s g pooled pooled average scores decreased from 9.57  (sd = 4.33) to 4.01 pooled was non-significant, − 2.45 (CI = [− 5.34, 0.44]), p = 0.096. •• (sd = 4.37) in two groups [44 ] and VGS pooled scores pooled decreased from 38.14 (sd = 10.87) to 29.13 (sd pooled pooled Erroneous Beliefs = 10.01) at post-intervention for the two other groups [45, •• 46 ]. Hedges’ g was − 1.09 (CI = − 1.54, − 0.64), p < Two studies were included in the analyses of exposure 0.001, corresponding to a large effect [29, 32]. therapy’s impact on erroneous beliefs at post intervention 1 3 188 Current Addiction Reports (2022) 9:179–194 Craving : last measure GD n Fig. 2 Meta-analyses’ Forest-plots 1 3 Current Addiction Reports (2022) 9:179–194 189 GD screening instruments: last measure Time spent gambling: last measure Fig. 2 (continued) 1 3 190 Current Addiction Reports (2022) 9:179–194 Erroneous beliefs: post intervenon Erroneous beliefs: Last measure Fig. 2 (continued) •• [45, 46 ]. Pooled mean Gambling Related Cognitions Discussion Scale [49] scores decreased from 68 (sd = 21.5) to 55.4 pooled (sd = 19.5) which was also non-significant, Hedge’s This systematic review and meta-analysis aimed to describe pooled g = − 0.65 (CI = [− 1.34, 0.04]), p = 0.064. how exposure therapy is implemented in the treatment of Two studies were included in the analyses of exposure GD, as well as its efficacy in reducing cravings, gambling therapy’s impact on erroneous beliefs at last measure [45, behaviour and screening test scores, as well as decreasing •• 46 ]. Pooled Gambling Related Cognitions Scale [48] erroneous beliefs and improving perceived self-efficacy. mean scores decreased from 68 (sd = 21.5) to 34.15 pooled (sd = 25.14). A large effect was observed for this meas- pooled Studies Description ure, Hedge’s g = − 1.31 (CI = [− 2.00, − 0.62]), p < 0.001 [29, 32]. To date, exposure therapy for GD has been most widely Table 5 summarises data relating to quantitative analyses studied in predominantly male participants, with more recent for each outcome. 1 3 Current Addiction Reports (2022) 9:179–194 191 Table 5 Summary of quantitative findings Variable Pre intervention Post intervention Last follow-up Hedges’ g CI (95%) p pooled mean pooled mean (pooled pooled mean (pooled sd) sd) (pooled sd) GD screening instruments (pre-post- 9.57 (4.33) 4.01 (4.37) N/A − 1.087 − 1.536, − 0.637 < 0.001 intervention) 38.14 (10.87) 29.13 (10.01) Victorian gambling screen (pre-last 38.14 (10.87) N/A 15.83 (16.33) − 1.162 − 1.976, − 0.347 0.002 follow-up) Time (pre-post intervention) 18.51 (6.52) 3.22 (4.32) N/A − 2.136 − 3.034, − 1.238 > 0.001 Time (pre-intervention – last 18.02 (8.05) 8.05 2.90 (2.72) − 2.452 − 5.340, 0.437 0.096 follow-up Craving (pre-post intervention) 12.31 (6.49) 8.17 (6.12) N/A − 0.955 − 1.782, − 0.129 0.024 Craving (pre-intervention—last 13.71 (7.32) N/A 2.88 (10.21) − 1.010 − 1.508, − 0.512 > 0.001 follow-up) Erroneous beliefs (pre-post 68 (21.5) 55.4 (19.5) N/A − 0.653 − 1.343, 0.038 0.064 intervention) Erroneous beliefs (pre-intervention – 68 (21.5) N/A 34.15 (25.14) − 1.308 − 1.999, − 0.617 < 0.001 last follow-up) Pooled means and SD are presented in two lines to differentiate SOGS score (first result) and VGS score (second result). Hedges’ g, CI, and p data combine results from SOGS and VGS on this line. studies striving to include more women in their samples. be the new learning brought about by exposure, which Exposure therapy for GD was studied in two countries, Aus- would in turn reduce the craving to gamble. Given that tralia and Spain, and participants mainly preferred electronic this conceptualisation has yet to be applied to GD, future gambling machines. Participants were mostly seen individu- studies in line with this understanding would further clarify ally and in outpatient settings. how exposure therapy works, while potentially providing Most studies presented a mix of imaginal and in vivo a treatment description that better reflects participants’ exposure with exposure intensity gradually progressing as subjective experience. participants became increasingly capable of successfully Last of all, the analysis of selected studies shows a high confronting each cue. Most exposure therapy studies were risk of bias as a result of insufficient blinding of study per - theoretically based