Cognitive Versus Exposure Therapy for Problem Gambling: Randomised Controlled Trial.

 New Study (1)Abstract


Problem gambling-specific cognitive therapy (CT) and behavioural (exposure-based) therapy (ET) are two core cognitive-behavioural techniques to treating the disorder, but no studies have directly compared them using a randomised trial.


To evaluate differential efficacy of CT and ET for adult problem gamblers at a South Australian gambling therapy service.


Two-group randomised, parallel design. Primary outcome was rated by participants using the Victorian Gambling Screen (VGS) at baseline, treatment-end, 1, 3, and 6 month follow-up.


Of eighty-seven participants who were randomised and started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET = 21). Both groups experienced comparable reductions (improvement) in VGS scores at 12 weeks (mean difference -0.18, 95% CI: -4.48-4.11) and 6 month follow-up (mean difference 1.47, 95% CI: -4.46-7.39).


Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates and reduce drop-out.

Smith, D. P., Battersby, M.W., Harvey, P.W., Pols, R.G., & Ladouceur, R. (2015). Cognitive versus exposure therapy for problem gambling: Randomised controlled trial. Behavior Research and Therapy, 69, 100-110. doi: 10.1016/j.brat.2015.04.008

Guest Blogger Dr. Judith Beck: Helplessness

I recently presented a Master’s Clinician Class at the Anxiety and Depression Association of America. My topic was cognitive conceptualization of personality disorders. I asked for a volunteer to describe a case so as a group, we could conceptualize the client, using the Cognitive Conceptualization Diagram (Beck, 2005).ADAA 2015 Registration I have changed certain details to protect the client but his difficulties are fairly typical of someone with avoidant personality disorder.

Joe is a 52 year old man who developed PTSD 32 years before, following a series of traumatic incidents. For a long time, he lived with his family and led a fairly reclusive life. He then moved into subsidized housing which he dislikes.

Joe has been in and out of therapy for many years with many therapists. Although he no longer displays symptoms of PTSD, and hasn’t for a long time, he suffers from dysthymia. His anxiety is fairly low as he avoids situations that could lead to distress. He hasn’t had a job since he developed PTSD and has made only half-hearted attempts to secure one. He does have a few friends, “drinking buddies,” but isn’t particularly close to any of them. His relationships with his family are somewhat strained.

When the therapist listed Joe’s automatic thoughts in situationsADAA 2015 with Cindy Aaronson, PhD where he either felt some (mild) distress or acted in a dysfunctional way (using avoiding something), it became clear that Joe has very strong core beliefs of helplessness. Many patients have a belief in one of the three subcategories of helplessness; Joe seems to have core beliefs of being ineffective in all three.

When Joe discusses his future, he says, “My crummy apartment is preventing me from living my life.” When he considers doing his therapy homework, he thinks, “I won’t be able to do it right.” This represents the subcategory of believing one is ineffective in getting things done.

When Joe imagines going to session without having done his homework, he thinks, “She [his therapist] will be mad if I don’t do it.” When they discuss fixing up his apartment, he thinks, “I don’t want to talk about this. It will be too upsetting.” This represents the subcategory of believing one is ineffective in being able to protect oneself, in this case, in being emotionally vulnerable.

When Joe discusses his past, he thinks, “I’ve wasted so many opportunities. I’m a loser.” When Joe fails to protest a teasing insult from his buddy, he thinks, “I should have said something. I’m a wimp.” This represents the subcategory of being ineffective as compared to others.

Joe’s sense of helplessness has led to extensive behavioral avoidance. He procrastinates, avoids doing homework or cleaning up his apartment. It has led to extensive social avoidance. He avoids intimacy in relationships. And it has led to extensive cognitive and emotional avoidance. He over-intellectualizes, changes the subject in therapy, and avoids even thinking about upsetting topics. And he fails to take responsibility for improving his life, blaming his mother, PTSD, and his living situation for holding him back.

Clients’ emotional and behavioral reactions always make sense once we understand what they are thinking. And the patterns or themes in their thinking always make sense once we understand the fundamental ways they view themselves, other people, and their worlds.


Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.

Long-Term Comparison of Traditional CBT and Acceptance and Commitment Therapy

According to a recent study published in Behavior Therapy, traditional cognitive behavior therapy (CT) may be more effective for treating anxiety and depression in the long-term than Acceptance and Commitment Therapy (ACT). The current study is a follow up comparison of the long-term outcomes of CT and ACT. The original study measured symptoms of students seeking treatment, (n=132) age 18-52 (M=26.7) before and after receiving CT and ACT. At post treatment, both groups improved on measures of depression, anxiety, and general functioning, and the results did not yield a significant difference in effectiveness between the two samples receiving treatment.

This long-term follow up study, conducted 18 months later included a majority (n=91) of the original sample who received either CT (n=45) or ACT (n=46). Although participants in both treatment groups benefitted initially from the different therapies, participants from the CT treatment group gained significant and lasting improvement in their symptoms and functioning:


  • 81.8% of CT patients versus 60.7% of ACT patients remained reliably recovered on measures of depression (Beck Depression Inventory-II);
  • 72.7% of CT patients versus 56.0% ACT patients remained in the recovered range for anxiety (Beck Anxiety Inventory);
  • 46.4% of CT patients versus 22.6% ACT patients maintained improvements in interpersonal and occupational functioning (Outcome Questionnaire); and
  • 37.8% of CT patients versus 22.9% of ACT patients remained in the normative range on measures of quality of life (Quality of Life Inventory).

This is the first known comparison of the long-term efficiency of CT versus ACT. While research and replication studies are necessary, these preliminary findings suggest that traditional CT has long-term advantages over ACT in treating depression and anxiety, and in increasing general functioning and overall quality of life.