on habituation, such that exposure to dif- sonnel, random sequence generation and allocation con- ferent gambling cues induces craving, yet as the craving is cealment. Moreover, only two to three studies conducted in not acted upon, it decreases and would ultimately be extin- Spain and Australia could be included in each meta-analysis. guished. This rationale is akin to systematic desensitisation This highlights the necessity for more methodologically as originally developed in the 1950s [55]. sound studies to evaluate exposure therapy for GD in order Only three studies had therapeutic mechanisms other to better ascertain its efficacy. than habituation. McConaghy et  al.’s studies [40, 41] conceptualise exposure therapy as a means of altering the Exposure Therapy’s Efficacy behaviour completion mechanism, leading patients to no longer feel compelled to gamble in a gambling environment. Exposure therapy had a large effect on craving reduction at McConaghy et al. (1988) [40] conclude that it is not possible post intervention and was even larger at 6- and 12-month to determine if the behaviour completion mechanism better follow-up. Confidence intervals were also closer to the cor - explains exposure therapy’s efficacy. Echeburúa el al. responding g measure, indicating that results are more homog- [38] conceptualise that exposure therapy raises perceived enous at follow-up. These results from the limited literature self-efficacy to not gamble when faced with gambling on exposure therapy support its efficacy in lowering gam- situations. This conceptualisation resembles that of more bling cravings. The effect of exposure therapy was larger at recent inhibitory learning views of exposure therapy for follow-up, which is similar to other studies of CBT [see 57]. anxiety [56]. According to this model, exposure does not Improved results at follow-up may be attributable to partici- produce the unlearning between a cue and a conditioned pants’ continued application of techniques learned in therapy; response but rather produces a new learning that inhibits however, this has yet to be empirically tested. It is important the conditioned response. Combining this conceptualisation to mention that one study did not include follow-up data on to Echeburúa et  al.’s (2000) [38], craving would be the gambling craving, which may explain the more homogenous conditioned response and increased self-efficacy would results and higher effect size data. Overall, it is surprising that 1 3 192 Current Addiction Reports (2022) 9:179–194 only five of the 13 studies tested exposure therapy’s effect on who evaluated GD therapies including CBT, motivational reducing craving, given this variable’s crucial importance to interviewing therapy, integrative therapy and other psycho- treatment rationale. therapeutic interventions, found 14 RCTs. It is difficult to From a statistical viewpoint, a large decrease of gambling determine why exposure therapy has yet to be tested with screening instruments score was attained at post-treatment. a RCT design, but it is encouraging to see that 30% of the Using SOGS’s cut-off scores, pooled means decreased included studies used an empirical design with a lower risk •• •• from “probable pathological gambler” to “potential patho- of bias [44 , 45, 46 ]. Another limitation of this study is logical gambler”. Using VGS cut-off scores, pooled mean that studies were included regardless of their risk of bias due results decreased at post-intervention while remaining in the to the small number of studies meeting the inclusion crite- “problem gambler” range. For final follow-up, pooled mean ria. It was therefore necessary to combine this small num- results indicate a score of “borderline gambling”. These large ber of studies while remaining critical of results in order to decreases remain lower than what was obtained from CBT ascertain the pertinence of investigating exposure therapy’s in comparison to control in Cowlishaw et al.’s (2012) meta- efficacy for GD in future studies. Furthermore, the current analysis [2 ]. Looking at other therapies investigated in the meta-analysis used pre-post analyses within-participants due same meta-analysis, exposure therapy’s efficacy to lower to the lack of studies involving a control group; the pre-post participants gambling screening scores indicate that it is the design is known to overestimate effect sizes in comparison next best intervention to reduce GD severity. This result is to those computed from controlled studies [30]. The rigorous preliminary as it was derived from only a few studies with a study selection, with two independent interrater agreements high risk of bias. Nevertheless, these preliminary results are and double selection of data from selected studies, is the encouraging and support the efficacy of exposure therapy to main strength of the study. It is hoped that findings from reduce the severity of gambling behaviour. the present study showing the benefits of exposure therapy Results show that exposure therapy produces a substan- for GD will promote further, more methodologically rigor- tial decrease in time spent gambling at post-intervention, ous studies in order to reliably establish exposure therapy’s yet these results became non-significant at 6 to 12 months efficacy for treating GD. post-intervention. Given that confidence intervals were par - ticularly large at last follow-up, the loss of significance may be attributable to the larger variance resulting from a small Conclusion number of combined studies comprising few participants. Further studies with larger sample sizes are likely required to This study is the first meta-analysis on behavioural expo- detect statistical significance. Still, Echeburúa et al. (2000) sure therapy for GD. Pooled results from a small num- [38] have argued that adding relapse prevention after expo- ber of studies demonstrate a positive effect of exposure sure therapy produces more therapeutic success than expo- therapy for GD. The present study’s results show that sure therapy alone after 12 months. The effect of supple- exposure therapy reduces gambling cravings and sever- menting exposure therapy with relapse prevention should ity, as well as time spent gambling and erroneous beliefs. therefore also be studied in order to establish its added value. Future studies should investigate the efficacy of stand- Meta-analysis of two studies shows that exposure therapy ardized exposure therapy using a treatment manual in resulted in a non-significant decrease in participants’ erro- RCTs to obtain more reliable outcome da ta. Evaluating neous beliefs at post-intervention, yet showed a large and by which process exposure therapy leads to clinical effi- significant effect at 6 and 12 months. These results appear in cacy would also help in understanding the link between line with past studies suggesting that higher levels of errone- each efficacy variable. Overall, this study supports expo- ous beliefs are associated to with higher levels of problem sure therapy as a promising approach to the treatment of gambling severity [34, 58, 59]. Further studies evaluating GD and may assist in broadening therapeutic options for the impact of exposure therapy, a behaviour intervention, individuals suffering from GD. on erroneous beliefs will be necessary to better understand the exact mechanism driving the effect. Data Availability Data may be obtained via request. Limits and Strengths Declarations This meta-analysis was limited by the studies included for Ethics Approval Waived by the comité d’éthique de la recherche en analyses as these were few, at high risk of bias, and per- psychologie et en sciences de l’éducation de l’Université Laval on formed in only two countries (Australian and Spain). The 20/04/2018. literature search did not identify any randomised controlled Consent to Participate Not applicable. trials (RCTs). In comparison, Cowlishaw et al. (2012) [2 ], 1 3 Current Addiction Reports (2022) 9:179–194 193 Consent for Publication Not applicable. 10. Mellentin AI, Skøt L, Nielsen B, Schippers GM, Nielsen AS, Stenager E, et al. Cue exposure therapy for the treatment of alcohol use disorders: a meta-analytic review. Clin Psychol Rev. Conflict of Interest Stéphane Bouchard is president of, and owns 2017;57:195–207. https:// doi. org/ 10. 1016/j. cpr. 2017. 07. 006. shares in, Cliniques et Développement In Virtuo, a company that dis- 11. 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Journal

Current Addiction ReportsSpringer Journals

Published: Sep 1, 2022

Keywords: Gambling disorder therapy; Cognitive-behaviour therapy; Exposure therapy

References