Forman, E.M., Shaw, J.A., Goetter E.M., Herbert, J.D., Park, J.A., & Yuen, E.K, (2012). Long-term follow-up of a randomized controlled trial comparing acceptance and commitment therapy and standard cognitive behavior therapy for anxiety and depression. Behavior     Therapy, 43(4) 801-811

Cognitive Therapy Reduces the Severity of Psychosis

According to a recent study published in the British Medical Journal, cognitive therapy (CT) may reduce the severity of psychotic symptoms among individuals who develop psychosis. Participants (n = 288) identified as high-risk for developing a psychotic disorder were randomly assigned to receive either six months of CT plus mental state monitoring or mental state monitoring only. While CT did not significantly reduce the transition to psychosis, it did reduce the severity of psychotic symptoms in high-risk individuals. Further, the overall prevalence of transition to psychosis (8%) was lower than expected, and most participants in both groups improved over time. These findings impart an optimistic message to patients at risk for psychosis: Patients can improve with intervention, and CT may help with recovery.

Morrison, A. P., Stewart, S. L. K., French, P., Parker, S., Byrne, R., Birchwood, M., Brunet, K., … Dunn, G. (2012). Early detection and intervention evaluation for people at risk of psychosis: Multisite randomised controlled trial. British Medical Journal (online), 344, 7852.

CBT for Schizophrenia

CBT Training at Beck InstituteDr. Judith Beck greeting participants at Beck Institute’s first ever CBT for Schizophrenia Workshop.

Terapia Cognitiva Conductal [The Many Applications of Cognitive Therapy]

Dr. Beck discusses the many different applications of cognitive behavior therapy (CBT)—and states that he never would have expected CBT to be utilized in the treatment of so many different conditions. For example, CBT can be useful in the treatment of patients with epilepsy; it can reduce the likelihood of additional heart attacks among cardiac patients; and it can help with cancer-related depression.

A Monthly Summary of Beck Institute Updates [April 2012]

In its efforts to encourage the growth and dissemination of CBT throughout the world, the Beck Institute has expanded its online presence across social media and other platforms. To keep you (our readers) informed of our most recent updates, we’ve decided to implement a monthly summary including: blogs, CBT articles, and CBT trainings, and other updates for our readers. Please use the following links to go back and read what you may have missed from April 2012:

See what you missed in March

CBT/MET Therapy Helps Improve Symptoms in Comorbid MDD/AUD Adolescents

A recent, two-year acute phase trial published in Addictive Behaviors found both manual-based cognitive behavior therapy (CBT) and motivation enhancement therapy (MET) to be beneficial treatments for adolescents suffering from both major depressive disorder (MDD) and alcohol use disorder (AUD). This was the first controlled study to compare CBT/MET with fluoxetine or placebo versus naturalistic care (control group), among adolescents with comorbid MDD/AUD.

Participants included 50 adolescents (ages 15-20) who met DSM-IV criteria for AUD and MDD. Qualified and trained masters level staff delivered nine sessions of manual-based CBT/MET, coupled with either fluoxetine (SSRI) or a placebo pill, to participants in the experimental condition. The Hamilton Rating Scale for Depression (HAM-D-27) and the Beck Depression Inventory (BDI) were used to assess depressive symptoms. The timeline follow-back method (TLFB), a tool used to measure controlled drinking, assessed drinking behavior.

Participants in the experimental condition who received CBT/MET demonstrated superior outcomes to the control group who did not receive any psychological intervention. Furthermore, no differences were noted between participants who received CBT/MET and fluoxetine versus CBT/MET and a placebo. These findings suggest that CBT/MET may be most efficacious for the treatment of comorbid MDD/AUD.

Cornelius, J.R., et al. (2011). Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents. Addictive Behaviors, 36(8), 843-848.

The Biological Aspect of Depression

Dr. Aaron Beck discusses the neurological effects of depression and how Cognitive Behavior Therapy works in treating it. He also describes the biological aspect of the negative bias and how CBT can be used to reverse that bias. This video was taken at Beck Institute’s CBT for Children and Adolescents workshop. For more information, or to register for our next workshop visit:

November 14 – 16, 2011, Cognitive Behavior Therapy Workshop Level ll: Personality Disorders and Challenging Problems

Dr. Judith Beck demonstrates a how to conceptualize a challenging case.

Last week at Beck Institute we held our Level 2 CBT Workshop on Personality Disorders and Challenging Problems. Psychologists, psychiatrists, social workers, counselors, and other health and mental health professionals traveled from all over the world, including Canada, India, Peru and nine U.S. states, to receive training in Cognitive Behavior Therapy.

Participants received professional training from Judith S. Beck, Ph.D., Leslie Sokol, Ph.D., and Norman Cotterell, Ph.D.  Lectures and role-plays emphasized the need for the therapeutic alliance in order to establish rapport.  Dr. Sokol

Level 2 participants watched multiple live patient sessions while at Beck Institute

discussed patient collaboration and made it clear that a therapist should always be there for the client.  The use of mood checks was discussed and participants were told that a patient will often start with negative emotions and it is critical to probe them for positives to counter the negatives.

CBT Worksheet Demonstration

Dr. Judith Beck (above) demonstrated how to use a variety of CBT worksheets for therapists to use, such as the Cognitive Conceptualization Diagram. Dr. Beck encouraged workshop participants to roleplay (left and below) with one another to practice cognitive therapy techniques for personality disorders and challenging problems. Click here to learn more about our CBT workshops and how to register for our next Level 2 in February 2012. See below for more workshop highlights: